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Claims Procedure
Claims Procedure contract clause examples

Disability Claims. If a claim is related to any distribution or rights to which a Participant or other Claimant may be entitled in connection with the Participant’s termination by reason of suffering a Disability (“Disability Claim”) then, as soon as reasonable but within forty-five (45) days after receipt of such claim, the Committee will send to the Claimant by certified mail, postage prepaid, notice of the granting or denying, in whole or in part of such claim. This period within which the Committee must provide such notice may be extended twice, for up to thirty (30) days per extension, provided that the Committee # determines that an extension is needed and beyond the control of the Plan, and # notifies the Claimant prior to the expiration of the initial forty-five (45) day period or of the first thirty (30) day extension period. In the case of any extension request, the notice of extension shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and the Claimant shall be afforded at least forty-five (45) days within which to provide the specified information. If the Committee fails to notify the Claimant either that his or her claim has been granted or that it has been denied in whole or in part within the initial forty-five (45) day period or prior to the expiration of an extension, if applicable, then the claim shall be deemed to have been denied as of the last day of the applicable period, and the Claimant then may request a review of his or her claim. The Committee must ensure that all Disability Claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the Disability determination.

If the claim is a Disability Benefit Claim, within forty‑five (45) days following receipt of such claim by the Committee, notice of any approval or denial thereof, in whole or in part, shall be delivered to the Claimant or his duly authorized representative or such notice of denial shall be sent by mail to the Claimant or his duly authorized representative at the address shown on the claim form or such individual’s last known address. The aforesaid forty‑five (45) day response period may be extended to seventy‑five (75) days after receipt of the Claimant’s claim if it is determined that such an extension is necessary due to matters beyond the control of the Plan and if written notice of the extension to seventy‑five (75) days indicating the circumstances involved and the date by which a decision is expected to be made is furnished to the Claimant or his duly authorized representative within forty‑five (45) days after receipt of the Claimant’s claim. Thereafter, the aforesaid seventy‑five (75) day response period may be extended to one hundred five (105) days after receipt of the Claimant’s claim if it is determined that such an extension is necessary due to matters beyond the control of the Plan and if written notice of the extension to one hundred five (105) days indicating the circumstances involved and the date by which a decision is expected to be made is furnished to the Claimant or his duly authorized representative within seventy‑five (75) days after receipt of the Claimant’s claim. In the event of any such extension, the notice of extension shall specifically explain, to the extent applicable, the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and the Claimant shall be afforded at least forty‑five (45) days within which to provide any specified information which is to be provided by the Claimant.

Claims (Other than Disability Claims). For all claims other than Disability Claims, within ninety (90) days after receipt of such claim, the Committee will send to the Claimant by certified mail, postage prepaid, notice of the granting or denying, in whole or in part, of such claim, unless special circumstances require an extension of time for processing the claim. In no event may the extension exceed ninety (90) days from the end of the initial period. If such extension is necessary, the Claimant will be given a notice to this effect prior to the expiration of the initial ninety (90) day period. If the Committee fails to notify the Claimant either that his or her claim has been granted or that it has been denied in whole or in part within the initial ninety (90) day period or prior to the expiration of an extension, if applicable, then the claim shall be deemed to have been denied as of the last day of the applicable period, and the Claimant then may request a review of his or her claim.

14.6Disability Claims. If a Participant’s claim involves a determination of Disability, the following time periods shall apply in lieu of the time periods set forth in [Sections 14.2 through 14.4]. The Committee shall have 45 days to render its initial decision on a Claimant’s claim, and an additional 30 days if the Committee determines that special circumstances require an extension of time to process the claim. If an adverse decision involves a disability claim the notice of the decision shall also inform the Claimant that if a Plan guideline was relied on in making the adverse decision, a copy of the guideline will be provided to the Claimant, without charge, upon request. A Claimant shall have 180 days to appeal an initial adverse decision. The Committee shall render its decision on appeal within 45 days, with an extension of an additional 45 days if the Committee determines that special circumstances require an extension of time. The following additional rules apply to an appeal. First, the review will be conducted by a Plan fiduciary who did not make the original determination on the Claimant’s claim and is not the subordinate of that person. Second, the Claimant shall be provided the identity of any medical or vocational experts whose advice was obtained in connection with the determination, whether or not the advice was relied on by such Plan fiduciary. Third, any health care professional who is engaged for a consultation on appeal will be a different person from and not subordinate to any health care professional who the Committee consulted for the initial determination.

If the claim is a Disability Benefit Claim, the decision on review shall be issued promptly, but no later than forty‑five (45) days after receipt by the Committee of the Claimant’s request for review, or ninety (90) days after such receipt if a hearing is to be held or if other special circumstances exist and if written notice of the extension to ninety (90) days indicating the special circumstances involved and the date by which a decision is expected to be made on review is furnished to the Claimant or his duly authorized representative within forty‑five (45) days after the receipt of the Claimant’s request for a review.

