Benefit Determinations. The Plan, or a person or entity working on behalf of the Plan, will administer your Benefits and determine your Benefits in accordance with the terms of this Agreement. For Claim Denials, your Explanation of Benefits is your Notice of Adverse Benefit Determination. Other Adverse Benefit Determinations are described in section 2.F.
Benefit Determinations. You will furnish to us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on your instructions and certifications with respect to Participant benefits. You are fully responsible for determining:
(a) whether benefit payments are permitted under applicable law and the Plan and
(b) the existence or amount of Excess Contributions (plus gains or minus losses thereon), or that returns of Excess Contributions are permitted by the Plan and the Code. We may rely on your or your designee's statements or representations in honoring any benefit payment request. [We require that a Participant execute and submit to us an affidavit which we prepare in order that we may process that Participant's benefit payable under this contract if you, the Plan Sponsor, the Plan Trustee, and the Plan Administrator are no longer in existence at the time we receive that Participant's benefit payment request.]
Benefit Determinations. The Participant shall furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on his instructions and certifications with respect to his benefits.
Benefit Determinations. For the purpose of this Addendum, BCBSKC shall have the right to determine the amount of Benefits, if any, payable for any Covered Person. Employer delegates to BCBSKC discretionary authority to construe, interpret and apply the Plan for purposes of processing claims and appeals. BCBSKC, as claims fiduciary, has the full, final, binding and exclusive discretion to construe, interpret and apply the terms of the Plan as may be necessary in order to process claims and make determinations on appeal of claims. BCBSKC shall determine the extent of the benefits (if any) to which any Participant is entitled under the Plan. Decisions by BCBSKC shall be complete, final and binding on all parties. Such determination shall be on the same basis as would be applicable under the Group Contract(s) in the absence of this Addendum. In the event of legal action against BCBSKC, by or on behalf of a Covered Person for Benefits under the Group Contract(s) with respect to a denied claim, BCBSKC, at its own expense, shall undertake the defense of such action and shall pay any judgment rendered therein. BCBSKC shall have the right to settle any such action. The Employer shall reimburse BCBSKC for the portion of any such judgment or settlement which is for a Paid Claim under the Group Contract(s), and such Paid Claim shall be administered in accordance with the terms of this Addendum, including Articles 1 and 3.
Benefit Determinations. You must furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on your instructions and certifications with respect to your benefits. You are fully responsible for determining the existence or amount of Excess Contributions (plus gains or minus losses thereon), or that returns of Excess Contributions are permitted by the Code. We may rely on your statements or representations in honoring any benefit payment request.
Benefit Determinations. You will furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on your instructions and certifications with respect to Participant benefits. You are fully responsible for determining:
(a) whether benefit payments are permitted under applicable law and the Plan and
(b) the existence or amount of Excess Contributions (plus gains or minus losses thereon), or that returns of Excess Contributions are permitted by the Plan and the Code. We may rely on your or your designee's statements or representations in honoring any benefit payment request.
Benefit Determinations. The Contractholder must furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on the Contractholder's instructions and certifications with respect to your benefits. The Contractholder is fully responsible for determining:
(a) whether benefit payments are permitted under applicable law and the Plan and
(b) the existence or amount of Excess Contributions (plus gains or minus losses thereon), or that returns of Excess Contributions are permitted by the Plan and the Code. We may rely on the Contractholder's or its designee's statements or representations in honoring any benefit payment request.
Benefit Determinations. The Contractholder will furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on the Contractholder's instructions and certifications with respect to your benefits. The Contractholder is fully responsible for determining:
(a) whether benefit payments are permitted under applicable law and the Plan and
(b) the existence or amount of Excess Contributions (plus gains or minus losses thereon), or that returns of Excess Contributions are permitted by the Plan and the Code. We may rely on the Contractholder's or its designee's statements or representations in honoring any benefit payment request. [We require that you execute and submit to us an affidavit which we prepare in order that we may process your benefit payable under the Contract if the Contractholder, the Plan Sponsor, the Plan Trustee, and the Plan Administrator are no longer in existence at the time we receive your benefit payment request.]
Benefit Determinations. An application for the benefits of Section 207-c of the General Municipal Law shall be processed in the following manner:
(a) The Sheriff shall receive the application for the benefits and make a recommendation to the Clerk of the Board of Supervisors/Self-Insurance Administrator (hereinafter "Self Insurance Administrator") as to whether the applicant is entitled to 207-c benefits pursuant to Section 207-c of the General Municipal Law and this procedure. The Self Insurance Administrator shall promptly review the Sheriff's recommendation and the application, as well as any other pertinent documents or evidence available. Should the Self Insurance Administrator determine that the officer was injured in the performance of duty or that the officer was taken sick as a result of the performance of duty so as to necessitate medical or other lawful treatment, the Self Insurance Administrator shall, pursuant to Section 207-c, direct payment of the full amount of the regular salary or wages until the disability arising therefrom has ceased and shall insure that the County, through the health insurance provided to the officer, will be responsible for the cost of medical or other lawful treatment and for any hospital care associated with such injury or illness. (It is understood that any amounts not otherwise covered by the health insurance carrier will be paid or reimbursed, as necessary, by the County.) A written notice of such determination by the Self Insurance Administrator shall be provided to the officer, placed in the officer's personnel file and provided to the County Treasurer.
(b) The payment of full salary or wages may be discontinued as expressly provided by Section 207-c. Any review of eligibility for the continuation of benefits may only occur after an assessment of the medical condition of an officer or other information raises a question as to whether a disability may have ceased or whether the extent of a disability may have diminished so as to permit a light duty assignment, as the case may be.
(c) In the event a question arises as to either initial eligibility for benefits or the continuation of benefits once awarded, the following procedure shall apply:
(i) The Sheriff or the Sheriff's designee, and/or the Self Insurance Administrator shall promptly inquire into the fact(s) surrounding the matter at issue. An officer may be required to submit to one or more medical examinations as may be necessary to determine the existence of a disability or illn...
Benefit Determinations. NYLCare Mid-Atlantic retains authority and responsibility, after appropriate consultation with Doctors Health, to make all final benefit determinations. All communication to Enrollees regarding benefit determinations, bills, and other matters relating to NYLCare Mid-Atlantic shall be made by NYLCare Mid-Atlantic. All benefit determinations and communications with Enrollees shall be made by NYLCare Mid-Atlantic in a timely fashion.
