Insurance: 15 days to acknowledge, 90 to resolve, 30 to reconsider

This is an article inside the Insurance Code, not a separate law, and its value is that nearly everything it declares has a date or a verifiable requirement. It serves two distinct moments. When you buy the policy: what must be shown, explained and handed to you. And when you claim: how long they have to answer, what must be itemized for you, and what happens if a cheque you did not accept arrives. It applies generally to the insurance consumer; it is not the patient’s bill of rights or the health plan one, which are different.

The insurance consumer in Puerto Rico. The article opens by saying the insurance consumer shall enjoy all rights recognized to them in the laws and regulations applicable to them, including, but not limited to, those it lists. That phrase matters for two reasons: the list adds to what you already have and does not replace it, and it is not closed. There is nothing to register for or apply to. The claim deadlines apply from when the claim is notified and received, so the date you filed it is the fact everything is counted from.

• Being an insurance consumer. The article sets no eligibility requirements and demands no prior procedure for the rights to apply.Verified against the official source
• For the claim deadlines: having notified and filed the claim with the insurer. The fifteen and ninety days run from that date.Verified against the official source

• A copy of your policy. Right (g) guarantees it, and right (f) also gives you the language: individual policies must be written in the language the insured chooses between English and Spanish.
• A copy of these rights. Item (q) requires every Producer and Authorized Representative to hand it to you when arranging an insurance policy, and likewise to hand it to the insurer when a claim is presented.
• The claim notification sheet, together with the policy: right (l) names them as where the physical and/or electronic addresses are recorded to which the insurer must write you with the inspection dates.

1. 1

   Step 1: The fifteen days for acknowledgment

   Item (h) recognizes the right to have the insurer acknowledge receipt of your claim within fifteen (15) days of it being notified. It is the first clock and the easiest to verify: either the acknowledgment arrived or it did not. Write down the date you notified the claim, because this one runs from there and, from another starting point, so does the ninety-day one. If you filed in writing or through a portal, keep the evidence with its date.

2. 2

   Step 2: Ninety days to resolve, thirty for reconsideration

   Item (n) recognizes the right to have your claim resolved in a reasonable period within the first ninety (90) days of the claim being received. Note the construction: the law asks that it be reasonable and additionally sets a ninety-day ceiling from receipt. And item (o) covers what follows a determination you are not satisfied with: the right to request reconsideration of the insurer’s determination on your claim, and to have it addressed and resolved within thirty (30) days of the request being filed. File the reconsideration in writing and dated, because that is the point the thirty days run from. And item (m) adds something small but useful in that process: the right to request and receive an appointment to handle your reconsideration request.

3. 3

   Step 3: The cheque you did not accept is not a waiver

   This is the least-known right and the one that can cost the most to ignore. Item (j) recognizes the right to have the insurer send you its offer with an itemized adjustment for your evaluation before you receive a cheque you have not accepted, or concurrently with the cheque, without simply receiving it meaning a waiver of your claims. Three things in one sentence: the offer must come itemized, it must arrive before the cheque or with it, and receiving the cheque does not amount to accepting. Item (k) completes the itemization from the other side: the right to have the insurer include in the adjustment the reasons certain items of the claim were declined. If the adjustment arrived without those reasons, that is the item.

4. 4

   Step 4: The three inspection dates before closing your case

   Item (l) is what stops a claim from being closed because phone calls did not connect. It recognizes the right to receive from the insurer up to three (3) alternative inspection dates, in writing to the physical and/or electronic addresses contained in the policy and the claim notification sheet, where it could not be coordinated by phone; and it adds the part that gives it force: this before the insurer may close your claim. That is, the written attempt with up to three dates is a precondition to closure, not a courtesy. Which is why the physical and electronic addresses in your policy and notification sheet should be correct and current.

5. 5

   Step 5: What is yours before signing the policy

   Five rights cover the moment of purchase. Item (a): choosing the insurer and insurance intermediary of your preference. Item (c): requiring the insurance intermediary to show you their license; it is a direct question and the right is written so you can ask it. Item (d): that every producer or authorized representative identify and measure the risks you are exposed to, so the insurance product arranged fits your coverage need. Item (e): that whoever arranges your policy give you clear and complete guidance on the policy’s coverage, benefits, limits and exclusions, as well as the insured’s duties and obligations; note the guidance includes what the policy does not cover and what you must do, not only what you get. And item (f): that individual policies be written in the language the insured chooses between English and Spanish. To those add item (g), the right to obtain a copy of your policy.

6. 6

   Step 6: Insurance is not a condition of your loan

   Item (b) addresses a very specific bank-counter situation: the right to be told verbally and in writing that, in connection with a Financial Institution extending credit, granting that credit is not conditioned on purchasing insurance, or on purchasing it from institutions affiliated with that Institution. Note the law requires disclosure in both forms — verbal and written — and that it covers both scenarios: they may condition your credit neither on buying insurance nor on buying it from the bank’s affiliates.

7. 7

   Step 7: Good faith and the route to the Commissioner

   Item (i) states the general standard of conduct: the right to have the insurer act in good faith, fairly and equitably in evaluating and resolving your claim. It is what sustains the others when conduct does not fit a missed deadline but is not acceptable either. And item (p) gives the exit: the right to file an investigation request with the Insurance Commissioner. That is the forum this article names. What we do not publish: how that request is filed, what form it uses, what it costs or how long it takes to resolve. Article 1.120 names the right and does not regulate the procedure, and we read that article, not the rest of the Insurance Code.

8. 8

   Step 8: The copy they must hand you

   Item (q) is not a right of yours but an obligation on the other side, which makes it easy to verify: every Producer and Authorized Representative shall be required to hand a copy of the Consumer Rights established in this Article to the insured when arranging an insurance policy, and likewise to the insurer when a claim is presented to them. That is two deliveries at two distinct moments. If you never received that copy when buying the policy, you now know two things: that you can ask for it, and that its absence is a breach of this item.

First with your own insurer: the claim, and if you are not satisfied with the determination, the reconsideration request, which must be addressed and resolved within thirty days of filing. If that does not resolve it, item (p) names the forum: filing an investigation request with the Insurance Commissioner. The Office of the Insurance Commissioner is the industry’s regulator in Puerto Rico. What we do not publish: the procedure, the form, the cost or the deadlines of that investigation request, because Article 1.120 does not regulate them and we read that article, not the rest of the Insurance Code, which runs 635 pages. If the problem is specifically with a health plan — a denied coverage, a surprise bill, a medication — there are dedicated guides for those situations and their forums.

• Not noting the date you notified the claim: the fifteen and ninety days run from there.
• Depositing a cheque believing accepting it closes the matter: the law says simply receiving it is not a waiver of your claims.
• Accepting an adjustment with no itemization and no reasons for the declined items.
• Requesting reconsideration by phone and undated: the thirty days run from when the request is filed.
• Accepting your claim being closed without having received in writing up to three alternative inspection dates.
• Having outdated addresses in the policy and notification sheet, which is where the insurer must write you.
• Accepting a bank conditioning your credit on buying insurance or on buying it from its affiliates.
• Not asking the intermediary to show you their license, which is an express right.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov

• Office of the Insurance Commissioner (OCS)

  OCS

  www.ocs.pr.gov