Common use of Claims and Appeals Clause in Contracts

Claims and Appeals. If any part of an application for benefits under the Plan is denied, the following claim procedure applies: (a) The Administrator(s) shall act upon each application for benefits within ninety (90) days after receipt of the application. If special circumstances require an extension of time, such Administrator(s) shall notify the applicant of the delay and shall act within one hundred eighty (180) days after receipt of the application. The Administrator(s) shall also explain the reason for the delay and indicate the date on which a decision may be expected. If the Administrator(s) does not act on an application for benefits within ninety (90) days (or one hundred eighty (180) days, if applicable), the application will be deemed to have been denied. (b) If a claim is denied in whole or in part, the applicant shall be notified in writing of the following information: (1) the specific reasons for such denial; (2) specific reference to pertinent Plan provisions on 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 Plan's claim review procedure. (c) The applicant may appeal by delivering a written notice to the Administrator(s) within sixty (60) days after receiving notice of denial from the Administrator(s) or, if no notice of denial was received, within one hundred fifty (150) days (or two hundred forty (240) days, if applicable) after the claim was filed. The applicant's notice of appeal should: (1) request a review of his application for benefits by the Administrator(s); (2) set forth all of the grounds upon which his request for review is based and any facts in support; and (3) set forth any issues or comments which the applicant deems pertinent to his application. If he appeals, the applicant may review pertinent documents at any reasonable time and place specified by the Administrator(s) and may submit any additional written materials pertinent to the appeal not set forth in the notice of appeal. (d) Any appeal will be reviewed by the Administrator(s). The applicant, who may be represented by any person, will be entitled to appear before the Administrator(s) to present his claim. The Administrator(s) will decide the appeal not later than sixty (60) days after receiving the notice of appeal. If special circumstances require an extension of time, a decision will be made as soon as possible, but not later than one hundred twenty (120) days after receipt of the notice of appeal. The Administrator(s) shall also explain the reason for the delay and indicate the date on which a decision may be expected. The decision of the Administrator(s) will be in writing and will state clearly the reasons for the decision, including specific reference to the provisions of the Plan supporting the decision. The decision of the Administrator(s) on any and all appeals shall be final and conclusive upon all applicants.

Claims and Appeals. If any part of an application Participants may submit claims for benefits by giving notice to the Company pursuant to Section 9 of this Policy. If a Participant believes that he or she has not received coverage or benefits to which he or she is entitled under the Plan is deniedPolicy, the following claim procedure applies: (a) The Administrator(s) shall act upon each application for benefits within ninety (90) days after receipt of the application. If special circumstances require an extension of time, such Administrator(s) shall Participant may notify the applicant Board in writing of the delay and shall act within one hundred eighty (180) days after receipt of the application. The Administrator(s) shall also explain the reason a claim for the delay and indicate the date on which a decision may be expectedcoverage or benefits. If the Administrator(s) does not act on an application claim for coverage or benefits within ninety (90) days (or one hundred eighty (180) days, if applicable), the application will be deemed to have been denied. (b) If a claim is denied in whole or in part, the Board shall notify the applicant shall be notified in writing of the following information: such denial within thirty (130) days (which may be extended to sixty (60) days under special circumstances), with such notice setting forth: (i) the specific reasons for such the denial; (2ii) specific reference to pertinent Plan the Policy provisions on upon which the denial is based; (3iii) a description of any additional material or information necessary for the claimant applicant to perfect the claim and an explanation of why such material his or information is necessaryher claim; and (4iv) an explanation the procedures for requesting a review of the Plan's denial. Upon a denial of a claim by the Board, the Participant may: (i) request a review procedure. of the denial by the Board or, where review authority has been so delegated, by such other person or entity as may be designated by the Board for this purpose; (cii) The applicant may appeal by delivering a written notice review any Policy documents relevant to his or her claim; and (iii) submit issues and comments to the Administrator(s) Board or its delegate that are relevant to the review. Any request for review must be made in writing and received by the Board or its delegate within sixty (60) days after receiving of the date the applicant received notice of denial from the Administrator(s) orinitial denial, if no notice unless special circumstances require an extension of denial was received, within one hundred fifty (150) days (or two hundred forty (240) days, if applicable) after the claim was filedtime for processing. The Board or its delegate will make a written ruling on the applicant's notice of appeal should: (1) request a review of his application for benefits by the Administrator(s); (2) set forth all of the grounds upon which his ’s request for review is based setting forth the reasons for the decision and any facts in support; and (3) set forth any issues or comments the Policy provisions upon which the applicant deems pertinent to his applicationdenial, if appropriate, is based. If he appealsThis written ruling shall be made within thirty (30) days of the date the Board or its delegate receives the applicant’s request for review unless special circumstances require an extension of time for processing, the applicant may review pertinent documents at any reasonable time and place specified by the Administrator(s) and may submit any additional written materials pertinent to the appeal not set forth in the notice of appeal. (d) Any appeal which case a decision will be reviewed by the Administrator(s). The applicantrendered as soon as possible, who may be represented by any person, will be entitled to appear before the Administrator(s) to present his claim. The Administrator(s) will decide the appeal but not later than sixty (60) days after receiving the notice of appeal. If special circumstances require an extension of time, a decision will be made as soon as possible, but not later than one hundred twenty (120) days after receipt of the request for review. All extensions of time permitted by this Section 16 will be permitted at the sole discretion of the Board or its delegate. If the Board does not provide the Participant with written notice of the denial of his or her appeal. The Administrator(s) shall also explain , the reason for the delay and indicate the date on which a decision may be expected. The decision of the Administrator(s) will be in writing and will state clearly the reasons for the decision, including specific reference to the provisions of the Plan supporting the decision. The decision of the Administrator(s) on any and all appeals Participant’s claim shall be final and conclusive upon all applicantsdeemed denied.