Denied Claims

Long-Term Disability

If a claim for LTD benefits is denied, the claims administrator will notify you no later than 45 days after the receipt of the claim. This 45-day period may be extended for an additional 30 days if the claims administrator determines the extension is necessary due to matters beyond the control of the plan and notifies you of the extension before the end of the initial 45-day period. If you have not furnished information that is necessary for determining the claim, the claims administrator will notify you and describe the information that is needed.

If, prior to the end of the first 30-day extension, the claims administrator determines that, due to matters beyond the control of the plan, a decision cannot be made within that extension period, the period for making a determination with respect to the your claim may be extended for an additional 30 days, provided the claims administrator notifies you prior to the end of the first 30-day extension period of the circumstances requiring the extension and the expected date for making a determination.

In addition, in the case of any extension of the period in which to make a determination, the notice of extension will explain the standards on which your entitlement to an LTD benefit is based, the unresolved issues that prevent a determination with respect to the claim and the additional information needed to resolve those issues. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information.

While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 30 days after you furnish the missing information or, if you do not furnish the missing information, until 30 days after the date for furnishing such information.

If an LTD claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Other Claims

With respect to all claims other than claims for medical, dental, vision, flexible spending account and LTD benefits, the claims administrator will notify you of its determination no later than 90 days after the receipt of the claim. This 90-day period may be extended for an additional 90 days if the claims administrator determines the extension is necessary due to special circumstances and notifies you of the extension before the end of the initial 90-day period.

The notice of extension will indicate the special circumstances and the date by which the claims administrator expects to make a determination. If you have not furnished information that is necessary for determining the claim, the claims administrator will notify you no later than 30 days after receiving the claim and will describe the information that is needed. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information.

While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 90 days after the claimant furnishes the missing information or, if you do not furnish the missing information, until 90 days after the date for furnishing such information.

If your claim is denied by the claims administrator, you will have 60 days to file an appeal of the denial.

Notice of Denied Claims

If a claim for benefits is denied, you will be notified in writing, and the written notice will contain the following information:

The specific reasons for the benefit denial

Reference to the plan provisions on which the denial is based

A description of any additional material or information necessary to perfect your claim and an explanation of why such information is necessary

A description of the plan’s appeal process and applicable time limits (including the expedited process applicable to urgent care claims) and a statement of your right to bring a civil action under ERISA following an adverse determination on appeal

If an internal rule, guideline, protocol or other similar criterion was relied on in denying your benefit claim, a statement to that effect (a copy of the applicable rule, guideline, protocol or other similar criterion will be provided to you, upon request, free of charge)

If the benefit denial was based on medical necessity or experimental treatment or a similar exclusion on limit, an explanation of such scientific or clinical judgment and its application to your medical circumstances

If your claim for benefits is denied, you may not bring a lawsuit to recover the denied benefits until you have exercised all of your appeal rights and your appeal has been denied in whole or part.

Appeal of Denied Claims

If you wish to appeal the denial of a claim for benefits under the plan, you or your authorized representative must file written notice of the appeal before the time for filing the appeal expires. Your appeal must be filed with the claims administrator for all appeals related to denied claims for life insurance, personal accident insurance, long-term disability or business travel accident insurance.

Your written notice should state in reasonable detail all of the grounds upon which your appeal is based, including references to applicable plan provisions, and any issues or comments you feel are relevant to your claim. You should supply any documents, records or other information relating to your claim. You may also request copies of documents, records and other information relevant to your claim that are in the possession of the plan, which will be provided to you free of charge.

The appeals administrator will review the denial of your claim without deference to the decision of the claims administrator. If the denial of your claim was based in whole or in part on a medical judgment, the appeals administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who did not participate in the denial of your claim (and is not the subordinate of a health care professional who did participate in the claim denial). The appeals administrator will also identify the medical or vocational experts whose advice was obtained on behalf of the plan in denying your claim, without regard to whether the plan relied on such advice.

The applicable time limits to file an appeal of a benefit denial are set forth below:

LTD Claims: 180 days after the benefit denial; the appeals administrator will issue a decision within 45 days after receiving the appeal (this 45-day period may be extended for up to an additional 45 days on prior written notice to you).

All Other Claims: 60 days after the benefit denial; the appeals administrator will issue a decision within 60 days after receiving the appeal (this 60-day period may be extended for up to an additional 60 days on prior written notice to you).

Notice of Appeal Decision

If your appeal is denied, you will be notified in writing, and the written notice will contain the following information:

The specific reasons for the denial