Initial Benefit Determination Sample Clauses

Initial Benefit Determination. (1) The Administrator will notify the Claimant of the Administrator’s determination within a reasonable period of time, but in any event (except as described in paragraph (2) below) within 90 days after receipt of the Claim by the Administrator. (2) The Administrator may extend the period for making the benefit determination by 90 days if it determines that such an extension is necessary due to matters beyond the control of the Plan and if it notifies the Claimant, prior to the expiration of the initial-90 day period, of circumstances requiring the extension of time and the date by which the Administrator expects to render a decision.
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Initial Benefit Determination. A claim for benefits under this Agreement must be submitted in writing to the Board of Directors of USB, or its duly authorized representative (“Claims Administrator”), and such claim shall be subject to a full and fair review. If a claim is denied, the Claims Administrator shall provide written notice of the denial not later than ninety (90) days after the claim is received by the Claims Administrator. If an extension of time is required, written notice of the extension shall be given to the claimant prior to the termination of the initial 90-day period. In no event shall such extension exceed ninety (90) days from the end of the initial period. In the event a claim is denied, the Claims Administrator shall disclose to the claimant in writing the reasons for the denial, the provisions of the Agreement on which the denial 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 Agreement’s review procedures and the applicable time limits, and a statement of the right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review.
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Related to Initial Benefit Determination

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • Company Determination Final Any determination that the Company or the Board of Directors must make pursuant to this Article is conclusive.

  • Termination Date Determination Seller will not designate the Termination Date (as defined in the Receivables Sale Agreement), or send any written notice to Originator in respect thereof, without the prior written consent of the Agent, except with respect to the occurrence of such Termination Date arising pursuant to Section 5.1(d) of the Receivables Sale Agreement.

  • Eligibility Determination EOHHS will have sole authority for determining whether individuals or families meet any of the eligibility criteria and therefore are eligible to enroll in a Health Plan.