Denial Notices

Any notice of an adverse benefit decision will include the following:

• The specific reason or reasons for the adverse determination;
• Reference to the Fund's provisions on which the determination was based;
• A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why the information is necessary;
• A description of the Fund's review procedures, the time limits applicable to such procedures, and the claimant's right, at no charge, to have reasonable access to and to obtain copies of all relevant documents upon request, and a statement of the claimant's right to bring a civil action under ERISA Section 502(a) following an adverse determination on review;
• If an internal rule or guideline was applied in making the determination, a statement that the rule will be provided free of charge upon request;
• If the determination is based on a medical necessity or experimental exclusion, a statement that an explanation of the scientific or clinical judgment applied to make the determination will be provided free of charge upon request; and
• If the determination affects a claim for urgent health care, a description of the expedited review process applicable to such claims.