Content of a denial Clause Samples

Content of a denial. All claims for Plan benefits shall be subject to a full and fair review. If the Plan Administrator fully or partially denies any claim for benefits under the Plan, the Plan Administrator shall set forth in writing in a manner calculated to be understood by the Participant or any other person claiming benefits, the following information: (1) the specific reason for the denial; (2) the specific reference to the pertinent Plan provisions on which the denial is based, or if the claim is for Disability which is determined by the Plan Administrator, then, if applicable, a copy of the internal rule, guideline or protocol that was relied upon to make the determination or a statement that such rule was relied upon and a copy of such rule will be provided, free of charge, upon request; (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; (4) the appropriate information as to the steps to be taken for the claim to be submitted for review; and (5) an explanation of the Plan Administrator's review procedure as stipulated in this Plan, and a statement regarding the claimant's right to bring civil action under ERISA section 502(a) following an adverse determination on review. (6) If notice of the denial of a claim is not furnished to the claimant in accordance with the above within 90 days (unless circumstances beyond the Plan Administrator's control cause a lengthier period before a determination of the validity of a claim can be made), the claim shall be deemed denied. The claimant shall then be permitted to proceed to the review stage described in paragraph (b) below. (7) With respect to a Disability claim which is determined by the Plan Administrator, if notice of the denial of a claim is not furnished to the claimant in accordance with (1) through (5) above, within 45 days, (unless circumstances beyond the Plan Administrator's control cause a lengthier period before a determination of the validity of a claim can be made), the claim shall be deemed denied. The claimant shall then be permitted to proceed to the review stage described in paragraph (c) below. The 45-day time limit shall not be extended, except where there are special circumstances that require such an extension, and a written description of those circumstances is sent to the claimant within the 45-day period. If the Plan Administrator requires an extension, the extension shall not ...
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Content of a denial. All claims for Plan benefits shall be subject to a full and fair review. If the Plan Administrator fully or partially denies any claim for benefits under the Plan, the Plan Administrator shall set forth in writing in a manner calculated to be understood by the Participant or any other person claiming benefits, the following information: (1) the specific reason for the denial; (2) the specific reference to the 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; (4) the appropriate information as to the steps to be taken for the claim to be submitted for review; and (5) an explanation of the Plan Administrator’s review procedure as stipulated in this Plan. (6) If notice of the denial of a claim is not furnished to the claimant in accordance with the above within 90 days (unless circumstances beyond the Plan Administrator’s control cause a lengthier period before a determination of the validity of a claim can be made), the claim shall be deemed denied. The claimant shall then be permitted to proceed to the review stage described in paragraph (b) below.
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