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Jefferson Pilot Life Ins.#1
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RFP No. 01-10-01 Employee Dental, Life, Insurance
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Jefferson Pilot Life Ins.#1
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Last modified
6/18/2012 10:02:26 PM
Creation date
12/28/2010 3:46:06 PM
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CityClerk-Bids_RFP_RFQ
Project Name
Employee Insurance
Bid No. (xx-xx-xx)
01-10-01
Project Type (Bid, RFP, RFQ)
RFP
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CLAIMS PROCEDURES - CONTINUED <br />REVIEW PROCEDURE. Within 60 days after receiving a denial notice, the Insured Person or Beneficiary may request a <br />aim review by sending the Company a written request, along with any written comments or other items to support the <br />claim. The Insured Person or Beneficiary may review certain non - privileged information relating to the request for review. <br />The Company will review the claim and send the Insured Person or Beneficiary a written notice of their decision within 60 <br />days after receiving the request for review; or within 120 days, if special circumstances require an extension. The notice <br />will state the reasons for the Company's decision under the terms of this Policy. <br />RIGHT OF RECOVERY. If benefits have been overpaid on any claim, full reimbursement to the Company is required <br />within 60 days. If reimbursement is not made, the Company has the right to: <br />(1) reduce future benefits until full reimbursement is made; and <br />(2) recover such overpayments from the Insured Person or his or her Beneficiary or estate. <br />Such reimbursement is required whether the overpayment is due to fraud, the Company's error in processing a claim, or <br />any other reason. <br />LEGAL ACTIONS. No legal action to recover any benefits may be brought until 60 days after the required written proof of <br />claim has been given. No legal action may be brought after the expiration of the applicable statute of limitations, running <br />from the time written proof of claim must be given. <br />COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically reserves to the <br />Group Policyholder or Employer, the Company has the authority to manage this Policy, to administer claims, to interpret <br />Policy provisions, and to resolve questions arising under this Policy. The Company's authority includes (but is not limited <br />to) the right to: <br />(1) establish and enforce procedures for administering this Policy and claims under it; <br />(2) determine Employees' eligibility for insurance and entitlement to benefits; <br />(3) determine what information the Company reasonably requires to make such decisions; and <br />la(4) . resolve all matters when a claim review is requested. <br />ny decision the Company makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured <br />Person's or Beneficiary's right to request a state insurance department review or to bring legal action. <br />• <br />GL1101 -13A FL L /ADD <br />19 05101101 <br />
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