Appeal of Denial of Claim Sample Clauses
Appeal of Denial of Claim. (i) If a claimant’s claim for Benefits is denied, the Claims Administrator shall provide notice to the claimant in writing of the denial within ninety (90) days after its submission. The notice shall be written in a manner calculated to be understood by the claimant and shall include:
a) The specific reason or reasons for the denial;
b) Specific references to the Agreement provisions on which the denial is based;
c) A description of any additional material or information necessary for the applicant to perfect the claim and an explanation of why such material or information is necessary; and
d) An explanation of the Agreement’s claims review procedures and a statement of claimant’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination.
(ii) If special circumstances require an extension of time for processing the initial claim, a written notice of the extension and the reason therefor shall be furnished to the claimant before the end of the initial ninety (90) day period. In no event shall such extension exceed ninety (90) days.
(iii) If a claim for Benefits is denied, the claimant, at the claimant’s sole expense, may appeal the denial to the Chairman of the Board of Directors of the Company (the “Appeals Administrator”) within sixty (60) days of the receipt of written notice of the denial. In pursuing such appeal the applicant or his duly authorized representative:
a) may request in writing that the Appeals Administrator review the denial;
b) may review pertinent documents; and
c) may submit issues and comments in writing.
(iv) The decision on review shall be made within sixty (60) days of receipt of the request for review, unless special circumstances require an extension of time for processing, in which case a decision shall be rendered as soon as possible, but not later than one hundred twenty (120) days after receipt of the request for review. If such an extension of time is required, written notice of the extension shall be furnished to the claimant before the end of the original sixty (60) day period. The decision on review shall be made in writing, shall be written in a manner calculated to be understood by the claimant, and, if the decision on review is a denial of the claim for Benefits, shall include:
a) The specific reason or reasons for the denial;
b) Specific references to the Agreement provisions on which the denial is based;
c) A description of any additional material or information necessary for ...
Appeal of Denial of Claim. (a) If a Claim is denied, in whole or in part, or if a Claim is neither approved nor denied within the period specified in Section 7.2(b) or, if applicable, Section 7.2(c) (i.e., is deemed “denied”), Claimant may appeal the denial to the Committee within 60 days after receipt of such denial (or after such Claim is deemed denied). In pursuing such appeal, Claimant or his or her duly authorized representative:
i. may request in writing that the Committee review the denial;
ii. may receive, upon request and free of charge, reasonable access to documents, records and other information relevant to the Claim for benefits; and
iii. may submit documents, records and comments and other information in writing.
(b) Upon receipt of a request for review from a Claimant, the Committee shall make a full and fair evaluation. The decision on review shall be made by the Committee within 60 days of receipt of the request for review. If the Committee determines that special circumstances require an extension of time for processing the Claim, the Claimant or representative will receive a written notice of the extension before the end of the initial 60-day period. The extension notice shall indicate the special circumstances requiring the extension and the date by which the Plan expects to render the determination on review. The decision on review shall be made in writing, shall be written in a manner calculated to be understood by Xxxxxxxx, and, if the decision on review is a denial of the Claim for benefits, shall include:
i. The specific reason or reasons for the denial;
ii. References to the specific Plan provisions on which the denial is based;
iii. A statement that Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to Claimant’s Claim for benefits; and
iv. A statement of Xxxxxxxx’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination.
(c) For these purposes, a document, record or other information is “relevant” to the Claim if it:
i. was relied upon the Claims Administrator in making a decision on the Claim;
ii. was submitted, considered or generated in the course of the Claims Administrator’s making a decision on the Claim without regard to whether the Claims Administrator relied upon it in making that decision; or
iii. complies with administrative processes and safeguards which are designed to ensure and to verify that ...
Appeal of Denial of Claim. (a) Except as otherwise noted below with respect to the appeal of a denial of a Claim involving a Disability, if a Claim is denied, in whole or in part, or if a Claim is neither approved nor denied within the period specified in Section 7.2(b) or, if applicable, Section 7.2(c) (i.e., is deemed "denied"), Claimant may appeal the denial to the Committee within 60 days (180 days if the Claim relates to Disability status) after receipt of such denial (or after such Claim is deemed denied). In pursuing such appeal, Claimant or his or her duly authorized representative:
i. may request in writing that the Committee review the denial;
ii. may receive, upon request and free of charge, reasonable access to documents, records and other information relevant to the Claim for benefits; and
iii. may submit documents, records and comments and other information in writing.
(b) Upon receipt of a request for review from a Claimant, the Committee shall make a full and fair evaluation. The decision on review shall be made by the Committee within sixty (60) days (forty-five (45) days if the appeal is from a denied Claim as to disability status) of receipt of the request for review. If the Committee determines that special circumstances require an extension of time for processing the Claim, the Claimant or representative will receive a written notice of the extension before the end of the initial sixty (60) or forty-five (45) day period, as applicable. The extension notice shall indicate the special circumstances requiring the extension and the date by which the Plan expects to render the determination on review. The decision on review shall be made in writing, shall be written in a manner calculated to be understood by Xxxxxxxx, and, if the decision on review is a denial of the Claim for benefits, shall include:
i. The specific reason or reasons for the denial;
ii. References to the specific Plan provisions on which the denial is based;
iii. A statement that Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to Claimant's Claim for benefits; and
iv. A statement of Xxxxxxxx's right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination.
(c) For these purposes, a document, record or other information is "relevant" to the Claim if it:
i. was relied upon the Claims Administrator in making a decision on the Claim;
ii. was submitted, conside...