Reconsideration by The Plan Sample Clauses
The "Reconsideration by The Plan" clause establishes a process by which decisions made by the plan administrator or governing body can be reviewed upon request. Typically, this clause allows a participant or beneficiary to formally ask for a review if they disagree with an initial determination regarding benefits, eligibility, or claims. The process may involve submitting additional information or documentation for further evaluation. Its core function is to provide a fair mechanism for resolving disputes and ensuring that decisions are accurate and consistent, thereby protecting the rights of plan participants.
Reconsideration by The Plan. The IRO will forward any information submitted by Member or the Member’s authorized representative to The Plan, within 1 business day of its receipt. The Plan may reconsider its adverse benefit determination or final internal adverse benefit determination that is the subject of the external review. Reconsideration by The Plan may not delay or terminate the IRO’s external review. The external review may be terminated only if The Plan decides, on completion of its reconsideration, to reverse its adverse benefit determination or final internal adverse benefit determination and provide coverage for the requested health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination. The Plan will notify the Member or the Member’s authorized representative and the IRO immediately in writing of its decision. The IRO will terminate the external review on receipt of the notice from The Plan.