Common use of Adverse Benefit Determinations Clause in Contracts

Adverse Benefit Determinations. An adverse benefit determination is any of the following: • Denial of a benefit (in whole or part), • Reduction of a benefit, • Termination of a benefit, • Failure to provide or make a payment (in whole or in part) for a benefit, • Denial, reduction, termination, or failure to make a payment based on the imposition of a preexisting condition exclusion, a source of injury exclusion, or other limitation on covered benefits, and • Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is at (000) 000-0000 or 0-000-000-0000.

Adverse Benefit Determinations. An adverse benefit determination is any of the following: •  Denial of a benefit (in whole or part), •  Reduction of a benefit, •  Termination of a benefit, •  Failure to provide or make a payment (in whole or in part) for a benefit, •  Denial, reduction, termination, or failure to make a payment based on the imposition of a preexisting condition exclusion, a source of injury exclusion, or other limitation on covered benefits, and •  Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is at (000) 000-0000 or 0-000-000-0000.