Common use of Review of Claims Clause in Contracts

Review of Claims. 1. The Participant or any other person who believes that he or she is entitled to receive benefits under the Agreement may make a written request for such benefits to the Administrator, which for this purpose and for this purpose only shall be the "named fiduciary" of the Agreement within the meaning of Section 503 of ERISA. 2. Once a request for benefits has been made, the Administrator shall review the claim for benefits. If the claim is wholly or partially denied, notice of the decision shall be furnished to the claimant within ninety (90) days after receipt of the claim, unless special circumstances require an extension of up to an additional ninety (90) days for processing the claim. If such an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90-day period. This notice shall indicate the circumstances requiring the extension of time and the date by which the Administrator expects to render the final decision. In the event that no notice of the denial of a claim is furnished to the claimant under this subsection, the claim shall be deemed denied and the claimant may request review under subsection 4 below. 3. If a claim is denied in whole or in part, notice of the decision provided to the claimant shall contain: (i) the specific reason or reasons for the denial; (ii) specific reference to relevant provisions of the Agreement on which the denial is based; (iii) a description of any additional material or information necessary for the claimant to perfect the claim together with an explanation of why such material or information is necessary; and (iv) appropriate information as to the steps to be taken if the claimant wishes to submit his or her claim for review. 4. The Participant or any other person who has had a claim denied under this Section shall be entitled to request the Administrator to give further consideration to his or her claim by filing with the Administrator a written request for review. This request must contain a written statement of the reasons why the claimant believes his or her claim should be allowed. Any request for review must be filed with the Administrator no later than sixty (60) days after receipt of the notice of denial of the claim. a. The request for review shall be in writing and shall include specific reasons for the decision, as well as specific references to the pertinent Agreement provisions on which the decision is based. b. Once a request for review has been made under this subsection, the Administrator shall conduct a hearing to review the claim within the next sixty (60) days, unless special circumstances require an extension of the time for processing, in which case a decision shall be rendered no later than one hundred twenty (120) days after receipt of a request for review. If an extension of time for review is required because of special circumstances, written notice of the extension shall be furnished to the claimant prior to the commencement of the extension. If the decision on review is not furnished to the claimant within the sixty (60) day period (or the 120-day period if an extension of time is required because of special circumstances), the claim shall be deemed denied on review.

Review of Claims. 1. The Participant Plan Administrator shall provide a claimant with written or any other person who believes that he or she is entitled to receive benefits under the Agreement may make a written request for such benefits to the Administrator, which for this purpose and for this purpose only shall be the "named fiduciary" electronic notification of the Agreement within Plan's benefit determination. Any electronic notification shall comply with the meaning of Section 503 of ERISA.standards imposed by 29 CFR 2560.503- 2. Once a request for benefits has been made, the Administrator shall review the claim for benefits. If the claim is wholly or partially denied, notice of the decision shall be furnished to the claimant within ninety (90) days after receipt of the claim, unless special circumstances require an extension of up to an additional ninety (90) days for processing the claim. If such an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90-day period. This notice shall indicate the circumstances requiring the extension of time and the date by which the Administrator expects to render the final decision1. In the event that no notice case of an adverse benefit determination, the denial of notification shall be set forth, in a claim is furnished manner calculated to be understood by the claimant under this subsection, the claim shall be deemed denied and the claimant may request review under subsection 4 below.include: 3. If a claim is denied in whole or in part, notice of the decision provided to the claimant shall contain: (ia) the The specific reason or reasons for the denial; adverse determination; (iib) Reference to the specific reference to relevant Plan provisions of the Agreement on which the denial benefit determination is based; ; (iiic) a A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits; (d) A description of any additional material or information necessary for the claimant to perfect the claim together with and an explanation of why such material or information is necessary; ; (e) An explanation that a full and (iv) appropriate information as to fair review by the steps to Plan Administrator of the decision denying the claim may be taken if requested by the claimant wishes to submit or his or her claim for review. 4. The Participant or any other person who has had a claim denied under this Section shall be entitled to request the Administrator to give further consideration to his or her claim authorized representative by filing with the Administrator Plan Administrator, within 180 days after such notice of denial has been received, a written request for such review. This request must contain a written ; (f) A statement describing any voluntary appeal procedures offered by the Plan and the claimant's right to obtain the information about such procedures; (g) A statement of the reasons why claimant's right to bring an action under section 502(a) of ERISA if his claim is denied upon appeal. The decision of the claimant believes his or her claim should Plan Administrator on review shall be allowed. Any request for review must be filed with the Administrator no made promptly, but not later than sixty (60) 60 days after the Plan Administrator's receipt of the notice of denial of the claim. a. The request for review shall be in writing and shall include specific reasons for the decision, as well as specific references to the pertinent Agreement provisions on which the decision is based. b. Once a request for review has been made under this subsection, the Administrator shall conduct a hearing to review the claim within the next sixty (60) daysreview, unless special circumstances require an extension of the time for processing, in which case a decision shall be rendered no as soon as possible, but not later than one hundred twenty (120) 120 days after receipt of a the request for review. If an extension of time for review is required because of special circumstances, written notice of the extension shall be furnished to the claimant prior to the commencement of the extension. If the The decision on review is not furnished shall be made in writing. A denial on review shall include specific reasons for the denial, written in a manner calculated to be understood by the claimant, and shall include specific references to the claimant within pertinent Plan provisions on which the sixty denial is based. The review decision of the Plan Administrator shall be made in the sole discretion of the Plan Administrator, and the Plan Administrator shall be charged with the sole responsibility for interpretation of the Plan. Adverse benefit determinations and denials on review of claims under the Medical Expense Reimbursement Account shall include the following information: (60i) day period If an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination (or the 120-day period if an extension of time is required because of special circumstancescollectively, “guideline”), either a copy of the claim shall guideline or a statement that the guideline was relied on in making the adverse determination and that a copy will be deemed denied provided free of charge upon request; (ii) If the adverse benefit determination is based on reviewa 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 free of charge upon request.

