Appeal of Denied Claim. A claimant may appeal the denial of his/her claim and have the Plan Administrator reconsider the decision. The claimant or the claimant’s authorized representative has the right to:
(a) request an appeal by written request to the Plan Administrator not later than sixty (60) days after receipt of notice from the Plan Administrator denying his claim;
(b) review or receive copies, upon request and free of charge, any documents, records or other information “relevant” (within the meaning of Department of Labor Regulation 2560.503-1(m)(8)) to the claimant’s claim; and
(c) submit written comments, documents, records and other information relating to his/her claim. In deciding a claimant’s appeal the Plan Administrator shall take into account all comments, documents, records and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial review of the claim. If the claimant does not provide all the necessary information for the Plan Administrator to decide the appeal, the Plan Administrator may request additional information and set deadlines for the claimant to provide that information. The Plan Administrator will make a decision with respect to such an appeal within sixty (60) days after receiving the written request for such appeal or, in special circumstances, within one-hundred twenty (120) days after receiving the written request for such appeal. The claimant will be advised of the Plan Administrator’s decision on the appeal in writing. The notice will set forth (1) the specific reasons for the decision, (2) specific reference to Plan provisions upon which the decision on the appeal is based, (3) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records or other information relevant to the claimant’s claim, and (4) a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA following a wholly or partially denied claim for benefits. In no event shall a claimant or any other person be entitled to challenge a decision of the Plan Administrator in court or in any other administrative proceeding unless and until the claim and appeal procedures described above have been complied with and exhausted.
Appeal of Denied Claim. Within sixty (60) days (180 days if the claim for benefits is due to a Participant’s Disability) after the receipt by the claimant of a notification of the denial (in whole or in part) of his claim, the claimant, or his duly authorized representative, may make a written application to the Plan Administrator, in person or by certified mail, postage prepaid, to be afforded a review of such denial. Upon such timely-submitted application, the claimant shall be provided a full and fair review of his claim and the adverse benefit determination under which (1) the claimant requesting such review may submit any comments, documents, records and/or other information relating to his claim, and (2) such claimant shall, upon written request, be provided free of charge reasonable access to, and copies of, all documents, records and other information relevant to the claimant’s claim for benefits. Such review will take into account all comments, documents, records and other information submitted by the claimant, without regard to whether such information was submitted or considered in the initial benefit determination. In addition to the above, in the event of a claim due to a Participant’s Disability, the following shall apply with regard to the review of an adverse benefit determination:
(a) Such review will not afford deference to the initial adverse benefit determination and will be conducted by a committee appointed by the Sponsor, which is an appropriate named Fiduciary of the Plan and which shall neither be the individual who made the adverse benefit determination that is the subject of the appeal nor the subordinate of such individual (in the event an individual making the initial adverse benefit determination is a member of the review committee, he shall not participate in the committee’s review of the appeal).
(b) In the case of an appeal of an adverse benefit determination that is based in whole or in part on a medical judgment, the review committee shall consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The healthcare professional engaged for this purpose shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual.
(c) Each claimant will be provided with the identity of the medical or vocational experts whose advice was obtained on...
Appeal of Denied Claim. A claimant may request the Plan Administrator to review a denied claim. Such request shall be in writing and must be delivered to the Plan Administrator within sixty (60) days after receipt by the claimant of written notice of the denial of his or her claim. A claimant or his or her duly authorized representative may:
(a) review pertinent documents, and
(b) submit issues and comments in writing.
Appeal of Denied Claim a. REQUEST FOR REVIEW. If your claim is denied or you have not received a response within the initial or extended 90-day determination period, you may request a review by notice given in writing to the Administrator. Such request must be made within 60 days after your receipt of the written notice of adverse benefit determination, or in the event that you have not received a response with the initial 90-day or extended 90-day period, within 60 days after the expiration of the applicable 90-day period, unless extended by the Administrator for good cause shown.
Appeal of Denied Claim
