NOTIFY THE CLAIMANT IN
WRITING OF THE DENIAL OF THE CLAIM WITHIN NINETY (90) DAYS AFTER THE COMMITTEE
RECEIVES THE CLAIM, PROVIDED THAT IN THE EVENT OF SPECIAL CIRCUMSTANCES SUCH
PERIOD MAY BE EXTENDED.
(II)
IN THE EVENT OF SPECIAL CIRCUMSTANCES, THE
NINETY (90) DAY PERIOD MAY BE EXTENDED FOR A PERIOD OF UP TO NINETY (90) DAYS
(FOR A TOTAL OF ONE HUNDRED EIGHTY (180) DAYS). IF THE INITIAL NINETY (90) DAY
PERIOD IS EXTENDED, THE COMMITTEE OR ITS DESIGNEE SHALL NOTIFY THE CLAIMANT IN
WRITING WITHIN NINETY (90) DAYS OF RECEIPT OF THE CLAIM. THE WRITTEN NOTICE OF
EXTENSION SHALL INDICATE THE SPECIAL CIRCUMSTANCES REQUIRING THE EXTENSION OF
TIME AND PROVIDE THE DATE BY WHICH THE COMMITTEE EXPECTS TO MAKE A DETERMINATION
WITH RESPECT TO THE CLAIM. IF THE EXTENSION IS REQUIRED DUE TO THE CLAIMANT'S
FAILURE TO SUBMIT INFORMATION NECESSARY TO DECIDE THE CLAIM, THE PERIOD FOR
MAKING THE DETERMINATION SHALL BE TOLLED FROM THE DATE ON WHICH THE EXTENSION
NOTICE IS SENT TO THE CLAIMANT UNTIL THE EARLIER OF (I) THE DATE ON WHICH THE
CLAIMANT RESPONDS TO THE COMMITTEE'S REQUEST FOR INFORMATION, OR (II) EXPIRATION
OF THE FORTY-FIVE (45) DAY PERIOD COMMENCING ON THE DATE THAT THE CLAIMANT IS
NOTIFIED THAT THE REQUESTED ADDITIONAL INFORMATION MUST BE PROVIDED.
(III)
IF NOTICE OF THE DENIAL OF A CLAIM IS NOT
FURNISHED WITHIN THE REQUIRED TIME PERIOD DESCRIBED HEREIN, THE CLAIM SHALL BE
DEEMED DENIED AS OF THE LAST DAY OF SUCH PERIOD.
(IV)
IF A CLAIM IS WHOLLY OR PARTIALLY DENIED, THE
NOTICE TO THE CLAIMANT SHALL SET FORTH:
(A)
THE SPECIFIC REASON OR REASONS FOR THE DENIAL;
(B)
SPECIFIC REFERENCE TO PERTINENT PLAN
PROVISIONS UPON WHICH THE DENIAL IS BASED;
(C)
A DESCRIPTION OF ANY ADDITIONAL MATERIAL OR
INFORMATION NECESSARY FOR THE CLAIMANT TO COMPLETE THE CLAIM REQUEST AND AN
EXPLANATION OF WHY SUCH MATERIAL OR INFORMATION IS NECESSARY;
(D)
APPROPRIATE INFORMATION AS TO THE STEPS TO BE
TAKEN AND THE APPLICABLE TIME LIMITS IF THE CLAIMANT WISHES TO SUBMIT THE
ADVERSE DETERMINATION FOR REVIEW; AND
7
(E)
A STATEMENT OF THE CLAIMANT'S RIGHT TO BRING
A CIVIL ACTION UNDER SECTION 502(A) OF ERISA FOLLOWING AN ADVERSE DETERMINATION
ON REVIEW.
(B)
CLAIM DENIAL REVIEW.
(I)
IF A CLAIM HAS BEEN WHOLLY OR PARTIALLY
DENIED, THE CLAIMANT MAY SUBMIT THE CLAIM FOR REVIEW BY THE COMMITTEE. ANY
REQUEST FOR REVIEW OF A CLAIM MUST BE MADE IN WRITING TO THE COMMITTEE NO LATER
THAN SIXTY (60) DAYS AFTER THE CLAIMANT RECEIVES NOTIFICATION OF DENIAL OR, IF
NO NOTIFICATION WAS PROVIDED, THE DATE THE CLAIM IS DEEMED DENIED. THE CLAIMANT
OR HIS DULY AUTHORIZED REPRESENTATIVE MAY:
(A)
UPON REQUEST AND FREE OF CHARGE, BE PROVIDED
WITH REASONABLE ACCESS TO, AND COPIES OF, RELEVANT DOCUMENTS, RECORDS, AND OTHER
INFORMATION RELEVANT TO THE CLAIMANT'S CLAIM; AND
(B)
SUBMIT WRITTEN COMMENTS, DOCUMENTS, RECORDS,
AND OTHER INFORMATION RELATING TO THE CLAIM. THE REVIEW OF THE CLAIM
DETERMINATION SHALL TAKE INTO ACCOUNT ALL COMMENTS, DOCUMENTS, RECORDS, AND
OTHER INFORMATION SUBMITTED BY