Notice of Decision on Review After Appeal
The decision on any review of your claim will be given to
you in writing. The notice of a denial of a claim on review
will state:
- The specific reason(s) for the determination;
- Reference to the specific Plan provision(s) on which
the determination is based;
- A statement that you are entitled to receive reasonable
access to and copies of all documents relevant to your
claim, upon request and free of charge;
- A statement of your right to bring a civil action under
ERISA Section 502(a) following an adverse benefit
determination on review;
- If an internal rule, guideline or protocol was relied
upon by the Plan, you will receive either a copy of the
rule or a statement that it is available upon request at
no charge; and
- If the determination was based on the absence of
medical necessity, or because the treatment was
experimental or investigational, or other similar
exclusion, you will receive an explanation of the
scientific or clinical basis for the determination
applying the terms of the Plan to your claim, or a
statement that it is available upon request at
no charge.
