Appeal/Arbitration Policy Regarding Coverage Disputes

Coverage Determination

Interpretation of coverage is determined by the claims administrator and/or coverage counsel at the time a claim against a covered member is received by the NCSIG.  A written response indicating coverage, limited coverage, or no coverage shall be issued to the covered member against whom the claim has been made. 

Appeals of Coverage Denials (Due Process) 

In the event that a question or dispute occurs regarding the applicability of coverage(s), as determined by the NCSIG, arising out of an occurrence or claim against a covered member, the covered member may make a written request to have the denial of coverage reviewed by the Board of Directors at its next or at a special meeting.  The Board of Directors will hear both sides of the issue(s) and announce their finding.  If the denial is affirmed, the covered member may then petition in writing for binding arbitration. 

Arbitration of Coverage Disputes

1. In the event that a question(s) or a dispute(s) concerning the applicability of coverage to an occurrence or claim against the covered member has not been resolved through the appeal procedure, either the covered member or the NCSIG may make a written request for arbitration. Where such a request is made, arbitration shall be a condition precedent to the filing of any civil action concerning or in any way arising out of such question(s) or dispute(s).
2. The covered member and the NCSIG shall select an arbitrator. Each party will bear the expense of the arbitrator equally.  The finding of the arbitrator will constitute a determination of the matter(s) in question or dispute.
3. If the covered member and the NCSIG fail to agree upon an arbitrator, each party will select an arbitrator and the two arbitrators will select a third. If they cannot agree upon the third arbitrator within thirty (30) days, either may request selection by a judge of a court having jurisdiction.  Each party will bear the expense of the third arbitrator equally.  A decision agreed to by two of the three arbitrators will constitute a determination of the matter in question or dispute.