Benefit Denials Sample Clauses

Benefit Denials. The Administrator is responsible for evaluating all claims for reimbursement under the Medical Expense Reimbursement Plan and the Group Medical Insurance Plan. The Administrator will decide a Participant’s claim within a reasonable time not longer than 30 days after it is received. This time period may be extended for an additional 15 days for matters beyond the control of the Administrator, including in cases where a claim is incomplete. The Participant will receive written notice of any extension, including the reasons for the extension and information on the date by which a decision by the Administrator is expected to be made. The Participant will be given 45 days in which to complete an incomplete claim. The Administrator may secure independent medical or other advice and require such other evidence as it deems necessary to decide the claim. If the Administrator denies the claim, in whole or in part, the Participant will be furnished with a written notice of adverse benefit determination setting forth: 1. the specific reason or reasons for the denial; 2. reference to the specific Plan provision on which the denial is issued; 3. a description of any additional material or information necessary for the Participant to complete his claim and an explanation of why such material or information is necessary, and
Sample 1Sample 2Sample 3See All (6)
AutoNDA by SimpleDocs

Related to Benefit Denials

  • Disability Benefits Technology Errors and Omissions Not less than $1,000,000 each claim Not less than $2,000,000 in aggregate At the time of the first transaction with an Authorized User and updated in accordance with Contract Crime Insurance Not less than $50,000 Commercial General Liability Not less than $5,000,000 each occurrence Updated in accordance with Contract General Aggregate $2,000,000 Products – Completed Operations Aggregate $2,000,000 Personal and Advertising Injury $1,000,000 Business Automobile Liability Insurance Not less than $5,000,000 each occurrence

  • Denials A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not medically necessary, a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing a medical appeal.

  • Application for Benefits Requests for short-term leaves shall be in writing, upon the appropriate form prescribed and provided by the District, and shall be filed with the unit member's supervisor and the appropriate manager five (5) days in advance of the intended leave (except in emergency situations), unless otherwise stated by the provisions of the specific leave.

  • Denial If NB denies the Applicant, NB shall furnish a written statement stating its reasons. The Applicant shall have the opportunity to discuss the decision with the Director of Social Services. The Applicant has the right to an administrative fair hearing. If NB denies an Applicant based in part on an indicated child abuse or maltreatment report, the Applicant has a right to a fair hearing regarding the report. The request must be made within 90 days of receiving the written denial notice. (See Disclosures, page 10.)

  • Claims for Benefits All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is a Pre-Service or Urgent Care Claim, a Health Professional with knowledge of the Member’s Condition will be permitted to act as the Member’s authorized representative, and will be notified of all approvals on the Member’s behalf.

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

  • Disability Benefit If the Executive terminates employment due to Disability prior to Normal Retirement Age, the Company shall pay to the Executive the benefit described in this Section 2.3 in lieu of any other benefit under this Agreement.

  • Retirement Benefits Due to either investment or employment during the marriage, either the Husband or Wife: (check one)

  • Survivor Benefits 1. A surviving dependent of a retiree who was eligible to receive a Retiree Medical Grant, as stated above in A through C, and who qualifies for a monthly allowance shall be eligible for fifty (50) percent of the Grant authorized for the retiree. 2. A surviving eligible retiree who qualifies for a monthly retirement allowance who was married to a retiree who was also eligible for a Grant shall receive the survivor benefit described in D.1., above, or his or her own Grant, whichever is greater. Such retiree shall not be eligible for both Grants.

  • Early Retirement Benefits If elected in the Adoption Agreement, an Early Retirement benefit may be available to individuals who meet the age and Service requirements that are specified in the Adoption Agreement. A Participant who attains his or her Early Retirement Date will become fully vested, regardless of any vesting schedule which otherwise might apply. If a Participant separates from Service with a nonforfeitable benefit before satisfying the age requirements, but after having satisfied the Service requirement, the Participant will be entitled to elect an Early Retirement benefit upon satisfaction of the age requirement.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!