Claims Procedure Clause Example with 4 Variations from Business Contracts
This page contains Claims Procedure clauses in business contracts and legal agreements. An example clause is provided at the top of the page, followed by clauses with minor variations. You can view the text differences by selecting the "Show Differences" option.
Claims Procedure. a) The Participant, or his beneficiary hereunder or authorized representative (the "Claimant"), may file a claim for benefits under the Plan by written communication to the Committee or its designee. A claim is not considered filed until such communication is actually received. Within 90 days (or, if special circumstances require an extension of time for processing, 180 days, in which case written or electronic notice and description of such special circumstances, and the date by which the Commi...ttee expects to tender its decision, shall be provided within the initial 90-day period) after the filing of the claim, the Committee will either: (i) approve the claim and take appropriate steps for satisfaction of the claim; or (ii) if the claim is wholly or partially denied, advise the Claimant of such denial by furnishing to him a written or electronic notice of such denial setting forth (A) the specific reason or reasons for the denial; (B) specific reference to pertinent provisions of the Plan on which the denial is based and, if the denial is based in whole or in part on any rule of construction or interpretation adopted by the Committee, a reference to such rule, a copy of which shall be provided to the Claimant; (C) a description of any additional material or information necessary for the Claimant to perfect the claim and an explanation of the reasons why such material or information is necessary; and (D) a description of the Plan's appeal 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 the Employee Retirement Income Security Act of 1974, as amended ("ERISA") following a denial of the claim on appeal. 8 b) The Claimant may request a review of any denial of his claim by written application to the Committee within 60 days after receipt of the notice of denial of such claim. The Committee shall afford the Claimant an opportunity to review and receive, without charge, all relevant documents, information and records and to submit issues and comments in writing to the Committee. The Committee shall take into account all comments, documents, records and other information submitted by the Claimant relating to the claim regardless of whether the information was submitted or considered in the initial benefit determination. Within 60 days (or, if special circumstances require an extension of time for processing, 120 days, in which case notice and description of such special circumstances and the expected date of decision shall be provided within the initial 60-day period) after receipt of written application for review, the Committee will provide the Claimant with its decision in writing or by electronic communication, including, if the Claimant's claim is not approved, (A) specific reasons for the decision, (B) specific references to the Plan provisions on which the decision is based, (C) a statement that the Claimant may receive on request all relevant records at no charge; and (D) a statement of the Claimant's right to bring an action under Section 502(a) of ERISA. c) The internal claims procedures set forth in this Section 15 are mandatory. If a Claimant fails to follow these claims procedures, or to timely file a request for appeal in accordance with this Section 15, the denial of the Claim shall become final and binding on all persons for all purposes.View More
Variations of a "Claims Procedure" Clause from Business Contracts
Claims Procedure. a) The Participant, or his beneficiary hereunder or authorized representative (the "Claimant"), (a) Claim. A Participant or, following the Participant's death, a Beneficiary (collectively referred to in this Section 15 as a "claimant") may file submit a claim for benefits under the Plan. Any claim for benefits under the Plan by written communication shall be made in writing to the Committee Committee. (b) Claim Decision. In the case of a claim for benefits that is wholly or its designee. A claim... is not considered filed until such communication is actually received. Within partially denied, within 90 days (or, (or 180 days in special cases if special circumstances require an extension of time for processing, 180 days, in which case written or electronic notice and description of such special circumstances, and the date by which the Committee expects to tender its decision, shall be provided within furnishes notice of the 10 extension before the end of the initial 90-day period) after the filing claim has been filed, the Committee shall provide the person who filed the claim a written approval or denial of the claim, the Committee will either: (i) approve the claim and take appropriate steps for satisfaction claim. A notice of the claim; denial of a claim, in whole or (ii) if in part, shall set forth: (i) the claim is wholly or partially denied, advise the Claimant of such denial by furnishing to him a written or electronic notice of such denial setting forth (A) the specific reason or reasons for the denial; (B) specific (ii) reference to pertinent the specific Plan provisions of the Plan on upon which the denial is based and, if the denial is based in whole or in part on any rule of construction or interpretation adopted by the Committee, a reference