Claims and Appeals Procedure Clause Samples

The Claims and Appeals Procedure clause outlines the process by which individuals can submit claims for benefits or dispute decisions made under an agreement, such as an insurance policy or employee benefit plan. Typically, this clause details the steps required to file a claim, the documentation needed, the timeline for review, and the method for appealing denied claims, often including deadlines and contact information for appeals. Its core practical function is to provide a clear, structured method for resolving disputes and ensuring that claimants have a fair opportunity to have their concerns addressed.
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Claims and Appeals Procedure. A. A Claimant shall have the right to submit a claim for benefits under the Plan and to appeal any denial of a claim for benefits. Any request for a Plan benefit or to clarify the Claimant’s rights to future benefits under the terms of the Plan shall be considered to be a claim. (However, this claims procedure does not govern casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of the Plan, nor does it govern a request for a determination regarding eligibility for coverage except such a determination as is requested or necessary in connection with a claim for benefits.) An authorized representative of the Claimant may act on behalf of the Claimant in pursuing a benefit claim or appeal of an Adverse Benefit Determination. The individual or individuals responsible for deciding the benefit claim or appeal, as applicable, may require the representative to provide reasonable written proof that the representative has in fact been authorized to act on behalf of the Claimant. The Plan requires no fee or other cost for the making of a claim or appealing an Adverse Benefit Determination. B. A claim for benefits will be considered as having been made when submitted in writing by the Claimant to the Administrator, in care of: EnPro Industries, Inc. Attn: Senior Vice President — Human Resources (Severance Claim) 5▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇., ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Any claim should include the following: Claimant’s name, address, telephone number, and social security number. Claimant’s dates of employment with the Company. Claimant’s job title and position with Company. The reasons for Claimant’s termination of employment; and A statement of the reasons why Claimant is entitled to severance benefits under the Plan. C. The Administrator will determine whether, or to what extent, the claim may be allowed or denied under the terms of the Plan. If the claim is wholly or partially denied, the Administrator shall notify the Claimant of the Plan’s Adverse Benefit Determination within a reasonable period of time, but not later than 90 days after the Administrator receives the claim, unless the Administrator determines that special circumstances require an extension of time 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. Such extension may not exceed an additional 90 days from...
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Claims and Appeals Procedure. The Company has provided to the Employee a copy of the Claims and Appeals procedures which will be followed under this Agreement and which are incorporated herein by reference.
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Claims and Appeals Procedure. The Trustees shall provide forms necessary to make applications for pension benefits, to designate beneficiaries and to elect the method of payment of Retirement benefits. The Trustees shall pass upon all applications for pension benefits and the supporting evidence required by the Trustees. In the event an application for pension benefit is denied, or modified, the applicant shall be notified of such action of the Trustees in writing, and be given an opportunity to present additional evidence within a reasonable time. Should the Trustees determine that such additional evidence is still insufficient to establish an applicant’s right to pension benefits, he shall be notified in writing and shall be given an opportunity to appear before the Board of Trustees to present any other evidence he deems relevant to the application. The Trustees hereby adopt the claim and appeals process set forth in Department of Labor Regulation 2560.503-1. The Trustees shall full authority to interpret the provisions of this Plan and it is within the sole and absolute discretion of the Trustees to determine if you are entitled to receive a benefit and the amount of the benefit. The decision will be final and binding. a) To appeal the denial of a Plan benefit, a claimant must file a written notice with the Benefit Office within sixty (60) days of the date the denial of a claim was received. A claimant may submit written comments, documents, records, and other information relating to the claim to the Board of Trustees for their review in the appeal. The Board of Trustees will provide free of charge, all documents, records, and other information relevant to the claim for benefits. b) In the event of a discrepancy between the records maintained by the Plan and claims asserted by a Participant, an Employee, a Retiree, or any other person or entity, the Trustees shall rely upon the records established and maintained by the Plan unless shown, to their satisfaction, of which they shall have sole discretion, that said records shall be modified. The burden of proving a claim for benefits which differs from the records established and maintained by the Plan shall be upon the Participant, employer, Retiree, or any other person or entity. c) A claimant may legally authorize someone else to file a request for review and otherwise act for the claimant’s benefit. The claimant and/or representative can review material in the Plan’s files that are related to the claim and submit written comments a...
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Claims and Appeals Procedure. The following shall be the basic claims and appeals procedure for this Plan, however, the Administrative Committee may adopt such additional procedures not inconsistent with the following as it deems appropriate.
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Claims and Appeals Procedure. B. LONG-TERM DISABILITY
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Claims and Appeals Procedure. The Company has provided to Employee a copy of the Claims and Appeals procedures which will be followed under this Agreement and which are incorporated herein by reference.
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Claims and Appeals Procedure 
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Related to Claims and Appeals Procedure

