If your claim is denied

Notice of adverse benefit determination

Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination:

  • The specific reason or reasons for the adverse benefit determination;
  • Reference to the specific plan provisions on which the determination is based;
  • A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;
  • A description of the plan's review procedures and the time limits applicable, including a statement of a claimant's rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal; and
  • Upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding the claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit.

Process for formal appeals relating to claim denials

A claimant will have 180 days following receipt of an adverse benefit determination to appeal the decision to the same claims administrator. The claimant will be notified of the decision not later than 60 days after the appeal is received by the claims administrator. A claimant may submit written comments, documents, records and other information relating to the claim, whether or not the materials or information was submitted in connection with the initial claim. The claimant may also request that the claims administrator provide, free of charge, copies of all documents, records and relevant information relating to the claim.

An appeal will be reviewed and the decision made by a reviewer not involved in the initial decision — the initial claims determination will not be taken into consideration. Appeals involving medical necessity will be considered by an approved health care professional.

Notice of benefit determination on appeal

Every notice of determination on appeal will be provided in writing or electronically and, if an adverse benefit determination, will include:

  • The specific reason or reasons for the adverse benefit determination;
  • Reference to the specific plan provisions on which the determination is based;
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other relevant information;
  • A statement describing any voluntary appeal procedures offered by the plan and any claimant's right to bring an action under ERISA section 502(a);
  • Upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit; and
  • A statement that you or your plan may have other voluntary alternative dispute resolution options such as mediation and that one way to find out what may be available is to contact your local U.S. Department of Labor office and your State insurance regulatory agency.

The applicable claims administrator’s decision on your appeal is final, conclusive and not subject to further review (unless the claims administrator provides an additional level of voluntary review or voluntary alternative dispute resolution options and the claimant exercises that right). The applicable claims administrator has full and exclusive authority and discretion to grant and deny claims under the plan, including the power to interpret the plan, and to make any related findings of fact. 

If following exhaustion of the plan's appeal procedure, if you still believe that you are entitled to participate in the plan or are entitled to benefits under the plan, you may file a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). You may not file a civil action unless you have exhausted the plan’s claims and appeals procedure.

 

Publication date: April 2021

 

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