Claims and Appeals Involving a Determination of Disability or Temporary Disability. As set out fully in the Active Plan Document, claims which require a determination of Disability or Temporary Disability will be ruled on within 45 days after receipt of a completed application. In some cases, additional time may be needed, up to another 30 days. The Administrator or the Claims Committee may extend the time to resolve the claim for only two (2) additional 30 day periods. The denial of a claim or part of a claim will be provided in writing, in a culturally and linguistically appropriate manner, and will include the specific reason(s) for the denial; a reference to pertinent Plan provisions, specific internal rules, guidelines, protocols, standards or other similar criteria; an explanation of the basis for disagreeing with or not following the opinion of the Employee; a description of any additional information necessary to perfect the claim; and an explanation of the steps to be taken if the Employee wishes to appeal the denial. An Employee (or his authorized representative) may appeal any denial by filing a written request for review. The written appeal must be filed with the Administrator within 180 days from the date of receipt of the written denial. Use of the Plan’s Appeal Procedure is mandatory. An Employee may submit in writing issues, comments and evidence for consideration by the reviewing party. An Employee may request copies of all documents, records, and other information relied on by the Administrator or the Claims Committee in making the adverse determination including any internal rule, guideline, protocol or other criteria. There is no charge to the Employee for these copies. The Employee may also supply additional medical or other information in support of his claim. If, in considering an appeal, the Trustees or the Claims Committee become aware of any new or additional evidence that was considered, relied upon, or generated by the Administrator or the Claims Committee in making the adverse determination or any new or additional rationale for making the adverse determination, copies of such new or additional evidence or rationale will be provided to the Employee, as soon as possible. The Employee will then have 30 days after receiving such new or additional evidence or rationale to submit a written response to the Trustees or the Claims Committee.
Claims and Appeals Involving a Determination of Disability or Temporary Disability
