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requiring the extension and the date by which the Plan expects to render a decision. In the case of any extension, the notice of
extension shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a
decision on the claim, and the additional information needed to resolve those issues. The Claimant shall be afforded at least 45 days
within which to provide the specified information.
In the event that a period of time is extended due to a Claimant’s failure to submit information necessary to decide a claim, the
period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the
Claimant until the date on which the Claimant responds to the request for additional information.
The Plan Administrator’s notice to the Claimant shall: (i) specify the reason or reasons for the denial; (ii) reference the specific
Plan provisions on which the denial is based; (iii) describe any additional material and information needed for the Claimant to perfect
his claim for benefits; (iv) explain why the material and information is needed; (v) inform the Claimant of the Plan’s appeal
procedures and the time limits applicable to such procedures, including a statement of the Claimant’s right to bring a civil action
under ERISA section 502(a) following an adverse benefit determination on appeal; (vi) provide the Claimant with any internal rule,
guideline, protocol, or other similar criterion that was relied upon in making the adverse determination or a statement that such rule,
guideline, protocol, or other similar criterion was relied upon and a copy will be provided free of charge upon request; and
(vii) provide the Claimant with an explanation of any scientific or clinical judgment for the determination if benefit determination is
based on a medical necessity or experimental treatment or similar exclusion or limit or a statement that the benefit is based on such an
exclusion or limit and such explanation will be provided free of charge.
Any appeal made by a Claimant must be made in writing to the Plan Administrator within 180 days after receipt of the Plan
Administrator’s notice of denial of benefits. The Claimant may submit written comments, documents, records, and other information
relating to the claim for benefits. The Claimant shall be provided, upon request and free of charge, reasonable access to, and copies
of, all documents, records, and other information relevant to the Claimant’s claim for benefits. The Plan Administrator shall review
the claim taking into account all comments, documents, records, and other information submitted by the Claimant relating to the
claim, without regard to whether such information was submitted or considered in the initial benefit determination. The review shall
not afford deference to the initial adverse benefit determination and shall be conducted by an appropriate named fiduciary who is
neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such
individual. If the adverse benefit determination is based in whole or in part on a medical judgment, the appropriate named fiduciary
shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the
medical judgment. Such health care professional shall be an individual who is neither an individual who was consulted in connection
with the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual. The Claimant shall be
provided with the identity of medical or vocational experts whose advise was obtained on behalf of the Plan in connection with the
adverse benefit determination, without regard to whether the advice was relied on.
The Plan Administrator shall provide adequate written notice to the Claimant of the Plan’s benefit determination on review. The
notice must be furnished within 45 days of the date that the request for review is received by the Plan without regard to whether all of
the information necessary to make a benefit determination on review is received. The Claimant shall be notified in writing within this
initial 45-day period if special circumstances require an extension of the time needed to process the claim. The notice shall indicate
the special circumstances requiring an extension of time and the date by which the Plan Administrator expects to render the
determination on review. In no event shall such extension exceed a period of 45 days from the end of the initial 45-day period.
RESTATEMENT DECEMBER 15, 2006 69 ARTICLE IX (5-19047)