Claims Administration An employee will be required to comply with any and all rules and regulations and/or limitations established by the carrier or applicable third party administrator and contained in the policy, and employees and their dependents shall look solely to such carrier or third party administration for the adjudication of the payment of any and all benefits claims.
Claims Administrator Pursuant to the Preliminary Approval Order, and subject to Court approval, Interim Co- Lead Counsel shall engage a qualified Claims Administrator. The Claims Administrator will assist with the settlement claims process as set forth herein. 1. The Claims Administrator shall effectuate the notice plan approved by the Court in the Preliminary Approval Order, shall administer and calculate the claims, and shall oversee distribution of the Net Settlement Fund in accordance with the Plan of Distribution. 2. The Claims Administrator also shall assist in the development of the Plan of Distribution and the resolution of any disputes regarding the Plan of Distribution.
Plan Administration AvMed may from time to time adopt reasonable policies, procedures, rules and interpretations to promote the orderly and efficient administration of this Contract.
Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
Project Administration Designation Pursuant to Paragraph (B) of Rule 164-1-21 of the Administrative Code, the Recipient shall designate its Chief Executive Officer, Chief Fiscal Officer and Project Manager in Appendix B of this Agreement. Changes in these designations must be made in writing.
Claims and Review Procedure In the event that any claim for benefits that must initially be submitted in writing to the Board of Directors, is denied (in whole or in part) hereunder, the claimant shall receive from First Charter a notice of denial in writing within 60 days, written in a manner calculated to be understood by the claimant, setting forth the specific reasons for denial, with specific reference to pertinent provisions of this Supplemental Agreement. Any disagreements about such interpretations and construction shall be submitted to an arbitrator subject to the rules and procedures established by the American Arbitration Association. The arbitrator shall be acceptable to both First Charter and the Executive (or Beneficiary); if the parties cannot agree on a single arbitrator, the disagreement shall be heard by a panel of three arbitrators, with each party to appoint one arbitrator and the third to be chosen by the other two. No member of the Board of Directors shall be liable to any person for any action taken under Article VIII except those actions undertaken with lack of good faith.
Settlement Administration 5.1. The Settlement Administrator shall, under the supervision of the Court, administer the relief provided by this Settlement Agreement by processing Claim Forms in a rational, responsive, cost effective, and timely manner. The Settlement Administrator shall maintain reasonably detailed records of its activities under this Settlement Agreement. The Settlement Administrator shall maintain all such records as are required by applicable law in accordance with its normal business practices and such records will be made available to Class Counsel and Defendants’ Counsel upon request. The Settlement Administrator shall also provide reports and other information to the Court as the Court may require. The Settlement Administrator shall provide Class Counsel and Defendants’ Counsel with information concerning Notice, administration, and implementation of the Settlement Agreement. Should the Court request, the Parties, in conjunction with the Settlement Administrator, shall submit a timely report to the Court summarizing the work performed by the Settlement Administrator, including a report of all amounts paid to each Settlement Class Member on account of Approved Claims. Without limiting the foregoing, the Settlement Administrator shall: (a) Forward to Defendants’ Counsel, with copies to Class Counsel, all documents and other materials received in connection with the administration of the Settlement Agreement within thirty (30) days after the date on which all Claim Forms have been finally approved or disallowed per the terms of the Settlement Agreement; (b) Receive requests for exclusion and other requests from the Settlement Class and promptly provide a copy of such requests to Class Counsel and Defendants’ Counsel upon receipt (“the Opt-Out List”). If the Settlement Administrator receives any exclusion forms or other requests from the Settlement Class after the Objection/Exclusion Deadline, the Settlement Administrator shall promptly provide copies thereof to Class Counsel and Defendants’ Counsel; (c) Provide weekly reports to Class Counsel and Defendants’ Counsel, including without limitation, reports regarding the number of Claim Forms received, the number determined to be rejected, the number of Approved Claims, and the number of calls to be paid per Settlement Class Member; and (d) Make available for inspection by Class Counsel or Defendants’ Counsel the Claim Forms, any documentation or other evidence submitted in support thereof, and any correspondence received by the Settlement Administrator at any time upon reasonable notice. 