Diligence Required in Reviewing Claims; Nonwaivable Liability Is Not Created; Definitions

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  2. Georgia Code
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  5. Diligence Required in Reviewing Claims; Nonwaivable Liability Is Not Created; Definitions

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  1. Any claim administrator, health care advisor, private review agent, or other person or entity which administers benefits or reviews or adjusts claims under a managed care plan shall exercise ordinary diligence to do so in a timely and appropriate manner in accordance with the practices and standards of the profession of the health care provider generally. Notwithstanding any other provision of law to the contrary, any injury or death to an enrollee resulting from a want of such ordinary diligence shall be a tort for which a recovery may be had against the managed care entity offering such plan, but no recovery shall be had for punitive damages for such tort.
  2. The provisions of this Code section may not be waived, shifted, or modified by contract or agreement and responsibility therefor shall be a duty which shall not be delegated. Any effort to waive, modify, delegate, or shift liability for a breach of the duty provided by this Code section, through a contract for indemnification or otherwise, shall be invalid.
  3. This Code section shall not create any liability on the part of an employer of an enrollee or that employer's employees, unless the employer is the enrollee's managed care entity. This Code section shall not create any liability on the part of an employee organization, a voluntary employee beneficiary organization, or a similar organization, unless such organization is the enrollee's managed care entity and makes coverage determinations under a managed care plan.
  4. As used in this Code section and in Code Section 51-1-49, the terms "claim administrator," "enrollee," "health care advisor," and "private review agent" shall be defined as set forth in Chapter 46 of Title 33 except that "enrollee" shall include the enrollee's eligible dependents; "managed care entity" and "managed care plan" shall be defined as set forth in Code Section 33-20A-3; and "independent review" means a review pursuant to Article 2 of Chapter 20A of Title 33, the "Patient's Right to Independent Review Act."

(Code 1981, §51-1-48, enacted by Ga. L. 1999, p. 350, § 1.)

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1999, punctuation was revised in subsection (d).

Editor's notes.

- Ga. L. 1999, p. 350, § 4, not codified by the General Assembly, provides: "For purposes of certifying independent review organizations by the Health Planning Agency, or its successor agency, this Act shall become effective upon its approval by the Governor (April 20, 1999) or upon its becoming law without such approval. For all other purposes, this Act shall become effective on July 1, 1999, and shall be applicable to any contract, policy, or other agreement of a managed care plan or health maintenance organization if such contract, policy, or agreement provides for health care services or reimbursement therefor and is issued, issued for delivery, delivered, or renewed on or after July 1, 1999."

Law reviews.

- For annual survey article discussing developments in insurance law, see 51 Mercer L. Rev. 313 (1999). For note on 1999 enactment of this Code section, see 16 Ga. St. U.L. Rev. 151 (1999).


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