Receiving Your Benefits

Filing a Claim

Urgent Care Claims

If a claim is urgent, you will be notified of the Plan Administrator’s decision, adverse or not, as soon as possible taking into account the medical or dental circumstances, but not later than 72 hours after the plan received the claim, unless the claim does not contain sufficient information on which to base a decision.

If the claim is incomplete and additional information is required, you will be notified as soon as possible, but not later than 24 hours after the plan received the claim, of the information required and give you at least 48 hours to provide it.

You will then be notified of the Plan Administrator’s decision as soon as possible, but not later than 48 hours after the earlier of:

The receipt of any additional information by the plan; or

The end of the 48 hours given to you to provide additional information.

A claim is “urgent” in the following cases:

Where application of the 30-day time period for non-urgent care claims could reasonably be expected to seriously jeopardize your life or health or ability to regain maximum function;

In the opinion of a physician with knowledge of your medical or dental condition, the application of the 30-day time period for non-urgent care claims would subject you to severe pain that could not be adequately managed without the care that is the subject of the claim; or

If a physician with knowledge of your medical or dental condition determines that a claim is urgent, such determination will be dispositive.

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.