A.R.S. tit. 20 ch. 21 — Arizona Revised Statutes Title 20 Chapter 21 — Health Care Insurer Liability

20-3151. Definitions For the purposes of this section: 1. "Enrollee" means an individual who is enrolled in a health care plan provided by a health care insurer. 2. "Health care insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, medical service corporation or hospital and medical service corporation. 3. "Health care plan" means a policy, contract or evidence of coverage issued to an enrollee. Health care plan does not include limited benefit coverage as defined in section 20-1137. 4. "Health care professional" means a professional who is regulated pursuant to title 32, chapter 7, 8, 11, 13, 14, 15, 15.1, 16, 17, 18, 19, 19.1, 25, 28, 29, 33, 34, 35, 39 or 41, title 36, chapter 6, article 7 or title 36, chapter 17. 20-3152. Exemptions; waiver A. This chapter does not create: 1. Any liability on the part of any employer or employer group purchasing organization that purchases coverage or assumes risk on behalf of its employees or on behalf of self-funded employee benefit plans. 2. Any new or additional liability on the part of a health care insurer for harm caused that is attributable to the medical negligence of a treating health care professional or health care institution as defined in section 36-401. B. This chapter does not abrogate or limit any other theory of liability or defense otherwise available at law. C. Any waiver by an enrollee of any provision of this chapter is contrary to public policy and is unenforceable and void. D. An enrollee who files an action pursuant to section 20-3153 may not pursue a common law action for breach of the duty of good faith and fair dealing against the health care insurer. An enrollee who files a common law action for breach of the duty of good faith and fair dealing against a health care insurer may not pursue an action pursuant to section 20-3153. 20-3153. Health care insurer liability A. A health care insurer is liable for any damages caused to the insurer's enrollee by the insurer's delay in authorizing or failure to authorize a request for medically necessary health care services covered under the health care plan or by the insurer's denial of payment of benefits covered under the health care plan if both: 1. The health care insurer delayed authorizing or failed to authorize the requested health care services or denied payment of the covered benefits without a reasonable basis for that action. 2. The health care insurer knew that it acted without a reasonable basis or failed to perform an investigation or evaluation adequate to determine whether its action was supported by a reasonable basis. B. A health care insurer: 1. Is liable under this section if the insurer's conduct was a cause of the enrollee's damages and if the damages would not have occurred without that conduct. 2. Is not liable under this section if the insurer's conduct under this section was inadvertent or unintentional. 20-3154. Health care appeals; admissibility In an action under this chapter, any person, enrollee or health care insurer may introduce into evidence for any purpose any of the documents, findings, decisions or information concerning events that occurred in the health care appeals process pursuant to chapter 15, article 2 of this title. The fact that the enrollee did not participate in the health care appeals process may also be introduced into evidence. 20-3155. Notice of intent to file suit A. Before an enrollee files an action pursuant to section 20-3153, the enrollee shall either: 1. Complete the health care appeals process prescribed in chapter 15, article 2 of this title. 2. Provide written notice to the health care insurer at least thirty days before filing suit stating the enrollee's intention to file suit and setting forth the basis for the suit. B. If the enrollee provides notice pursuant to subsection A, paragraph 2 of this section, the enrollee shall deliver the notice to the health care insurer in compliance with the terms specified for delivery of written notices prescribed in the policy, contract or evidence of coverage. If the policy, contract or evidence of coverage does not specify the terms for delivery of written notices, the enrollee may provide notice to the last representative of the health care insurer who corresponded in writing with the enrollee. C. Participation in the health care appeals process prescribed in chapter 15, article 2 of this title does not prohibit or limit the enrollee from filing suit at the conclusion of the appeals process.