Disability Claims Procedure. 7.3.1 Each person having or claiming an interest in this Agreement shall have the right to submit a claim with respect to a benefit under this Section 7.3 if the benefit is Disability-related or under Section 7.1 if not Disability-related. Such claim shall be in writing addressed to the Bank and shall be delivered personally or by certified or registered mail, return receipt requested. The claim shall state with particularity:
(a) the benefit claimed;
(b) the provisions of the Agreement upon which the claimant relies in support of his claim; and
(c) all facts believed to be relevant in connection with such claim.
7.3.2 In the event that the decision amounts to a denial of the claim in whole or in part, such decision shall be in writing, written in a culturally and linguistically appropriate manner, addressed to the claimant and shall be delivered personally or by certified or registered mail, return receipt requested, setting forth the following:
(a) the reason or reasons for rejection of the claim;
(b) the particular provisions of the Agreement relied upon in reaching such adverse benefit determination and including specific internal rules, guidelines, protocols, standards or other similar criteria of the Agreement relied upon in making the adverse benefit determination;
(c) a description of any additional information needed from the claimant to perfect such claim and the reason as to why such additional information is needed;
(d) a statement outlining the review procedure available hereunder; and
(e) a discussion of the decision, including an explanation of the basis for disagreeing with or not following:
(i) the views presented by the claimant to the Bank of health care professionals treating the claimant and vocational professionals who evaluated the claimant;
(ii) the view of medical or vocational experts whose advice was obtained on behalf of the Bank in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and
(iii) a disability determination regarding the claimant presented by the claimant to the Bank and made by the Social Security Administration. The decision will include a statement as to whether or not an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination, and if so relied upon, either the specific rule, guideline, protocol, or other similar criterion shall be provided to the cla...
Disability Claims Procedure. Notwithstanding Sections 10-11, if a claim for benefits involves a determination as to whether a Participant suffered a Disability, the procedures of this Section 10 will apply. Any reference to the claimant includes the claimant’s authorized representative. If the claimant’s claim is denied in whole or in part, the HR Representative will notify the claimant within a reasonable period of time, but not later than forty-five (45) days after the HR Representative receives the claim. The forty-five (45) day period will begin to run once a claim is filed, without regard to whether the claimant has provided all the information necessary to make the benefit determination. If the HR Representative determines that an extension is needed for reasons beyond the HR Representative’s control, it may take up to two thirty (30) day extensions for consideration of the claim. If the HR Representative takes an extension, he or she will notify the claimant in writing of the reason for the extension and the date by which a decision is expected before the end of the initial forty-five (45) day period (or, for a second extension, before the end of the first extension). The notice of extension will include an explanation of the standards on which the entitlement to the benefit claimed is based, the unresolved issues that are preventing a decision, and the additional information needed to resolve the issues. If the HR Representative requests additional information, the claimant will have at least forty-five (45) days after receipt of the notice of extension to provide the information. The period during which the HR Representative waits for the claimant to respond to the request for information will not count against the thirty (30) day extension period (i.e. the thirty (30) day extension period will be tolled from the date the notice of extension is sent to the claimant to the date on which the claimant responds to the request for additional information). The HR Representative’s notice of denial will explain the reason for the denial, refer to the specific Plan provisions on which the denial is based describe any additional information or material needed from the claimant to perfect his or her claim and why this information or material is necessary, and describe the Plan’s claims review procedures and time limits. Additionally, if the HR Representative relies on an internal rule, guideline, or protocol in denying the claim, it will either provide a copy of the rule, guideline or p...
Disability Claims Procedure. 6.3.1 Each person having or claiming an interest in this Agreement shall have the right to submit a claim with respect to a benefit under this Section 6.3 if the benefit is Disability-related or under Section 6.1 if not Disability-related. Such claim shall be in writing addressed to the Bank and shall be delivered personally or by certified or registered mail, return receipt requested. The claim shall state with particularity:
6.3.1.1 the benefit claimed;
6.3.1.2 the provisions of the Agreement upon which the claimant relies in support of his claim; and
6.3.1.3 all facts believed to be relevant in connection with such claim. Within forty-five (45) days from the receipt of the claim, a decision on the merits thereof shall be reached and communicated to the claimant. An extension of up to thirty (30) days beyond the initial 45-day period may be made if the Bank determines that such extension of time is required. Failure to so notify the claimant shall be deemed to be a denial of the claim.
6.3.2 In the event that the decision amounts to a denial of the claim in whole or in part, such decision shall be in writing, written in a culturally and linguistically appropriate manner, addressed to the claimant and shall be delivered personally or by certified or registered mail, return receipt requested, setting forth the following:
6.3.2.1 the reason or reasons for rejection of the claim;
6.3.2.2 the particular provisions of the Agreement relied upon in reaching such adverse benefit determination and including specific internal rules, guidelines, protocols, standards or other similar criteria of the Agreement relied upon in making the adverse benefit determination;
6.3.2.3 a description of any additional information needed from the claimant to perfect such claim and the reasons as to why such additional information is needed;
6.3.2.4 a statement outlining the review procedure available hereunder; and
6.3.2.5 a discussion of the decision, including an explanation of the basis for disagreeing with or not following:
(i) the views presented by the claimant to the Bank of health care professionals treating the claimant and vocational professionals who evaluated the claimant;
(ii) the views of medical or vocational experts whose advice was obtained on behalf of the Agreement in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and
(iii) a disability determination regarding t...
Disability Claims Procedure. Notwithstanding anything herein to the contrary, with respect to a claim for benefits under this Agreement based on Disability (other than approval for payment of benefits, directly or indirectly, under any long-term disability plan maintained by the Company), the Claims Manager shall furnish to the claimant written notice of the disposition of a claim within 45 days after the application therefore is submitted; provided, if matters beyond the control of the Claims Manager require an extension of time for processing the claim, the Claims Manager shall furnish written notice of the extension to the claimant prior to the end of the initial 45-day period; and, provided further, if matters beyond the control of the Claims Manager require an additional extension of time for processing the claim, the Claims Manager shall furnish written notice of the second extension to the claimant prior to the end of the initial 30-day extension period, and such extension shall not exceed an additional, consecutive 30-day period. Notice of any extension under this Section 12(c)(i) shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues. In the event the claim is denied, the notice of the disposition of the claim shall provide the specific reasons for the denial, citations of the pertinent provisions of this Agreement, explanation as to how the claimant can perfect the claim and/or submit the claim for review (where appropriate), and a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA following an adverse determination on review.