to such rule, a copy of which shall be provided to the Claimant; (C) based; (iii) a description of any additional material or information necessary for the Claimant to perfect needed before the claim can be considered and an explanation of the reasons why such material or information is necessary; and (D) a description (iv) an explanation of the Plan's appeal procedures claim review procedure set forth below and the time limits applicable to such procedures, appeals, including a statement of the Claimant's claimant's right to bring a civil action under Section section 502(a) of ERISA following an adverse benefit determination on appeal. (c) Request for Review. Within 60 days of the Employee Retirement Income Security Act receipt of 1974, as amended ("ERISA") following a denial notice denying a claim, the claimant or the claimant's duly authorized representative may request, in writing, a full review of the claim on appeal. 8 b) The Claimant may by the Committee. In connection with any such review, the claimant or the claimant's authorized representative (i) will be provided, upon request a review and free of any denial of his claim by written application charge, reasonable access to, and copies of, all documents, records and other information relevant to the Committee within 60 days after receipt of the notice of denial of such claim. The Committee shall afford the Claimant an opportunity to review claim for benefits and receive, without charge, all relevant documents, information and records and to (ii) may submit issues and comments in writing to the Committee. The Committee shall take into account make a decision within 60 days after the request for a review (or 120 days in the event of special circumstances if the Committee furnishes notice of the extension before the end of the initial 60-day period). The Committee's decision will be binding on all comments, parties. A final notice of the denial of the claim on appeal, in whole or in part, shall set forth: (i) the reason or reasons for the denial; (ii) reference to the specific Plan provisions upon which the denial is based; (iii) the claimant's right to, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information submitted by the Claimant relating relevant to the claim regardless of whether the information was submitted or considered in the initial benefit determination. Within 60 days (or, if special circumstances require an extension of time for processing, 120 days, in which case notice benefits; and description of such special circumstances and the expected date of decision shall be provided within the initial 60-day period) after receipt of written application for review, the Committee will provide the Claimant with its decision in writing or by electronic communication, including, if the Claimant's claim is not approved, (A) specific reasons for the decision, (B) specific references to the Plan provisions on which the decision is based, (C) a statement that the Claimant may receive on request all relevant records at no charge; and (D) (iv) a statement of the Claimant's claimant's right to bring an a civil action under Section section 502(a) of ERISA. c) The internal (d) Exhaustion; Scope of Review. No claimant may bring an action for any alleged wrongful denial of Plan benefits in a court of law unless the claims procedures set forth in this Section 15 above are mandatory. exhausted and a final determination is made by the Committee. If a Claimant fails to follow these claims procedures, or to timely file claimant challenges a request for appeal in accordance with decision under this Section 15, a review by the denial court of law will be limited to the facts, evidence and issues presented during the claims procedure set forth above. Facts and evidence that become known to the claimant after having exhausted the claims procedure must be brought to the attention of the Claim Committee for reconsideration of the claims determination. Issues not raised during the claims procedure shall become final and binding on all persons for all purposes. be deemed waived. View More
Claims Procedure. a) The Participant, or his beneficiary hereunder or authorized representative (the "Claimant"), (a) Presentation of Claim. Any Participant (such Participant being referred to below as a "Claimant") may file a claim for benefits under the Plan by written communication deliver to the Committee or its designee. A a written claim is not considered filed until for a determination with respect to the benefits payable to such communication is actually received. Within Claimant pursuant to the Plan. If ...such a claim relates to the contents of a notice received by the Claimant, the claim must be made within 60 days after such notice was received by the Claimant. All other claims must be made within 180 days of the date on which the event that caused the claim to arise occurred. The claim must state with particularity the determination desired by the Claimant. (b) Notification of Decision. The Committee shall consider a Claimant's claim within a reasonable time, but no later than 90 days (or, if after receiving the claim. If the Committee determines that special circumstances require an extension of time for processing, 180 days, in which case processing the claim, written or electronic notice and description of the extension shall be furnished to the Claimant prior to the termination of the initial 90 day period. In no event shall such extension exceed a period of 90 days from the end of the initial 