Claims Appeal

You have a Denied Claim / Ineligible Card Transaction:

You should receive this notice no later than 30 days after we receive the claim or mark your card transaction as ineligible. This notice should contain (a) the reason(s) for the denial and the plan provisions on which the denial is based, and (b) a description of the plan’s appeal procedures and the time limits applicable to such procedures. You have the right to request all documentation relevant to your claim. If you disagree with this denial, you can file a written appeal with us no later than 180 days after receipt of this notice. Submit all information relevant to your claim and any additional information that you believe would support your claim. You will receive a written answer no later than 30 days after we receive the appeal. If the appeal is denied, you can file a second appeal with your plan administrator at your place of employment. We will furnish the details of the second appeal process upon request.

Claim Appeal Procedure

The Plan has established the following claims review procedures in the event you are denied a benefit under this Plan.  

Step 1:  Notice is received from American Benefits Group (ABG). If your claim is denied, you will receive written notice from ABG that your claim is denied as soon as reasonably possible but no later than 30 days after receipt of the claim.  For reasons beyond the control of ABG, ABG may take up to an additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the end of the 30-day period. If the reason for the additional time is that you need to provide additional information, you will have 45 days from the notice of the extension to obtain that information. The time period during which ABG must make a decision will be suspended until the earlier of the date that you provide the information or the end of the 45-day period.

Step 2:  Review your notice carefully. Once you have received your notice from ABG, review it carefully. The notice will contain:

  1. the reason(s) for the denial and the Plan provisions on which the denial is based;
  2. a description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information;
  3. a description of the Plan’s appeal procedures and the time limits applicable to such procedures; and
  4. a right to request all documentation relevant to your claim.

Step 3:  If you disagree with the decision, file an Appeal.  If you do not agree with the decision of ABG and you wish to appeal, you must file your appeal no later than 180 days after receipt of the notice described in Step 1.  You should submit all information identified in the notice of denial as necessary to perfect your claim and any additional information that you believe would support your claim.

Step 4:  Notice of Denial is received from ABG.  If the claim is again denied, you will be notified in writing as soon as possible but no later than 30 days after receipt of the appeal by the ABG.

Step 5:  Review your notice carefully. You should take the same action that you took in Step 2 described above. The notice will contain the same type of information that is provided in the first notice of denial provided by ABG.

Step 6:  If you still disagree with the ABG’s decision, file a 2nd Level Appeal with the Plan Administrator.  If you still do not agree with the ABG’s decision and you wish to appeal, you must file a written appeal with the Plan Administrator within the time period set forth in the first level appeal denial notice from ABG. You should gather any additional information that is identified in the notice as necessary to perfect your claim and any other information that you believe would support your claim.

If the Plan Administrator denies your 2nd Level Appeal, you will receive notice within 30 days after the Plan Administrator receives your claim. The notice will contain the same type of information that was referenced in Step 2 above.

Important Information

Other important information regarding your appeals:

  • Each level of appeal will be independent from the previous level (i.e., the same person(s) or subordinates of the same person(s) involved in a prior level of appeal will not be involved in the appeal);
  • On each level of appeal, the claims reviewer will review relevant information that you submit even if it is new information; and
  • You cannot file suit in federal court until you have exhausted these appeals procedures.