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Decision Upon Review
Decision Upon Review contract clause examples

If special circumstances require an extension of time for processing, the decision shall be rendered as soon as possible, but not later than 120 days (or in the case of a disability claim, 90 days) after receipt of the request for review, provided that written or electronic notice and explanation of the delay, including the special circumstances causing the delay and the date by which the Plan expects to render its decision, are provided to the claimant prior to commencement of the extension. Such decision by the Appeals Committee shall not be subject to further review.

The Committee’s decision on review will be made not later than sixty (60) days after his or her receipt of the request for review, unless special circumstances require an extension of time for processing, in which case a decision will be rendered as soon as possible, but not later than one-hundred-twenty (120) days after receipt of the request for review. This notice to the claimant will indicate the special circumstances requiring the extension and the date by which the Committee expects to render a decision and will be provided to the claimant prior to the expiration of the initial period.

If the claim is not a Disability Benefit Claim, the decision on review shall be issued promptly, but no later than sixty (60) days after receipt by the Committee of the Claimant’s request for review, or one hundred twenty (120) 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 one hundred twenty (120) 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 sixty (60) days after the receipt of the Claimant’s request for a review.

A decision will be rendered no more than 60 days after the receipt of the request for review, except that such period may be extended for an additional 60 days if the Plan Committee determines that circumstances (such as for a meeting) require such extension. If an extension of time is required, written notice of the extension will be furnished to the claimant before the end of the initial 60-day period.

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.

The Compensation Committee or its delegate shall furnish a final written decision on formal review not later than 60 days after receipt of the notification of appeal, unless special circumstances require an extension of the time for processing the appeal or the appeal relates to a Disability claim. In no event, however, shall the Compensation Committee or its delegate respond later than 120 days after a request for an appeal. The decision on the appeal shall be written in a manner calculated to be understood by the claimant, shall include specific reasons for the decision, shall contain specific references to the pertinent Plan provisions on which the decision is based, and shall include any other topics required to be addressed for a Disability claim.

The decision on the review of the denied claim shall be rendered by the Committee within sixty (60) days after the receipt of the request for review (if no hearing is held) or within sixty (60) days after the hearing if one is held. However, if special circumstances require an extension of the period of time for considering an appeal, the 60-day period can be extended for an additional 60 days by giving the claimant written notice of the extension, the reason why the extension is necessary, and the date a decision is expected. The decision shall be written and shall state the specific reasons for the decision including references to the specific provisions of this Plan on which the decision is based.

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.

Unless special circumstances require an extension of time, not later than 60 days (or in the case of a disability claim, 45 days) after receipt of the request for review, the Appeals Committee shall render and furnish to the claimant a written or electronic decision, which shall include # the specific reason or reasons for the denial; # specific references to the pertinent Plan provisions on which the denial is based; # a statement of the claimant’s right, upon request and free of charge, to receive reasonable access to and copies of documents, records and other information relevant to the claim; and # a statement of the claimant’s right to bring an action under [Section 502(a)] of ERISA. In the case of a disability claim denial, the notice shall be provided in a culturally and linguistically appropriate manner (to the extent required by the regulations under [Section 503] of ERISA) and in addition to the above, shall include # a statement of the applicable contractual limitations period, including the calendar date that such period will expire with respect to the claim and # the information set forth in items [(A) through (C)] of the second paragraph of “Denial of Claim” above.

A decision will be rendered no more than 60 days after the Plan Administrator’s receipt of the request for review, except that such period may be extended for an additional 60 days if the Plan Administrator determines that special circumstances (such as for a hearing) require such extension. If an extension of time is required, written notice of the extension will be furnished to the claimant before the end of the initial 60-day period.

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