5.2. The Settlement Administrator shall employ reasonable procedures to screen claims for abuse or fraud, including without limitation, by cross-referencing the information provided on the Claim Form against the Class List, and by reviewing the evidentiary proof submitted by Settlement Class Members. The Settlement Administrator shall reject a Claim Form, or any part of a claim for a payment reflected therein, where there is evidence of abuse or fraud. The Settlement Administrator shall also reject a Claim Form that does not contain all requested information necessary to screen the claim for fraud or abuse, after giving the claimant a reasonable opportunity of no greater than twenty-one (21) days to provide any requested missing information. The Settlement Administrator shall notify the claimant regarding the missing information via email, telephone call or direct mail, whichever is the most practical based on the information provided in the Claim Form. The validation of all Claim Forms by the Settlement Administrator shall occur no later than fourteen (14) days after the Effective Date and the Settlement Administrator shall give notice of such validation to counsel on that date. 5.3. Defendants and the Class Representatives will have the right to challenge the number of calls received by each Settlement Class Member that are eligible for payment. All challenges will be presented to the Special Master who will make a binding determination as to the number of calls received by each Settlement Class Member entitled to receive payment on account of an Approved Claim. To effectuate such challenge, the party making the challenge must provide email notice to the Settlement Administrator, Special Master and opposing counsel informing them of the claim(s) that party seeks to challenge and the factual basis for that challenge within thirty (30) days of the Settlement Administrator’s validation of all Claim Forms as an Approved Claims determination of the number of calls entitled to a pro rata payment, and notice of the validation. Challenges must be made to individual or designated groups of Claim Forms; so-called “blanket” or “mass” challenges to all Claim Forms without differentiation will not be allowed. 5.4. For Settlement Class Members that submit a Claim Form indicating that they received three (3) calls or fewer, the presumption of three (3) calls can be rebutted by Defendants’ challenges. All other Settlement Class Members will have the ultimate burden if their Claim Form is challenged to demonstrate the number of calls, greater than one (1), that they received. 5.5. In the event of a challenge, the Settlement Administrator shall notify each Settlement Class Member via email, telephone call or direct mail, whichever is the most practical based on the information provided in the Claim Form, that (i) the Settlement Class Member must within thirty (30) days either submit supplemental documentation to prove each call claimed or schedule a telephonic hearing with the Special Master where the Settlement Class Member must testify as to the basis for each separate call claimed, (ii) the Settlement Class Member has the burden of proving the specific number of calls received, and (iii) that the Settlement Class Member will still receive a payment on account of an Approved Claim regardless of the outcome of the challenge. Following the Claims Deadline, but in no event later than one hundred eighty (180) days after Final Judgment, the Special Master will make a determination regarding the claims under challenge, including the number of calls received by the Settlement Class Member (1) based on the information already submitted, and (2) by requiring additional information in the form of (i) either supplemental documentation to prove each call claimed or testimony before the Special Master as to the basis for each separate call claimed. The Special Master’s determination regarding the claims under challenge shall be final and binding on the Parties. If the challenged Settlement Class Member does not timely submit the supplemental documentation or testify before the Special Master, the Special Master shall sustain the Defendants’ challenge and the Settlement Class Member will have an Approved Claim for one (1) call. If the challenged Settlement Class Member does timely submit the supplemental documentation or testify before the Special Master, the Special Master will then, in his sole discretion, make a determination as to the number of calls for which the Settlement Class member can recover. To the extent the Special Master sustains Defendants’ challenge, the Settlement Class member will be permitted to recover for at least one (1) call.
Claims Review Population A description of the Population subject to the Claims Review.
Appeals Procedure If Employee appeals to the Administrator, Employee or his authorized representative may submit in writing whatever issues and comments he believes to be pertinent. The Administrator shall reexamine all facts related to the appeal and make a final determination of whether the denial of benefits is justified under the circumstances. The Administrator shall advise Employee in writing of: (1) The Administrator's decision on appeal. (2) The specific reasons for the decision. (3) The specific provisions of the Agreement on which the decision is based. Notice of the Administrator's decision shall be given within 60 days of the Claimant's written request for review, unless additional time is required due to special circumstances. In no event shall the Administrator render a decision on an appeal later than 120 days after receiving a request for a review.
Certification of the Settlement Class For purposes of this Settlement only, the Parties stipulate to the certification of the Settlement Class, which is contingent upon the Court entering the Final Approval Order and Judgment of this Settlement and the occurrence of the Effective Date.