THE SPECIFIC PLAN PROVISIONS ON
WHICH THE DENIAL IS BASED;
(C)
DESCRIBE ANY ADDITIONAL MATERIAL OR
INFORMATION NECESSARY FOR THE CLAIMANT TO PERFECT THE CLAIM (IF PERFECTION OF
THE CLAIM IS POSSIBLE) AND AN EXPLANATION OF WHY SUCH MATERIAL OR INFORMATION IS
NECESSARY; AND
8
(D)
EXPLAIN THE STEPS AND TIME LIMIT FOR
REQUESTING REVIEW OF THE CLAIM.
If the Administrator determines that an extension of time for processing is
required, written notice of the extension shall be furnished to the Claimant
prior to termination of the original 60-day period.
In no event shall such
extension exceed sixty (60) days from the end of such initial period.
6.4.
CLAIM REVIEW.
A CLAIMANT (OR HIS AUTHORIZED
REPRESENTATIVE) SHALL HAVE SIXTY (60) DAYS FROM THE DATE THE ADMINISTRATOR'S
NOTICE IS MAILED IN WHICH TO FILE AN APPEAL OF THE DENIAL OF HIS CLAIM.
ANY
SUCH APPEAL MUST: (A) BE IN WRITING; (B) REQUEST REVIEW OF THE CLAIMANT'S CLAIM;
(C) SET FORTH EACH GROUND ON WHICH THE REQUEST FOR REVIEW IS BASED AND THE FACTS
IN SUPPORT THEREOF; AND (D) PROVIDE ANY OTHER COMMENTS THE CLAIMANT BELIEVES
PERTINENT AND HELPFUL TO HIS APPLICATION.
THE CLAIMANT (OR THE CLAIMANT'S DULY
AUTHORIZED REPRESENTATIVE) MAY (I) REQUEST ACCESS TO, AND COPIES OF, ALL
DOCUMENTS, RECORDS, AND OTHER INFORMATION RELEVANT TO THE CLAIM, WHICH SHALL BE
PROVIDED TO CLAIMANT FREE OF CHARGE AND (II) SUBMIT WRITTEN COMMENTS OR OTHER
DOCUMENTS.
ANY CLAIMANT WHO FAILS TO TIMELY FILE SUCH A WRITTEN APPEAL SHALL BE
ESTOPPED AND BARRED FROM ANY FURTHER CHALLENGE TO THE ADMINISTRATOR'S
DETERMINATION TO DENY HIS CLAIM.
6.5.
REVIEW OF DETERMINATION.
THE ADMINISTRATOR
SHALL COMPLETE ITS REVIEW AND DECIDE THE APPEAL WITHIN SIXTY (60) DAYS AFTER THE
WRITTEN REQUEST FOR REVIEW WAS RECEIVED BY THE ADMINISTRATOR (OR WITHIN
ONE-HUNDRED TWENTY (120) DAYS IF SPECIAL CIRCUMSTANCES REQUIRE ADDITIONAL TIME,
AND IF WRITTEN NOTICE OF SUCH EXTENSION AND CIRCUMSTANCES IS GIVEN TO THE
CLAIMANT WITHIN THE INITIAL 60-DAY PERIOD).
IN CONDUCTING ITS REVIEW, THE
ADMINISTRATOR MAY, IN ITS SOLE DISCRETION, REQUIRE THE CLAIMANT TO SUBMIT SUCH
ADDITIONAL DOCUMENTS OR OTHER EVIDENCE AS THE ADMINISTRATOR DEEMS NECESSARY OR
APPROPRIATE.
THE ADMINISTRATOR'S DECISION SHALL BE FINAL AND BINDING ON ALL
PERSONS WITH RESPECT TO THE CLAIMANT'S APPEAL.
THE ADMINISTRATOR SHALL NOTIFY
THE CLAIMANT IN WRITING THAT THE CLAIM HAS BEEN ALLOWED IN FULL OR THAT THE
CLAIM HAS BEEN DENIED, IN WHOLE OR IN PART, AND ANY DENIAL NOTICE MUST SET
FORTH:
(A)
SPECIFIC REASONS FOR THE DECISION;
(B)
SPECIFIC REFERENCE(S) TO THE PERTINENT PLAN
PROVISIONS UPON WHICH THE DECISION WAS BASED;
(C)
A STATEMENT THAT CLAIMANT IS ENTITLED TO
REASONABLE ACCESS TO, AND COPIES OF, ALL DOCUMENTS, RECORDS OR OTHER INFORMATION
RELEVANT TO THE CLAIM UPON REQUEST AND FREE OF CHARGE; AND
(D)
SUCH OTHER MATTERS AS THE ADMINISTRATOR
DEEMS RELEVANT.
6.6.
REIMBURSEMENT OF COSTS.
IF THE COMPANY, AN
AFFILIATE, THE PLAN, A CLAIMANT, OR A SUCCESSOR IN INTEREST TO ANY OF THE
FOREGOING BRINGS LEGAL ACTION TO ENFORCE ANY OF THE PROVISIONS OF THIS PLAN, THE
PREVAILING