Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is a Pre-Service or Urgent Care Claim, a Health Professional with knowledge of the Member’s Condition will be permitted to act as the Member’s authorized representative, and will be notified of all approvals on the Member’s behalf.
Claims for Benefits. All claims by the Executive for benefits under this Agreement shall be directed to and determined by the Board and shall be in writing. Any denial by the Board of a claim for benefits under this Agreement shall be delivered to the Executive in writing and shall set forth the specific reasons for the denial and the specific provisions of this Agreement relied upon. The Board shall afford a reasonable opportunity to the Executive for a review of the decision denying a claim and shall further allow the Executive to appeal to the Board a decision of the Board within sixty (60) days after notification by the Board that the Executive’s claim has been denied. In no event shall the Board’s claims or appeals determination be given any deference or weight in any subsequent legal proceeding.
Claims for Benefits. All claims by the Executive for benefits under this Agreement shall be directed to and determined by the Board and shall be in writing. Any denial by the Board of a claim for benefits under this Agreement shall be delivered to the Executive in writing and shall set forth the specific reasons for the denial and the specific provisions of this Agreement relied upon. The Board shall afford a reasonable opportunity to the Executive for a review of the decision denying a claim and shall further allow the Executive to appeal to the Board a decision of the Board within sixty (60) days after notification by the Board that the Executive’s claim has been denied.
Claims for Benefits. (a) Any claim for specific benefits under this Agreement shall be made in writing to the Administrator. If any claim for benefits under this Agreement is wholly or partially denied, notice of the decision shall be furnished to the claimant within a reasonable period of time, not to exceed 90 days after receipt of the claim by the Administrator, unless special circumstances require an extension of time for processing the claim. If such an extension of time is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90-day period. In no event shall such extension exceed the period of 90 days from the end of such initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date on which the administrator expects to render a decision.
(b) The Administrator shall provide every claimant who is denied a claim for benefits written notice setting forth, in a manner calculated to be understood by the claimant, the following:
(1) specific reasons for the denial;
(2) specific reference to pertinent provisions upon which the denial is based; (3) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and (4) an explanation of the Agreement's claims review procedure as set forth below.
(c) The claimant may appeal the denial of his claim to the named fiduciary for a full and fair review. The claimant or his duly authorized representative may request a review upon written application to the Administrator, review pertinent documents, and submit issues and comments in writing. A claimant (or his duly authorized representative) shall request a review by filing a written application for review with the Board or its designee (the "Reviewer") at any time within 60 days after receipt by the claimant of written notice of the denial of his claim.
(d) The decision on review shall be made by the Reviewer, who may, in his discretion, hold a hearing on the denied claim; the Reviewer shall make his decision promptly, and not later than 60 days after the Administrator receives the request for review, unless special circumstances require extension of time for processing, in which case a decision shall be rendered as soon as possible, but not later than 120 days after receipt of the request for review. If such an extension of time for review is required, writt...
Claims for Benefits. Each time we process a Claim submitted by you or your Health Care Provider, we explain how we processed it in the form of an Explanation of Benefits (EOB). The EOB is not a bill. It simply explains how your benefits were applied to that particular Claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the Health Care Provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the Health Care Provider. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is a Pre-Service or Urgent Care Claim, a Health Professional with knowledge of the Member’s Condition will be permitted to act as the Member’s authorized representative, and will be notified of all approvals on the Member’s behalf.
Claims for Benefits. All claims by the Executive for benefits under this Agreement shall be directed to and determined by the Board and shall be in writing. Any denial by the Board of a claim for benefits under this Agreement shall be delivered to the Executive in writing and shall set forth the specific reasons for the denial and the specific provisions of this Agreement relied upon. The Board shall afford a reasonable opportunity to the Executive for a review of the decision denying a claim and shall further allow the Executive to appeal to the Board a decision of the Board within sixty (60) days after notification by the Board that the Executive's claim has been denied. In no event shall the Board’s claims or appeals determination be given any deference or weight in any subsequent legal proceeding. Any further dispute or controversy arising under or in connection with this Agreement shall be settled exclusively by arbitration, paid for by the Company, in Boston, Massachusetts, in accordance with the rules of the American Arbitration Association then in effect; provided, however, that the evidentiary standards set forth in this Agreement shall apply; and further provided that the parties agree that the binding arbitration protocol shall be structured such that a decision will issue not later than ninety (90) days following notice in the event of a dispute concerning Good Reason pursuant to Section 3(b). Judgment may be entered on the arbitrator’s award in any court having jurisdiction. Notwithstanding any provision of this Agreement to the contrary, the Executive shall be entitled to seek specific performance of the Executive’s right to be paid until the Termination Date during the pendency of any dispute or controversy arising under of in connection with this Agreement.
Claims for Benefits. Other than claims for benefits arising in the ordinary course of the administration and operation of the Employee Plans, no claims, investigations or arbitrations are pending or threatened against any Employee Plan or against the Company, any ERISA Affiliate, any trust or arrangement created under or as part of any Employee Plan, any trustee, fiduciary, custodian, administrator or other person or entity holding or controlling assets of any Employee Plan, and no basis to anticipate any such claim or claims exists.
Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received by AvMed. If a Claim is an Urgent Care or Pre-Service Claim, a Health Professional with knowledge of the Member’s Condition shall be permitted to act as the Member’s authorized representative and will be notified of all approvals on the Member’s behalf.
a. Pre-Service Claims.
i. Initial Claim.
1) AvMed shall notify the Claimant of the benefit determination with respect to a Pre-Service Claim not later than 15 days after receipt of the Claim.
2) AvMed may extend this period one time for up to 15 days, if we determine that such an extension is necessary due to matters beyond our control, and we notify the Claimant, before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which we expect to render a decision.
a) If such an extension is necessary because the Claimant failed to submit the information required to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice to provide the specified information.
b) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre- Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed, not later than five days following such failure.
c) XxXxx's period for making the benefit determination shall be tolled from the date the notification of the extension is sent to the Claimant, until the date the Claimant responds to the request for additional information.
3) If the Claimant fails to supply the requested information within the 45-day period, the Claim shall be denied.
Claims for Benefits. A Participant may submit a written claim for benefits under the Plan in accordance with the terms and conditions set forth in this Section 18.
Claims for Benefits. Benefits under the Health Benefits Plan shall be paid in accordance with procedures for the submission of claims for benefits established under that plan.
