Within 60 days (or, for a disability claim, 180 days) after receipt of such notice of denial, the claimant may request, by mailing or delivery of written notice to the Plan, a review by the Administrator of the decision denying the claim. The claimant will be provided an opportunity to submit written comments, documents, records, and other pertinent information. The claimant will also be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim. The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
For a disability claim, the review will not afford deference to the initial claim denial and will be conducted by an appropriate named fiduciary of the Plan who is neither the individual who denied the claim that is the subject of the appeal, nor the subordinate of such individual. In deciding an appeal of any claim denial that is based in whole or in part on medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. Such health care professional will be an individual who is neither an individual who was consulted in connection with the initial denial, nor the subordinate of any such individual. The Administrator will identify the medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the claim denial, without regard to whether the advice was relied upon in denying the claim.
After such review, the Administrator will determine whether the denial of the claim was correct and will notify the claimant in writing of its determination within a reasonable period of time, but not later than 60 days (or, for a disability claim, 45 days) after the receipt of a claimant’s request for review by the Administrator; provided, however, that an extension of time not exceeding 60 days (or, for a disability claim, 45 days) will be available if special circumstances require an extension of time for processing the appeal. If so, notice of such extension, indicating what special circumstances exist and the date by which a final decision is expected to be rendered, will be furnished to the claimant before the initial 60-day (or, for a disability claim, 45-day) period expires.
The claimant will be advised of the Administrator’s decision in writing. If the appeal is denied, the notice of denial shall set forth, in a manner calculated to be understood by the claimant, the specific reason for such denial; reference to the specific Plan provisions on which the benefit determination is based; 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 claim; and a statement of the claimant’s right to bring an action under Section 502(a) of ERISA.
For a disability claim, the written notice of decision will further set forth:
| • | | If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request; |
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