  • Appeals Procedure If Employee appeals to the Administrator, Employee or his authorized representative may submit in writing whatever issues and comments he believes to be pertinent. The Administrator shall reexamine all facts related to the appeal and make a final determination of whether the denial of benefits is justified under the circumstances. The Administrator shall advise Employee in writing of: (1) The Administrator's decision on appeal. (2) The specific reasons for the decision. (3) The specific provisions of the Agreement on which the decision is based. Notice of the Administrator's decision shall be given within 60 days of the Claimant's written request for review, unless additional time is required due to special circumstances. In no event shall the Administrator render a decision on an appeal later than 120 days after receiving a request for a review.

  • Claims and Review Procedure In the event that any claim for benefits that must initially be submitted in writing to the Board of Directors, is denied (in whole or in part) hereunder, the claimant shall receive from First Charter a notice of denial in writing within 60 days, written in a manner calculated to be understood by the claimant, setting forth the specific reasons for denial, with specific reference to pertinent provisions of this Supplemental Agreement. Any disagreements about such interpretations and construction shall be submitted to an arbitrator subject to the rules and procedures established by the American Arbitration Association. The arbitrator shall be acceptable to both First Charter and the Executive (or Beneficiary); if the parties cannot agree on a single arbitrator, the disagreement shall be heard by a panel of three arbitrators, with each party to appoint one arbitrator and the third to be chosen by the other two. No member of the Board of Directors shall be liable to any person for any action taken under Article VIII except those actions undertaken with lack of good faith.

  • Claims Procedure An Executive or Beneficiary (“claimant”) who has not received benefits under this Agreement that he or she believes should be distributed shall make a claim for such benefits as follows:

  • Claim Procedure Any Person entitled to indemnification hereunder shall (i) give prompt written notice to the indemnifying party of any claim with respect to which it seeks indemnification (provided that the failure to give prompt notice shall impair any Person’s right to indemnification hereunder only to the extent such failure has prejudiced the indemnifying party) and (ii) unless in such indemnified party’s reasonable judgment a conflict of interest between such indemnified and indemnifying parties may exist with respect to such claim, permit such indemnifying party to assume the defense of such claim with counsel reasonably satisfactory to the indemnified party. If such defense is assumed, the indemnifying party shall not be subject to any liability for any settlement made by the indemnified party without its consent (but such consent shall not be unreasonably withheld, conditioned or delayed). An indemnifying party who is not entitled to, or elects not to, assume the defense of a claim shall not be obligated to pay the fees and expenses of more than one counsel for all parties indemnified by such indemnifying party with respect to such claim, unless in the reasonable judgment of any indemnified party a conflict of interest may exist between such indemnified party and any other of such indemnified parties with respect to such claim. In such instance, the conflicted indemnified parties shall have a right to retain one separate counsel, chosen by the Holders representing a majority of the Registrable Securities included in the registration if such Holders are indemnified parties, at the expense of the indemnifying party.

  • Claims and Suits (a) The Receiver shall have the right, in its discretion, to (i) defend or settle any claim or suit against the Assuming Bank with respect to which the Receiver has indemnified the Assuming Bank in the same manner and to the same extent as provided in Article XII, and (ii) defend or settle any claim or suit against the Assuming Bank with respect to any Liability Assumed, which claim or suit may result in a loss to the Receiver arising out of or related to this Agreement, or which existed against the Failed Bank on or before Bank Closing. The exercise by the Receiver of any rights under this Section 9.3(a) shall not release the Assuming Bank with respect to any of its obligations under this Agreement. (b) In the event any action at law or in equity shall be instituted by any Person against the Receiver and the Corporation as codefendants with respect to any asset of the Failed Bank retained or acquired pursuant to this Agreement by the Receiver, the Receiver agrees, at the request of the Corporation, to join with the Corporation in a petition to remove the action to the United States District Court for the proper district. The Receiver agrees to institute, with or without joinder of the Corporation as coplaintiff, any action with respect to any such retained or acquired asset or any matter connected therewith whenever notice requiring such action shall be given by the Corporation to the Receiver.