following the date of the decision on the final appeal under the STD Plan or (B) two years after the claim arose.
What happens if my claim is denied? The Plan Administrator (or its delegate) has the exclusive discretionary authority to construe and to interpret the STD Plan, to decide all questions of eligibility for benefits and to determine the amount of such STD benefits, and its decisions on such matters are final and conclusive. Benefits under the STD Plan will be paid only if the Plan Administrator (or its delegate) decides in its discretion that the applicant is entitled to them. Any interpretation or determination made pursuant to such discretionary authority will be upheld on judicial review, unless it is shown that the interpretation or determination was an abuse of discretion.
The term Plan Administrator, as used below in describing the STD Plan’s claims and appeals process, includes the delegate of the Plan Administrator, the Claims Administrator.
With respect to all claims for benefits under the STD Plan filed on or after April 1, 2018, the following procedures will apply. For claims for benefits under the STD Plan filed prior to April 1, 2018, the claims procedures set forth in the STD Plan document effective January 1, 2017 will apply. If you have made a claim for STD benefits, including a claim for eligibility under the STD Plan, and your claim is denied, you will receive a written denial notice within 45 days of the date that the claim was received. This notice will be made in a culturally and linguistically appropriate matter and will include –
The specific reason or reasons for the denial;
The specific reference to any provisions of the STD Plan on which the denial is based;
A description of any additional material or information you may submit to perfect your claim and an explanation of why such material or information is necessary;
A description of the STD Plan’s claims review procedure (including the time limits applicable to such process);
Your right to review, upon request and free of charge, relevant documents and other information;
Your right to file suit under ERISA with respect to any adverse determination after appeal of your claim;
A discussion of the decision, including an explanation of the basis for disagreeing with or not following:
- The views you presented to the STD Plan of health care professionals who treated who and vocational professionals who evaluated you;
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