Common use of Claims Review Procedures Clause in Contracts

Claims Review Procedures. 1. If the Claims Administrator denies a claim, the Claims Administrator shall provide a written denial notice to the Retired Participant. The notice shall be written in a manner calculated to be understood by the claimant and shall set forth (i) the specific reason(s) for the denial; (ii) specific references to the pertinent Plan or administrative provisions or procedures on which the denial is based; (iii) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation as to why such information is necessary; and (iv) an explanation of the Plan’s claims procedure. 2. After receipt of a written denial notice, the claimant shall have sixty (60) days to appeal the claim denial to the Claims Administrator. The claimant or his duly authorized representative may (i) appeal upon written notice to the Claims Administrator; (ii) review pertinent documents; and (iii) submit issues and comments in writing. 3. A decision by the Claims Administrator will be made no later than sixty (60) days after receipt of an appeal, unless special circumstances (in the opinion of the Claims Administrator) require an extension of time for processing, in which event a decision should be rendered as soon as possible, but in no event later than 120 days after such receipt. The decision of the Claims Administrator shall be written and shall include specific reasons for the decision, written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on which the decision is based.

Claims Review Procedures. 1. ) If the Claims Administrator denies a claim, the Claims Administrator shall provide a written denial notice to the Retired Participant. The notice shall be written in a manner calculated to be understood by the claimant and shall set forth (i) the specific reason(s) for the denial; (ii) specific references to the pertinent Plan or administrative provisions or procedures on which the denial is based; (iii) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation as to why such information is necessary; and (iv) an explanation of the Plan’s claims procedure. 2. ) After receipt of a written denial notice, the claimant shall have sixty (60) days to appeal the claim denial to the Claims Administrator. The claimant or his duly authorized representative may (i) appeal upon written notice to the Claims Administrator; (ii) review pertinent documents; and (iii) submit issues and comments in writing. 3. ) A decision by the Claims Administrator will be made no later than sixty (60) days after receipt of an appeal, unless special circumstances (in the opinion of the Claims Administrator) require an extension of time for processing, in which event a decision should be rendered as soon as possible, but in no event later than 120 days after such receipt. The decision of the Claims Administrator shall be written and shall include specific reasons for the decision, written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on which the decision is based.