Review of Claims. 1. The Participant Plan Administrator shall provide a claimant with written or any other person who believes that he or she is entitled to receive benefits under the Agreement may make a written request for such benefits to the Administrator, which for this purpose and for this purpose only shall be the "named fiduciary" electronic notification of the Agreement within Plan's benefit determination. Any electronic notification shall comply with the meaning of Section 503 of ERISA. 2. Once a request for benefits has been made, the Administrator shall review the claim for benefits. If the claim is wholly or partially denied, notice of the decision shall be furnished to the claimant within ninety (90) days after receipt of the claim, unless special circumstances require an extension of up to an additional ninety (90) days for processing the claim. If such an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90standards imposed by 29 CFR 2560.503-day period. This notice shall indicate the circumstances requiring the extension of time and the date by which the Administrator expects to render the final decision1. In the event that no notice case of an adverse benefit determination, the denial of notification shall be set forth, in a claim is furnished manner calculated to be understood by the claimant under this subsection, the claim shall be deemed denied and the claimant may request review under subsection 4 below.include: 3. If a claim is denied in whole or in part, notice of the decision provided to the claimant shall contain: (ia) the The specific reason or reasons for the denial; adverse determination; (iib) Reference to the specific reference to relevant Plan provisions of the Agreement on which the denial benefit determination is based; ; (iiic) a A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits; (d) A description of any additional material or information necessary for the claimant to perfect the claim together with and an explanation of why such material or information is necessary; ; (e) An explanation that a full and (iv) appropriate information as to fair review by the steps to Plan Administrator of the decision denying the claim may be taken if requested by the claimant wishes to submit or his or her claim for review. 4. The Participant or any other person who has had a claim denied under this Section shall be entitled to request the Administrator to give further consideration to his or her claim authorized representative by filing with the Administrator Plan Administrator, within 180 days after such notice of denial has been received, a written request for such review. This request must contain a written ; (f) A statement describing any voluntary appeal procedures offered by the Plan and the claimant's right to obtain the information about such procedures; (g) A statement of the reasons why claimant's right to bring an action under section 502(a) of ERISA if his claim is denied upon appeal. The decision of the claimant believes his or her claim should Plan Administrator on review shall be allowed. Any request for review must be filed with the Administrator no made promptly, but not later than sixty (60) 60 days after the Plan Administrator's receipt of the notice of denial of the claim. a. The request for review shall be in writing and shall include specific reasons for the decision, as well as specific references to the pertinent Agreement provisions on which the decision is based. b. Once a request for review has been made under this subsection, the Administrator shall conduct a hearing to review the claim within the next sixty (60) daysreview, unless special circumstances require an extension of the time for processing, in which case a decision shall be rendered no as soon as possible, but not later than one hundred twenty (120) 120 days after receipt of a the request for review. If an extension of time for review is required because of special circumstances, written notice of the extension shall be furnished to the claimant prior to the commencement of the extension. If the The decision on review is not furnished shall be made in writing. A denial on review shall include specific reasons for the denial, written in a manner calculated to be understood by the claimant, and shall include specific references to the claimant within pertinent Plan provisions on which the sixty denial is based. The review decision of the Plan Administrator shall be made in the sole discretion of the Plan Administrator, and the Plan Administrator shall be charged with the sole responsibility for interpretation of the Plan. Adverse benefit determinations and denials on review of claims under the Medical Expense Reimbursement Account shall include the following information: (60i) day period If an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination (or the 120-day period if an extension of time is required because of special circumstancescollectively, “guideline”), either a copy of the claim shall guideline or a statement that the guideline was relied on in making the adverse determination and that a copy will be deemed denied provided free of charge upon request; (ii) If the adverse benefit determination is based on reviewa 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 free of charge upon request.