Common use of Benefit Denials Clause in Contracts

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