90 day period. The extension notice shall indicate the special circumstances, circumstances requiring an extension of time and the date by which the Committee expects to tender its decision, render the benefit determination. The Committee shall notify the Claimant in writing: (i) that the Claimant's requested determination has been made, and that the claim has been allowed in full; or 12 (ii) that the Committee has reached a conclusion contrary, in whole or in part, to the Claimant's requested determination, and such notice must set forth in a manner calculated to be provided within understood by the initial 90-day period) after Claimant: A. the filing specific reason(s) for the denial of the claim, the Committee will either: (i) approve the claim and take appropriate steps for satisfaction or any part of the claim; or (ii) if the claim is wholly or partially denied, advise the Claimant of such denial by furnishing to him a written or electronic notice of such denial setting forth (A) the it; B. specific reason or reasons for the denial; (B) specific reference reference(s) to pertinent provisions of the Plan on upon which the such denial is based and, if the denial is based in whole or in part on any rule of construction or interpretation adopted by the Committee, a reference to such rule, a copy of which shall be provided to the Claimant; (C) was based; C. a description of any additional material or information necessary for the Claimant to perfect the claim claim, and an explanation of the reasons why such material or information is necessary; and (D) a description D. an explanation of the Plan's appeal procedures claim review procedure and the time limits applicable to such procedures, including procedures set forth in Section 10(c); and E. a statement of the Claimant's right to bring a civil action under ERISA Section 502(a) following an adverse determination on review. (c) Review of a Denied Claim. On or before 60 days after receiving a notice from the Committee that a claim has been denied, in whole or in part, a Claimant (or the Claimant's duly authorized representative) may file with the Committee a written request for a review of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") following a denial of the claim on appeal. 8 b) claim. The Claimant (or the Claimant's duly authorized representative): (i) may, upon request and free of charge, have reasonable access to, and copies of, all documents, records and other information relevant to the claim for benefits; (ii) may submit written comments or other documents; and/or (iii) may request a hearing, which the Committee, in its sole discretion, may grant. (d) Decision on Review. The Committee shall render its decision on review of any denial of his claim by written application to the Committee within promptly, and no later than 60 days after receipt the Committee receives the Claimant's written request for a review of the denial of the claim. If the Committee determines that special circumstances require an extension of time for processing the claim, written notice of denial of such claim. The Committee the extension shall afford be furnished to the Claimant an opportunity to review and receive, without charge, all relevant documents, information and records and to submit issues and comments in writing prior to the Committee. termination of the initial 60 day period. In no event shall such extension exceed a period of 60 days from the end of the initial 60 day period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the Committee expects to render the benefit determination. In rendering its decision, the Committee shall take into account all comments, documents, records and other information submitted by the Claimant relating to the claim regardless of claim, without regard to whether the such information was submitted or considered in 13 the initial benefit determination. Within 60 days (or, if special circumstances require an extension of time for processing, 120 days, The decision must be written in which case notice a manner calculated to be understood by the Claimant, and description of such special circumstances and the expected date of decision shall be provided within the initial 60-day period) after receipt of written application for review, the Committee will provide the Claimant with its decision in writing or by electronic communication, including, if the Claimant's claim is not approved, (A) it must contain: (i) specific reasons for the decision, (B) decision; (ii) specific references reference(s) to the pertinent Plan provisions on upon which the decision is based, (C) was based; (iii) a statement that the Claimant may receive on is entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records and other information relevant records at no charge; (as defined in applicable ERISA regulations) to the Claimant's claim for benefits; and (D) (iv) a statement description of the Claimant's right to bring an a civil action under Section 502(a) of ERISA. c) The internal claims procedures set forth in this Section 15 are mandatory. If a Claimant fails to follow these claims procedures, or to timely file a request for appeal in accordance with this Section 15, the denial of the Claim shall become final and binding ERISA following an adverse benefit determination on all persons for all purposes. review. View More
