Example ContractsClausesdenial of claimVariants
Denial of Claim
Denial of Claim contract clause examples

In the event that any application for benefits is denied in whole or in part, the Company shall notify the applicant in writing of his right to an independent review of the denial. Such written notice shall set forth, in a manner calculated to be understood by the applicant, specific reasons for the denial, specific references to the Plan provisions on which the denial is based, a description of any information or material necessary to perfect the application, an explanation of why such material is necessary, an explanation of the Plan’s review procedure, (including an explanation of the applicant’s right to initiate a lawsuit under [section 502(a)] of ERISA if the applicant’s appeal is denied), and, in the case of a Disability Claim (defined below), each specific internal rule, guideline, protocol or other similar criteria relied upon in making such denial (or a statement that such criteria were relied upon and will be provided free of charge to the applicant upon request), if any. An application shall be granted, or written notice of a denial shall be given to the applicant, within 90 days (45 days in the case of a Disability Claim) after the Company receives a proper application, unless special circumstances (which are matters beyond the control of the Plan in the case of a Disability Claim) require an extension of time for processing the application. In no event shall such an extension exceed a period of 90 days (30 days in the case of a Disability Claim) from the end of the initial 90-day period (45-day period in the case of a Disability Claim). If such an extension is required, written notice thereof shall be furnished to the applicant before the end of the initial 90-day period (45-day period in the case of a Disability Claim) indicating the circumstances requiring an extension of time and the date by which the Company expects to render a decision. If the Company determines that a decision on a Disability Claim cannot be rendered within the initial 30-day extension period due to matters beyond the control of the Plan, the period for making a determination may be extended for an additional 30 days, provided that written notice is furnished to the applicant before the end of the initial 30-day extension period indicating the circumstances requiring an additional extension of time and the date by which the Company expects to render a decision. In the case of any extension with respect to a Disability Claim, the notice of extension shall specifically explain the standards on which benefit entitlement is based, the unresolved issues

days (90 days in the case of a Disability Claim) after the Company receives a proper request for review. If such an extension is required, written notice thereof shall be furnished to the applicant before the end of the initial 60-day period (45-day period in the case of Disability Claim). The Company shall give prompt, written notice of its decision to the applicant. In the event that the Company confirms the denial of the application for benefits in whole or in part, such notice shall set forth, in a manner calculated to be understood by the applicant, the specific reasons for such denial, specific references to the Plan provisions on which the decision is based, a statement that the applicant (or the applicant’s duly authorized representative) has the right, upon request and free of charge, to receive copies of and/or to review all pertinent documents (other than legally privileged documents), an explanation of the applicant’s right to initiate a lawsuit under [section 502(a)] of ERISA, and, in the case of a Disability Claim, each specific internal rule, guideline, protocol or other similar criteria relied upon in making such denial (or a statement that such criteria were relied upon and will be provided free of charge to the applicant upon request). In the case of a Disability Claim, such notice shall also include the following statement: “You and the Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact the local U.S. Department of Labor Office and your State insurance regulatory agency.”

Any person whose application for benefits is denied in whole or in part (or such person’s duly authorized representative) may appeal from the denial by submitting to the Company a request for an independent review of such application within 60 days (180 days in the case of a Disability Claim) after receiving written notice of the denial. Such independent review shall take into consideration all relevant documents and other information submitted by the applicant, whether or not such information was submitted in the initial benefit determination and, in the case of a Disability Claim, shall be conducted without deference to the initial determination. The Company shall give the applicant (or such applicant’s authorized representative), upon request and free of charge, copies of and/or an opportunity to review pertinent documents (except legally privileged materials) in preparing such request for review and an opportunity to submit issues and comments in writing. In the case of a Disability Claim, the Company shall identify each medical or vocational expert whose advice was obtained in connection with such denial, whether or not such advice was relied upon in making the denial. The request for review shall be in writing and shall be addressed as follows:

