Claim Administration Services Clause Samples
The Claim Administration Services clause defines the responsibilities and procedures for managing and processing claims under an agreement. Typically, this clause outlines which party is responsible for receiving, reviewing, and adjudicating claims, as well as the timelines and documentation required for claim submission and resolution. For example, it may specify that a third-party administrator will handle all claims or that the service provider must maintain records and provide regular status updates. The core function of this clause is to ensure that claims are handled efficiently and transparently, reducing disputes and delays in the claims process.
Claim Administration Services. The Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for benefits reported under each Policy (each, a “Claim” and, collectively, the “Claims”).
Claim Administration Services. The Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for losses reported under a Reinsured Contract (each a “Claim” and collectively the “Claims”). The Administrator shall pay Claims and associated expenses under the Reinsured Contracts to the extent that the Company provides it with funds sufficient to make such payments or the Administrator collects, on behalf of the Company, amounts due under the Ceded Reinsurance Agreements, the Affiliate Reinsurance Agreement or the Reinsurance Agreement; provided that the Administrator may, in its sole discretion, advance its own funds, such advances to be reimbursed from the collection of amounts due the Company under the Ceded Reinsurance Agreements, the Affiliate Reinsurance Agreement or the Reinsurance Agreement. In the event of the insolvency of the Company, the Administrator shall continue to make timely payments of Claims and associated expenses in accordance with the provisions set forth above, except as otherwise required under applicable law in any insolvency proceeding with respect to the Company.
Claim Administration Services. From and after the Inception Date, subject to Section 2.3, the Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for benefits and disbursements reported under each LBL Contract and Vermont Captive Contract (each, a “Claim” and collectively the “Claims”).
Claim Administration Services. From and after the Effective Date, subject to Section 2.3, the Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for benefits and disbursements reported under each Reinsured Contract (each, a “Claim” and collectively the “Claims”).
Claim Administration Services. Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim arising under an Insurance Contract (each, a “Claim” and collectively, the “Claims”). Administrator shall pay from its own funds in accordance with Article XVII all Claims and associated expenses.
Claim Administration Services. From and after the Effective Date, the Administrator shall acknowledge, consider, review, deny, settle, pay or otherwise dispose of each Claim reported under each Administered Contract. Notwithstanding the preceding sentence, the Company retains the final binding and exclusive discretionary authority with regard to the administration and disposition of all Claims.
Claim Administration Services. A. Upon receipt of the submitted claims, Claims Administrator shall perform certain services with respect to the review of Plan claims made by Plan participants including, but not limited to, the following:
1. Obtain appropriate and adequate documentation to make informed determinations regarding submitted claims under the Plan.
2. Review all aspects of the submitted claims including review of all documents and information, medical and otherwise, obtained to review eligibility for benefits and the amount of benefits, if any.
3. Pursuant to Article VII, use the services of third parties, e.g., physicians, rehabilitation experts, investigators, etc. as deemed appropriate by Claims Administrator.
4. Subject to Article III, determine whether the claimant is entitled to benefits under the terms of the Plan and if so, calculate benefit amount and notify Plan Sponsor whether the claim should be accepted or denied.
5. Complete claim determinations within seven (7) days after the receipt by Claims Administrator of all information necessary to make such a determination.
6. Notify claimants in writing as to the decision reached on the claim, the basis for the decision and their right to appeal the decision.
7. Option A – If Plan Sponsor requests Claim Administrator to prepare the W-2, Claim Administrator shall
a. Withhold and report any income taxes withheld and any Social Security and Medicare taxes withheld from each benefit payment. Annually prepare, file and forward to claimant, under Claim Administrator’s taxpayer identification number, any required Form W-2’s reporting benefits paid.
b. Quarterly notify the Plan Sponsor of the amount of Social Security and Medicare taxes withheld from benefits paid. The Plan Sponsor shall be responsible for reporting and paying the employer portion of Social Security and Medicare taxes and for any federal and/or state unemployment taxes on taxable benefits paid. Option B – If Plan Sponsor does not request Claim Administrator to prepare W-2s, Claim Administrator shall
a. Notify the Plan Sponsor of the amount of any taxes withheld from each benefit check. The Plan Sponsor shall be responsible for preparing, filing, and providing to claimants, under the Plan Sponsor’s taxpayer identification number, any required Form W- 2’s reporting benefits paid. Plan Sponsor shall be responsible for reporting and paying the employer portion of Social Security and Medicare taxes and any federal and/or state unemployment taxes on taxable benefits...
Claim Administration Services. Managing Agent shall perform claim administration services as more fully described in Appendix C for all claims incurred under Policies. Managing Agent shall perform claim administration services with the care, skill, prudence, and diligence of a person experienced in the group disability insurance claims administration industry, in accordance with customary group disability insurance claim administration practices and standards, and in compliance with all applicable laws, rules and regulations.
Claim Administration Services. From and after the Effective Date, subject to Section 1.2, the Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for benefits and disbursements reported under each Lincoln VA Contract (each, a “Claim” and collectively the “Claims”).
Claim Administration Services. The Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each claim for benefits reported under each Policy (each, a "Claim" and collectively the "Claims").