TO THE CLAIMANT UNTIL THE EARLIER OF (I) THE DATE ON WHICH THE
CLAIMANT RESPONDS TO THE PLAN'S REQUEST FOR INFORMATION OR (II) EXPIRATION OF
THE 45 DAY PERIOD COMMENCING ON THE DATE THAT THE CLAIMANT IS NOTIFIED THAT THE
REQUESTED ADDITIONAL INFORMATION MUST BE PROVIDED.
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.
(C)
IF THE CLAIM IS WHOLLY OR PARTIALLY DENIED,
THE NOTICE TO THE CLAIMANT SHALL SET FORTH:
(I)
THE SPECIFIC REASON OR REASONS FOR THE
DENIAL;
(II)
SPECIFIC REFERENCE TO PERTINENT PLAN
PROVISIONS UPON WHICH THE DENIAL IS BASED;
15
(III)
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;
(IV)
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
(V)
A STATEMENT OF THE CLAIMANT'S RIGHT TO BRING
A CIVIL ACTION UNDER SECTION 502(A) OF ERISA FOLLOWING AN ADVERSE DETERMINATION
ON REVIEW (COLLECTIVELY, THE "NOTICE REQUIREMENTS").
(D)
IF THE CLAIM HAS BEEN DENIED, THE CLAIMANT
MAY SUBMIT THE CLAIM FOR REVIEW.
ANY REQUEST FOR REVIEW OF A CLAIM MUST BE MADE
IN WRITING TO THE COMMITTEE NO LATER THAN 60 DAYS AFTER THE CLAIMANT RECEIVES
NOTIFICATION OF DENIAL OR, IF NO NOTIFICATION WAS PROVIDED, THE DATE THE CLAIM
IS DEEMED DENIED.
THE CLAIM WILL THEN BE REVIEWED BY THE COMMITTEE.
THE
CLAIMANT OR HIS DULY AUTHORIZED REPRESENTATIVE MAY:
(I)
UPON REQUEST AND FREE OF CHARGE, BE
PROVIDED WITH ACCESS TO, AND COPIES OF, RELEVANT DOCUMENTS, RECORDS, AND OTHER
INFORMATION RELEVANT TO THE CLAIMANT'S CLAIM; AND
(II)
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 THE CLAIMANT RELATING TO THE CLAIM, WITHOUT
REGARD TO WHETHER SUCH INFORMATION WAS SUBMITTED OR CONSIDERED IN THE INITIAL
CLAIM DETERMINATION.
(E)
THE DECISION OF THE COMMITTEE SHALL BE MADE
WITHIN 60 DAYS (SUCH PERIOD MAY BE EXTENDED TO 120 DAYS)
AFTER RECEIPT OF THE
CLAIMANT'S REQUEST FOR REVIEW, UNLESS SPECIAL CIRCUMSTANCES REQUIRE AN
EXTENSION.
(F)
IF THE INITIAL 60 DAY PERIOD IS EXTENDED,
THE COMMITTEE OR ITS DESIGNEE SHALL, WITHIN 60 DAYS OF RECEIPT OF THE CLAIM,
NOTIFY THE CLAIMANT IN WRITING OF SUCH EXTENSION.
THE WRITTEN NOTICE OF
EXTENSION WILL 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 WILL BE TOLLED FROM THE DATE ON WHICH THE EXTENSION
NOTICE IS SENT TO THE CLAIMANT UNTIL THE EARLIER OF (I) THE DATE ON WHICH