Common use of Claims Appeal Clause in Contracts

Claims Appeal. If a claim is denied in whole or in part, the Insured will receive written notification of the decision. An explanation of benefits worksheet will be provided by the Company showing the calculation of the total amount payable, charges not payable, and the reason why they are not payable. An Insured may request a review by filing a written application with the Company who will then review the claim and furnish copies of all documents and all reasons and facts relating to the decision. The Insured may then formally appeal the decision by filing a written request to the Company stating their opinion of the issues and other comments. This appeal must be submitted within 60 days of the receipt of written notice of denial. The Company will issue a decision within 60 days of receipt of the Insured’s written request unless special circumstances require an extension. The decision of the Company shall end the appeal procedure under the Company.