Reso 2001-399 - Laserfiche WebLink

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. ." . CLAIMS PROCEDURES. CONTINUED REVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Person or Beneficiary may request a ;Iaim review by sending the Company a written request, along with any written comments or other items to support the claim. The Insured Person or Beneficiary may review certain non-privileged information relating to the request for review. The Company will review the claim and send the Insured Person or Beneficiary a written notice of their decision within 60 days after receiving the request for review; or within 120 days, if special circumstances require an extension. The notice will state the reasons for the Company's decision under the terms of this Policy. RIGHT OF RECOVERY. If benefits have been overpaid on any claim, full reimbursement to the Company is required within 60 days, If reimbursement is not made, the Company has the right to: (1) reduce future benefits until full reimbursement is made; and (2) recover such overpayments from the Insured Person or his or her Beneficiary or estate, Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or any other reason, LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of claim has been given, No legal action may be brought after the expiration of the applicable statute of limitations, running from the time written proof of claim must be given. COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically reserves to the Group Policyholder or Employer, the Company has the authority to manage this Policy, to administer claims, to interpret Policy provisions, and to resolve questions arising under this Policy, The Company's authority includes (but is not limited to) the right to: (1) establish and enforce procedures for administering this Policy and claims under it; (2) determine Employees' eligibility for insurance and entitlement to benefits; (3) determine what information the Company reasonably requires to make such decisions; and (4). resolve all matters when a claim review is requested. my decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured Person's or Beneficiary's right to request a state insurance department review or to bring legal action, 19 UADD 05101/01 GLllOl-13A FL