Receiving Your Benefits

If Your Claim Is Denied

Review of Appeal

An independent fiduciary will review and render a decision on your appeal within the time frames outlined below and will notify you of its decision in writing. The independent fiduciary will not be an individual who participated in or decided your original claim nor be a subordinate to the original decision maker. No deference shall be given to the initial decision. The independent fiduciary may consult with a physician or other licensed health care professional to receive advice or other such evidence as it deems necessary to decide your claim, except that any medical expert consulted in connection with your appeal will be different from any expert consulted in your initial claim. (The identity of a medical expert consulted in connection with your appeal will be provided.)

The time frame review of your appeal, like your initial claim for benefits, depends on whether it is an urgent care claim, a claim requiring advance approval or pre-authorization, approval of an ongoing course of treatment or Post-Service Claim. Please pay attention to the following time frames:

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.