Claims Procedure. a) The Participant, 15.1 Filing a Claim. Any Participant or his beneficiary hereunder or authorized representative other person claiming an interest in the Plan (the "Claimant"), "Claimant") may file a claim for benefits under in writing with the Committee. The Committee shall review the claim itself or appoint an individual or entity to review the claim. 15.2 Claim Decision. The Claimant shall be notified within ninety (90) days after the claim is filed whether the claim is approved or denied, ...unless the Committee determines that special circumstances beyond the control of the Plan by written communication to require an extension of time, in which case the Committee or its designee. A claim is not considered filed until such communication is actually received. Within 90 may have up to an additional ninety (90) days (or, if special circumstances require to process the claim. If the Committee determines that an extension of time for processing, 180 days, in which case processing is required, the Committee shall 19 furnish written or electronic notice and description of such the extension to the Claimant before the end of the initial ninety (90) day period. Any notice of extension shall describe the special circumstances, circumstances necessitating the additional time and the date by which the Committee expects to tender render its decision, shall be provided within decision. 15.3 Notice of Denial. If the initial 90-day period) after the filing of Committee denies the claim, it must provide to the Committee will either: (i) approve the claim and take appropriate steps for satisfaction of the claim; or (ii) if the claim is wholly or partially denied, advise the Claimant of such denial by furnishing to him Claimant, in writing, a written or electronic notice of such denial setting forth (A) which includes: (a) the specific reason or reasons reason(s) for the denial; (B) (b) specific reference to the pertinent Plan provisions of the Plan on which the such denial is based and, if the denial is based in whole or in part on any rule of construction or interpretation adopted by the Committee, a reference to such rule, a copy of which shall be provided to the Claimant; (C) based; (c) a description of any additional material or information necessary for the Claimant to perfect the his or her claim and an explanation of the reasons why such material or information is necessary; and (D) (d) a description of the Plan's appeal 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 the Employee Retirement Income Security Act of 1974, as amended ("ERISA") ERISA following a denial of the claim on appeal. 8 b) The Claimant may appeal; and (e) if an internal rule was relied on to make the decision, either a copy of the internal rule or a statement that this information is available at no charge upon request. 15.4 Appeal Procedures. A request for appeal of a review of any denial of his denied claim by written application must be made in writing to the Committee within 60 sixty (60) days after receiving notice of denial. The decision on appeal will be made within sixty (60) days after the Committee's receipt of a request for appeal, unless special circumstances require an extension of time for processing, in which case a decision will be rendered not later than one hundred twenty (120) days after receipt of the a request for appeal. A notice of denial such an extension must be provided to the Claimant within the initial sixty (60) day period and must explain the special circumstances and provide an expected date of such claim. decision. The Committee reviewer shall afford the Claimant an opportunity to review and receive, without charge, all relevant documents, information and records and to submit issues and comments in writing to the Committee. The Committee reviewer shall take into account all comments, documents, records and other information submitted by the Claimant relating to the claim regardless of whether the information was submitted or considered in the initial benefit determination. Within 60 days (or, if special circumstances require an extension 15.5 Notice of time for processing, 120 days, in which case notice and description of such special circumstances and the expected date of decision shall be provided within the initial 60-day period) after receipt of written application for review, Decision on Appeal. If the Committee will denies the appeal, it must provide to the Claimant with its decision Claimant, in writing or by electronic communication, including, if writing, a notice which includes: (a) the Claimant's claim is not approved, (A) specific reasons reason(s) for the decision, (B) denial; 20 (b) specific references to the pertinent Plan provisions on which the decision such denial is based, (C) based; (c) a statement that the Claimant may receive on request all relevant records at no charge; (d) a description of the Plan's voluntary procedures and (D) deadlines, if any; (e) a statement of the Claimant's right to bring an action sue under Section 502(a) of ERISA. c) ERISA; and (f) if an internal rule was relied on to make the decision, either a copy of the internal rule or a statement that this information is available at no charge upon request. 15.6 Claims Procedures Mandatory. The internal claims procedures set forth in this Section 15 are mandatory. If a Claimant fails to follow these claims procedures, or to timely file a request for appeal in accordance with this Section 15, the denial of the Claim shall become final and binding on all persons for all purposes. View More
