Common use of Content of Notice Clause in Contracts

Content of Notice. The Administrator’s written or electronic notification of any adverse benefit determination must contain the following information: (1) The specific reason or reasons for the adverse determination. (2) Reference to the specific Plan provisions on which the denial is based. (3) A description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary. (4) Appropriate information as to the steps to be taken if the Claimant or beneficiary wishes to submit the claim for review. (5) In the case of disability benefits where the disability is determined by a physician chosen by the Administrator: (i) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge upon request. (ii) If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant’s medical circumstances, or a statement that such explanation will be provided to the Claimant free of charge upon request. If the claim has been denied or deemed denied, and the Claimant wants to submit the claim for review, the Claimant must follow the Claims Review Procedure below.