Common use of Review of Appeal Clause in Contracts

Review of Appeal. The Administrator will review and decide the Participant’s appeal within a reasonable time not longer than 60 days after it is submitted and will notify the Participant of its decision in writing. The individual who decides the appeal will not be the same individual who decided the initial claim denial and will not be that individual’s subordinate. The Administrator may secure independent medical or other advice and require such other evidence as it deems necessary to decide the appeal, except that any medical expert consulted in connection with the appeal will be different from any expert consulted in connection with the initial claim. (The identity of a medical expert consulted in connection with the Participant’s appeal will be provided.) If the decision on appeal affirms the initial denial of the Participant’s claim, the Participant will be furnished with a notice of adverse benefit determination on review setting forth: 1. The specific reason(s) for the denial, 2. The specific Plan provision(s) on which the decision is based, 3. A statement of the Participant’s right to review (on request and at no charge) relevant documents and other information, 4. If the Administrator relied on an “internal rule, guideline, protocol, or other similar criterion” in making the decision, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the Participant upon request,” and 5. A statement of the Participant’s right to bring suit under ERISA § 502(a).