Review of Disability Claims. If a Disability Claim is denied, the Claimant or the Claimant’s duly authorized representative, upon written application, may review pertinent documents, and may submit issues and comments in writing. The request must be addressed to the General Counsel of the Company at its then principal place of business. A Claimant must file such written request for review with the General Counsel within one-hundred-eighty (180) days after the receipt by the Claimant of a notice denying the initial claim or within one-hundred-eighty (180) days after the claim is deemed to be denied. Upon its receipt of the request for review, the General Counsel will notify the Company of the request and the Company will appoint a person other than a member of the Committee to be the claims reviewer. Upon its receipt of the request for review, the Committee must provide the Claimant, free of charge, and as soon as possible, any new or additional evidence considered or the rationale in connection with the Disability Claim. Such information must be provided in advance of the date on which the notice of the denial of the appeal is required to be provided, as discussed below in [Section 6.6(e)(i)], in order to give the Claimant a reasonable opportunity to respond prior to that date. The decision on review shall be rendered not later than forty-five (45) days after the Committee’s receipt of the Claimant’s request for review, unless special circumstances require an extension of time for processing, in which case the forty-five (45) day period may be extended to ninety (90) days if notice is provided to the Claimant in writing within the initial forty-five (45) day period stating the reason for the extension. If notice of the decision on the review is not furnished in accordance with this paragraph (ii), the claim will be deemed denied and the Claimant will be permitted to exercise his or her right to legal remedy pursuant to paragraph # of this [Section 6.6].

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 ofDenial of Claim” above.

If any claim for benefits is wholly or partially denied, unless special circumstances require an extension of time, the claimant shall be given written or electronic notice within 90 days (or in the case of a claim for disability benefits (a “disability claim”), 45 days) following the date on which the claim is filed, which notice shall set forth # the specific reason or reasons for the denial; # specific references to the pertinent Plan provisions on which the denial is based; # a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and # an explanation of the Plan’s claim review procedure, including the steps to be taken if the claimant wishes to submit the claim for review and the time limits for requesting a review.

Review Procedure. Within 60 days (180 days in the case of a claim regarding Disability) after the date on which a person receives a written notification of denial of claim (or, if written notification is not provided, within 60 days (180 days in the case of a claim regarding Disability) of the date denial is considered to have occurred), such person (or his duly authorized representative) may # file a written request with the Administrator for a review of his denied claim and of pertinent documents and # submit written issues and comments to the Administrator. The Administrator will notify such person of its decision in writing. Such notification will be written in a manner calculated to be understood by such person and will contain specific reasons for the decision as well as specific references to pertinent Plan provisions. The notification will explain that the person is entitled to receive, upon request and free of charge, reasonable access to and copies of all pertinent documents and has the right to bring a civil action following an adverse decision on review. The decision on review will be made within 60 days (45 days in the case of a claim regarding Disability). The Administrator may extend the period for making the decision on review by 60 days (45 days in the case of a claim regarding Disability) if special circumstances require an extension of time for processing the request such as an election by the Administrator to hold a hearing, and if written notice of such extension and circumstances is given to such person within the initial 60-day period (45 days in the case of a claim regarding Disability). If the decision on review is not made within such period, the claim will be considered denied.

Review Procedure. Within 60 days (180 days in the case of a claim regarding Disability) after the date on which a person receives a written notification of denial of claim (or, if written notification is not provided, within 60 days (180 days in the case of a claim regarding Disability) of the date denial is considered to have occurred), such person (or his or her duly authorized representative) may # file a written request with the Administrator for a review of his or her denied claim and of pertinent documents and # submit written issues and comments to the Administrator. The Administrator will notify such person of its decision in writing. Such notification will be written in a manner calculated to be understood by such person and will contain specific reasons for the decision as well as specific references to pertinent Plan provisions. The notification will explain that the person is entitled to receive, upon request and free of charge, reasonable access to and copies of all pertinent documents and has the right to bring a civil action following an adverse decision on review. The decision on review will be made within 60 days (45 days in the case of a claim regarding Disability). The Administrator may extend the period for making the decision on review by 60 days (45 days in the case of a claim regarding Disability) if special circumstances require an extension of time for processing the request such as an election by the Administrator to hold a hearing, and if written notice of such extension and circumstances is given to such person within the initial 60-day period (45 days in the case of a claim regarding Disability). If the decision on review is not made within such period, the claim will be considered denied.

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.

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.

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