Appealing a Denied LTD Claim

If your claim is denied, the Claims Processor will notify you of the adverse decision within a reasonable period of time, but not later than 45 days after receiving the claim.

This 45-day period may be extended for up to 30 days, if the Claims Processor: (1) determines the extension is necessary because of matters beyond the plan’s control, and (2) notifies you, before the end of the 45-day period, why the extension is needed and the expected decision date. If, before the end of the first 30-day extension, the Claims Processor determines, due to matters beyond the plan’s control, a decision cannot be rendered within that extension period, the determination period may be extended for up to an additional 30 days, provided the Claims Processor notifies you, before the end of the first 30-day extension period, why the extension is needed and the expected decision date.

The notice of extension shall explain: (1) the standards on which benefit entitlement is based, (2) the unresolved issues that prevent a claim decision, and (3) the additional information needed. You have at least 45 days to provide the information.

The claim determination time frame begins when a claim is filed, without regard to whether all the information necessary to make a claim determination accompanies the filing.

If an extension is necessary because you failed to submit necessary information, the days from the date the Claims Processor sends you the extension notice until you respond to the request for additional information are not counted as part of the claim determination period.

Any denial will include specific reasons for the denial, and the provisions of the Claims Processor contract on which the denial is based. It will also explain how to apply for a review of the denied claim. Where appropriate, it will also include a description of any material that is needed to complete or perfect your claim, and will explain why such material is necessary.

The Claims Processor is solely responsible for determining what constitutes a covered claim under this plan. If the Claims Processor denies your claim for benefits, in whole or in part, you have a right to appeal the denial. You have 180 days to appeal a denied claim. After the receipt of the request for review, the appeal must be decided within 45 days unless special circumstances apply, and notice is given before the first 45-day period expires. In this case, the decision on appeal must be rendered within 45 days from the extension.

Prior to rendering a decision on appeal, the Claims Processor will provide you with any new or additional evidence considered, relied upon, or generated in connection with your claim. When appropriate, the Claims Processor will also provide any new or additional rationale used in making the decision on appeal before rendering the decision. Any new or additional evidence or rationale will be provided free of charge and sufficiently in advance of the issuance of the decision on appeal to allow you a reasonable opportunity to respond.

Appeals may be submitted to the following provider: