- The views of medical or vocational experts whose advice was obtained on behalf of the STD Plan in connection with the adverse determination on your claim, without regard to whether the advice was relied upon in making the benefit determination; and
- Any Social Security Administration disability determination regarding you that you presented to the STD Plan.
If your claim was denied based on a medical necessity or experimental treatment or similar exclusion, an explanation of the scientific or clinical judgment for the determination, applying the terms of the STD Plan to your medical circumstances (or a statement of your right to receive such an explanation upon request); A statement disclosing any internal rule, guidelines, protocol or similar criteria relied on in making the adverse determination, or, alternatively, a statement that such rules, guidelines, protocols, standards or similar criteria do not exist; and A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. If, for reasons beyond the control of the Plan Administrator, an extension of time is required for processing the claim, you will receive a written notice of the extension, an explanation of the circumstances requiring extension and the expected date of the decision before the end of the 45- day period. The Plan Administrator may only extend the 45-day period twice, each for 30 days at a time. If at any time the Plan Administrator requires additional information in order to determine the claim, you will receive a written notice explaining the unresolved issues that prevent a decision on the claim and a listing of the additional information needed to resolve those issues. You will then have 45 days from the receipt of that notice to provide the additional information to the Plan Administrator, and during the time that a request for information is outstanding, the running of the time period in which your claim must be decided is suspended.
Appeal of a Denied Claim
If your claim has been denied in whole or in part and you would like your claim reconsidered, you must appeal the denial by submitting a written request for review to the Plan Administrator within 180 days of the date that you receive the claim denial notice, or else you will lose your right to appeal your denial. If you do not appeal on time, you will also lose your right to file suit in court, as you will have failed to exhaust your administrative appeal rights, which is generally a prerequisite to bringing suit.
Your right to appeal includes the opportunity for you or your legal representative to:
State the reasons why you feel your claim should not have been denied;
Submit written comments, documents, additional facts and other information supporting your claim;
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