Adverse Benefit Determination An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is (000) 000-0000 or 0-000-000-0000.
FINAL DETERMINATION BY BOARD The Board shall have the right and power to adjust and determine finally all questions as to the proper and timely performance of the work and the amounts earned under this Contract, all as provided in General Conditions.
Submission of a Claim 1. A disputing investor may submit a claim referred to in Article 32 (Claim by an Investor of a Member State) at the choice of the disputing investor:
Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.
Hearing Decision The decision of the Board shall be in writing and shall contain findings of fact and the personnel action approved, if any. The findings may reiterate the language of the pleadings or simply refer to them. The decision of the Board shall be certified to the Superintendent or designee who recommended the personnel action, and he/she shall enforce and follow this decision. A copy of the decision shall be delivered to the appellant or his/her designated representative personally or by registered mail. The decision of the Board shall be final.
Independence from Material Breach Determination Except as set forth in Section X.D.1.c, these provisions for payment of Stipulated Penalties shall not affect or otherwise set a standard for OIG’s decision that CHSI has materially breached this CIA, which decision shall be made at OIG’s discretion and shall be governed by the provisions in Section X.D, below.
Penalty Determination H&SC section 39619.7 requires CARB to provide information on the basis for the penalties it seeks. This Agreement includes this information, which is also summarized here. The provision of law the penalty is being assessed under and why that provision is most appropriate for that violation. The penalty provision being applied in this case is H&SC section 42402 et seq. because IIT sold, supplied, offered for sale, consumer products for commerce in California in violation of the Consumer Products Regulations (17 CCR section 94507 et seq.). The penalty provisions of H&SC section 42402 et seq. apply to violations of the Consumer Products Regulations because the regulations were adopted under authority of H&SC section 41712, which is in Part 4 of Division 26. The manner in which the penalty amount was determined, including aggravating and mitigating factors and per unit or per vehicle basis for the penalty. H&SC section 42402 et seq. provides strict liability penalties of up to $10,000 per day for violations of the Consumer Product Regulations with each day being a separate violation. In cases like this, involving unintentional violations of the Consumer Products Regulations where the violator cooperates with the investigation, CARB has obtained penalties for selling uncertified charcoal lighter material in California. In this case, the total penalty is $7,500 for selling uncertified charcoal lighter material in California. The penalty in this case was reduced because this was a strict liability first-time violation and IIT made diligent efforts to cooperate with the investigation. To come into compliance, IIT no longer offers Safegel BBQ & Fireplace Lighting Gel Fire Starter for commerce in California. Final penalties were determined based on the unique circumstances of this matter, considered together with the need to remove any economic benefit from noncompliance, the goal of deterring future violations and obtaining swift compliance, the consideration of past penalties in similar negotiated cases, and the potential cost and risk associated with litigating these particular violations. The penalty reflects violations extending over a number of days resulting in quantifiable harm to the environment considered together with the complete circumstances of this case. Penalties in future cases might be smaller or larger on a per ton basis. The final penalty in this case was based in part on confidential financial information or confidential business information provided by IIT that is not retained by CARB in the ordinary course of business. The penalty in this case was also based on confidential settlement communications between CARB and IIT that CARB does not retain in the ordinary course of business. The penalty also reflects CARB’s assessment of the relative strength of its case against IIT, the desire to avoid the uncertainty, burden and expense of litigation, obtain swift compliance with the law and remove any unfair advantage that IIT may have secured from its actions. Is the penalty being assessed under a provision of law that prohibits the emission of pollution at a specified level, and, if so a quantification of excess emissions, if it is practicable to do so. The Consumer Product Regulations do not prohibit emissions above a specified level, but they do limit the concentration of VOCs in regulated products. In this case, a quantification of the excess emissions attributable to the violations was not practicable.
Liability Calculation Method Per Claim Unless subject to a fixed dollar copayment, the calculation of Member liability on claims for Out-of-Area Covered Health Care Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Blue Shield by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Blue Shield by the Host Blue may be represented by one of the following:
Determination by Independent Firm In the event of any question arising with respect to the adjustments provided for in this Article 4 such question shall be conclusively determined by an independent firm of chartered accountants other than the Auditors, who shall have access to all necessary records of the Corporation, and such determination shall be binding upon the Corporation, the Warrant Agent, all holders and all other persons interested therein.
Third Party Claim A Claim where there is (a) a claim, demand, suit or action by a person who is not a Party, (b) a settlement with, judgment by, or liability to, a person who is not a Party, or (c) a fine or penalty imposed by a person who is not a Party.
