Review Process
You have the right to review documents relevant to your
claim. A document, record or other information will be
considered relevant if:
- It was relied upon by the Claim Administrator in
making the decision;
- It was submitted, considered or generated (regardless
of whether it was relied upon);
- It demonstrates compliance with the Claim Administrator’s
administrative processes for ensuring consistent
decision-making; or
- It constitutes a statement of Plan policy regarding the
denied treatment or service.
Upon request, you will be provided with the identification
of medical or vocational experts, if any, that gave advice
to the Claim Administrator on your claim, without
regard to whether their advice was relied upon in deciding
your claim.
Your claim will be reviewed by a different person from the
one who originally denied the claim. The reviewer will not
give deference to the initial adverse benefit determination.
The decision will be made on the basis of the record,
including such additional documents and comments that
may be submitted by you. If your claim was denied on the
basis of a medical judgment (such as a determination that
the treatment or service was not medically necessary or
was investigational or experimental), a health care professional
who has appropriate training and experience in a
relevant field of medicine will be consulted.