Claims Procedure. a) The Participant, 16.1 Filing a Claim. Any Participant or his beneficiary hereunder or authorized representative other person claiming an interest in the Plan (the "Claimant"), "Claimant") may file a claim for benefits under in writing with the Committee. The Committee shall review the claim itself or appoint an individual or entity to review the claim. 16.2 Claim Decision. The Claimant shall be notified within ninety (90) days after the claim is filed whether the claim is approved or denied, ...unless the Committee determines that special circumstances beyond the control of the Plan by written communication to require an extension of time, in which case the Committee or its designee. A claim is not considered filed until such communication is actually received. Within 90 may have up to an additional ninety (90) days (or, if special circumstances require to process the claim. If the Committee determines that an extension of time for processing, 180 days, in which case processing is required, the Committee shall furnish written or electronic notice and description of such the extension to the Claimant before the end of the initial ninety (90) day period. Any notice of extension shall describe the special circumstances, circumstances necessitating the additional time and the date by which the Committee expects to tender render its decision, shall be provided within decision. 16.3 Notice of Denial. If the initial 90-day period) after the filing of Committee denies the claim, it must provide to the Committee will either: (i) approve the claim and take appropriate steps for satisfaction of the claim; Claimant, in writing or (ii) if the claim is wholly or partially denied, advise the Claimant of such denial by furnishing to him electronic communication, a written or electronic notice of such denial setting forth (A) the which includes: (a) The specific reason or reasons reason(s) for the denial; (B) specific (b) Specific reference to the pertinent Plan provisions of the Plan on which the such denial is based and, if the denial is based in whole or in part on any rule of construction or interpretation adopted by the Committee, a reference to such rule, a copy of which shall be provided to the Claimant; (C) a based; (c) A description of any additional material or information necessary for the Claimant to perfect the his or her claim and an explanation of the reasons why such material or information is necessary; and (D) a (d) A description of the Plan's appeal 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 the Employee Retirement Income Security Act of 1974, as amended ("ERISA") ERISA following a denial of the claim on appeal. 8 b) The Claimant may appeal; and (e) If an internal rule was relied on to make the decision, either a copy of the internal rule or a statement that this information is available at no charge upon request. 16.4 Appeal Procedures. A request for appeal of a review of any denial of his denied claim by written application must be made in writing to the Committee within 60 sixty (60) days after receiving notice of denial. The decision on appeal will be made within sixty (60) days after the Committee's receipt of a request for appeal, unless special circumstances require an extension of time for processing, in which case a decision will be rendered not later than one hundred twenty (120) days after receipt of the a request for appeal. A notice of denial such an extension must be provided to the Claimant within the initial sixty (60) day period and must explain the special circumstances and provide an expected date of such claim. decision. The Committee reviewer shall afford the Claimant an opportunity to review and receive, without charge, all relevant documents, information and records and to submit issues and comments in writing to the Committee. The Committee reviewer shall take into account all comments, documents, records and other information submitted by the Claimant relating to the claim regardless of whether the information was submitted or considered in the initial benefit determination. Within 60 days (or, if special circumstances require an extension 16.5 Notice of time for processing, 120 days, in which case notice and description of such special circumstances and the expected date of decision shall be provided within the initial 60-day period) after receipt of written application for review, Decision on Appeal. If the Committee will denies the appeal, it must provide to the Claimant with its decision Claimant, in writing or by electronic communication, including, if the Claimant's claim is not approved, (A) a notice which includes: (a) The specific reasons reason(s) for the decision, (B) specific denial; (b) Specific references to the pertinent Plan provisions on which the decision such denial is based, (C) a based; (c) A statement that the Claimant may receive on request all relevant records at no charge; (d) A description of the Plan's voluntary procedures and (D) a deadlines, if any; (e) A statement of the Claimant's right to bring an action sue under Section 502(a) of ERISA. c) ERISA; and (f) If an internal rule was relied on to make the decision, either a copy of the internal rule or a statement that this information is available at no charge upon request. 16.6 Claims Procedures Mandatory. The internal claims procedures set forth in this Section 15 16 are mandatory. If a Claimant fails to follow these claims procedures, or to timely file a request for appeal in accordance with this Section 15, 16, the denial of the Claim shall become final and binding on all persons for all purposes. View More