For Disability Claims, the Committee shall provide written notification of its decision to the Claimant in a culturally and linguistically appropriate manner, including information on how to access non-English language services provided by the Plan. The notification shall include the information required to be included in the notice of the denial discussed in [Section 6.6(c)(ii)]. The decision (regardless of whether it is adverse to the Claimant) shall be made within a reasonable time period but not later than forty-five (45) days after receipt of the Claimant’s request for review, unless the claims reviewer determines that special circumstances require an extension of time to process the claim. If such an extension is required, written notice of the extension must be furnished to the Claimant before the end of the initial forty-five (45) day period, explaining the special circumstances and the time and date a determination can be expected. In no event shall the extension exceed a period of forty-five (45) days from the end of the initial period.

If the claim is not a Disability Benefit Claim, within ninety (90) days following receipt of such claim by the Committee, notice of any approval or denial thereof, in whole or in part, shall be delivered to the Claimant or his duly authorized representative or such notice of denial shall be sent by mail (postage prepaid) to the Claimant or his duly authorized representative at the address shown on the claim form or such individual’s last known address. The aforesaid ninety (90) day response period may be extended to one hundred eighty (180) days after receipt of the Claimant’s claim if special circumstances exist and if written notice of the extension to one hundred eighty (180) days indicating the special circumstances involved and the date by which a decision is expected to be made is furnished to the Claimant or his duly authorized representative within ninety (90) days after receipt of the Claimant’s claim.

Claim Procedure. If an Employee or former Employee makes a written request alleging a right to receive benefits under this Plan or alleging a right to receive an adjustment in benefits being paid under the Plan, the Committee shall treat it as a claim for benefit. All claims for benefit under the Plan shall be sent to the Committee and must be received within 30 days after termination of employment. If the Committee determines that any individual who has claimed a right to receive benefits, or different benefits, under the Plan is not entitled to receive all or any part of the benefits claimed, it will inform the claimant in writing of its determination and the reasons therefor in a manner calculated to be understood by the claimant. The notice will be sent within 60 days of the claim. The notice shall make specific reference to the reasons for denial and pertinent Plan provisions on which the denial is based, and describe any additional material or information necessary for the claim to succeed and a description of why it is necessary. Such notice shall, in addition, inform the claimant what procedure the claimant should follow to take advantage of the review procedures set forth below in the event the claimant desires to contest the denial of the claim. The claimant may within 90 days thereafter submit in writing to the Committee a notice that the claimant contests the denial of his claim by the Committee and desires a further review. The Committee shall within 60 days thereafter review the claim and authorize the claimant to appear personally and review pertinent documents and submit issues and comments relating to the claim to the persons responsible for making the determination on behalf of the Committee. The Committee will render its final decision with specific reasons therefor and in a manner calculated to be understood by the claimant, and will transmit it to the claimant within 60 days of the written request for review. If the Committee fails to respond to a claim filed in accordance with the foregoing within 60 days, the Committee shall be deemed to have denied the claim. This [Section 7.5] shall not serve to prohibit any Participant from bringing an action in a court of competent jurisdiction to enforce his rights under the

General. Each Participant (and each person or entity claiming rights under the Plan through such Participant) shall claim any benefit to which he or she is entitled under the Plan by a written notification to the Committee. If a claim is denied, it must be denied within a reasonable period of time, but not in excess of 90 days following receipt of the claim by the Committee unless the Committee determines that special circumstances require an extension of time for processing the claim, in which case, the Committee shall provide the claimant with written notice of extension prior to the termination of the initial 90 day period and shall have an additional 90 days from the expiration of the initial 90 day period to decide such claim. Any such notice of extension shall indicate the special circumstances requiring an extension of time and the date by which the Committee expects to render its decision, The Committee’s decision with respect to such claim shall be provided to the claimant in writing in a manner calculated to be understood by the claimant, and if such claim is denied, shall include # the specific reason for the denial, # reference to the specific Plan provisions on which the denial is based, # a description of additional information necessary for the claimant to present his claim, if any, and an explanation of why such information is necessary, and # an explanation of the Plan’s claim review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under [Section 502] of ERISA following an adverse determination on review.

If special circumstances require an extension of time for processing the claim (and in the case of a disability claim, such extension is necessary due to matters beyond the Plan’s control), written or electronic notice of the extension shall be furnished to the claimant prior to the end of the initial determination period set forth above. Such an extension may not exceed a period of 90 days (or in the case of a disability claim, 30 days) beyond the end of said initial determination period. If a disability claim cannot be processed within the first 30-day extension period due to matters beyond the Plan’s control, the Plan’s deadline for responding to the claim may be extended for up to an additional 30 days, provided that the claimant is so advised in writing or by electronic means within the first extension period. In each case, the extension notice shall indicate the special circumstances requiring the extension and the date by which the Plan expects to render its decision. In the case of a disability claim, each extension notice also shall specifically explain the standards on which the entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim and the additional information needed to resolve those issues, and the claimant shall be afforded at least 45 days within which to provide the specified information.

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