CLAIM AND APPEAL PROVISIONS. The Company will initially determine if a claim is to be allowed or denied (adverse benefit determination). The Company shall retain final discretionary authority for all benefit determinations and questions of Policy interpretation subject to the Insured’s right to an external review by the Director of Insurance and /or a registered Independent Review Organization. This provision applies only where the interpretation of this Policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq. The Company or the Third Party Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Company reserves the right to have an Insured seek a second medical opinion. Following is a description of how the Company processes Claims for benefits. A Claim is defined as any request for a benefit, made by a claimant or by a representative of a claimant, that complies with the Company's reasonable procedure for making benefit Claims. The times listed are maximum times only. A period of time begins at the time the Claim is filed. Decisions will be made within a reasonable period of time appropriate to the circumstances. "Days" means calendar days. There are different kinds of Claims and each one has a specific timetable for either approval, payment, request for further information, or denial of the Claim. If you have any questions regarding this procedure, please contact the Third Party Administrator. The definitions of the types of Claims are: Urgent Care Claim A Claim involving Urgent Care is any Claim for medical care or treatment where using the timetable for a non- urgent care determination could seriously jeopardize the life or health of the claimant; or the ability of the claimant to regain maximum function; or in the opinion of the attending or consulting Physician, would subject the claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim. A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent Care. If there is no such Physician, an individual acting on behalf of the Company applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine may make the determination. In the case of a Claim involving Urgent Care, the following timetable applies: Notification to ...
CLAIM AND APPEAL PROVISIONS. This section outlines the procedures for and the time periods applicable to Claim and Appeal determination decisions for Adverse Decisions. It is the policy of the Company to afford Insureds a full and fair review of Claim decisions and Appeal decisions as described in this contract. However, an Insured's rights accrued hereunder or under applicable state or federal law (including but not limited to ERISA) are not assignable to any person or entity. Authorized Representatives may be designated as provided in section A below.
