IN WRITING BY THE PLAN ADMINISTRATOR WITHIN NINETY (90) DAYS AFTER
THE RECEIPT OF THE CLAIM FOR BENEFITS.
THIS PERIOD MAY BE EXTENDED AN
ADDITIONAL NINETY (90) DAYS IF THE PLAN ADMINISTRATOR DETERMINES SUCH EXTENSION
IS NECESSARY AND THE PLAN ADMINISTRATOR PROVIDES NOTICE OF EXTENSION TO THE
CLAIMANT PRIOR TO THE END OF THE INITIAL NINETY (90) DAY PERIOD.
THE NOTICE
ADVISING OF THE DENIAL SHALL (I) SPECIFY THE REASON OR REASONS FOR DENIAL,
(II) MAKE SPECIFIC REFERENCE TO THE PLAN PROVISIONS ON WHICH THE DETERMINATION
WAS BASED, (III) DESCRIBE ANY ADDITIONAL MATERIAL OR INFORMATION NECESSARY FOR
THE CLAIMANT TO PERFECT THE CLAIM (EXPLAINING WHY SUCH MATERIAL OR INFORMATION
IS NEEDED), AND (IV) DESCRIBE THE PLAN'S REVIEW PROCEDURES AND THE TIME LIMITS
APPLICABLE TO SUCH PROCEDURES, INCLUDING A STATEMENT OF THE CLAIMANT'S RIGHT TO
BRING A CIVIL ACTION UNDER SECTION 502(A) OF ERISA FOLLOWING AN ADVERSE BENEFIT
DETERMINATION ON REVIEW.
SECTION 9.03
APPEALS OF DENIED ADMINISTRATIVE CLAIMS.
ALL APPEALS
SHALL BE MADE BY THE FOLLOWING PROCEDURE:
(A)
A CLAIMANT WHOSE CLAIM HAS BEEN DENIED SHALL FILE WITH THE PLAN
ADMINISTRATOR A NOTICE OF APPEAL OF THE DENIAL.
SUCH NOTICE SHALL BE FILED
WITHIN SIXTY (60) CALENDAR DAYS OF NOTIFICATION BY THE PLAN ADMINISTRATOR OF THE
DENIAL OF
12
A CLAIM, SHALL BE MADE IN WRITING, AND SHALL SET FORTH ALL OF THE FACTS UPON
WHICH THE APPEAL IS BASED.
APPEALS NOT TIMELY FILED SHALL BE BARRED.
(B)
THE NAMED APPEALS FIDUCIARY SHALL CONSIDER THE MERITS OF THE
CLAIMANT'S WRITTEN PRESENTATIONS, THE MERITS OF ANY FACTS OR EVIDENCE IN SUPPORT
OF THE DENIAL OF BENEFITS, AND SUCH OTHER FACTS AND CIRCUMSTANCES AS THE NAMED
APPEALS FIDUCIARY SHALL DEEM RELEVANT.
(C)
THE NAMED APPEALS FIDUCIARY SHALL RENDER A DETERMINATION UPON THE
APPEALED CLAIM WHICH DETERMINATION SHALL BE ACCOMPANIED BY A WRITTEN STATEMENT
AS TO THE REASONS THEREFOR.
THE DETERMINATION SHALL BE MADE TO THE CLAIMANT
WITHIN SIXTY (60) DAYS OF THE CLAIMANT'S REQUEST FOR REVIEW, UNLESS THE NAMED
APPEALS FIDUCIARY DETERMINES THAT SPECIAL CIRCUMSTANCES REQUIRE AN EXTENSION OF
TIME FOR PROCESSING THE CLAIM.
IN SUCH CASE, THE NAMED APPEALS FIDUCIARY SHALL
NOTIFY THE CLAIMANT OF THE NEED FOR AN EXTENSION OF TIME TO RENDER ITS DECISION
PRIOR TO THE END OF THE INITIAL SIXTY (60) DAY PERIOD, AND THE NAMED APPEALS
FIDUCIARY SHALL HAVE AN ADDITIONAL SIXTY (60) DAY PERIOD TO MAKE ITS
DETERMINATION.
IF THE DETERMINATION IS ADVERSE TO THE CLAIMANT, THE NOTICE
SHALL (I) PROVIDE THE REASON OR REASONS FOR DENIAL, (II) MAKE SPECIFIC REFERENCE
TO THE PLAN PROVISIONS ON WHICH THE DETERMINATION WAS BASED, (III) INCLUDE A
STATEMENT THAT THE CLAIMANT IS ENTITLED TO RECEIVE, UPON REQUEST AND FREE OF
CHARGE, REASONABLE ACCESS TO, AND COPIES OF, ALL DOCUMENTS, RECORDS AND OTHER
INFORMATION RELEVANT TO THE CLAIMANT'S CLAIM FOR BENEFITS, AND (IV) STATE THAT
THE CLAIMANT HAS THE RIGHT TO BRING AN ACTION UNDER SECTION 502(A) OF ERISA, AND
SUCH DETERMINATION SHALL BE SUBJECT TO DE NOVO REVIEW BY THE ARBITRATOR AS
PROVIDED IN SECTION 9.05 HEREOF.
SECTION