Common use of Claims and Review Procedures Clause in Contracts

Claims and Review Procedures. Generally the amount credited to the Shortfall Account will be paid under this Agreement without the necessity of the filing a claim. Employee or beneficiary or other person (such being referred to below as a “claimant”) may deliver to the Company a written claim for a determination with respect to the amounts payable to such claimant pursuant to this Agreement. The claim must state with particularity the determination desired by the claimant. Solely for purposes of this Section 7, the term “Company” refers to the Company and any committee designated by the Company to consider claimant’s claim or claimant’s appeal of a denied claim. The Company shall, within ninety (90) days after the receipt of a written claim, send written notification to the claimant as to its disposition, unless special circumstances require an extension of time for processing the claim. If such an extension is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial period. In no event shall such extension exceed a period of ninety (90) days from the end of such initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the Company expects to render the final decision. In the event the claim is wholly or partially denied, the written notification shall state the specific reason or reasons for the denial, include specific references to pertinent Agreement provisions on which the denial is based, provide an explanation of any additional material or information necessary for the claimant to perfect the claim and a statement of why such material or information is necessary, and set forth the procedure by which the claimant may appeal the denial of the claim, including a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review. If the claim has not been granted and notice is not furnished within the time period specified in the preceding paragraph, the claim shall be deemed denied for the purpose of proceeding to appeal in accordance with the following paragraph below. In the event a claimant wishes to appeal the denial of his claim, the claimant may request a review of such denial by making written application to the Company within sixty (60) days after receipt of the written notice of denial (or the date on which such claim is deemed denied if written notice is not received within the applicable time period specified in the paragraph above). Such claimant (or his duly authorized representative) may, upon written request to the Company, review documents which are pertinent to such claim, obtain copies of such documents free of charge, submit in writing issues and comments in support of his position, and may request a hearing, which the Company, in its sole discretion, may grant. Within sixty (60) days after receipt of the written appeal (unless an extension of time is necessary due to special circumstances or is agreed to by the parties), the Company shall notify the claimant of its final decision. Such final decision shall be in writing and shall include specific reasons for the decision and specific references to the pertinent Agreement provisions on which the decision is based. If an extension of time for review is required because of special circumstances, written notice of the extension shall be furnished to be claimant prior to the commencement of the extension. Any extension of time will not exceed sixty (60) days. Any decision on review shall take into consideration all comments, documents, records, and other information submitted by the claimant (or the claimant’s duly authorized representative) relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Such decision must be written in a manner calculated to be understood by the claimant, and it must contain specific reasons for the decision, specific reference(s) to the pertinent Agreement provisions upon which the decision was based, and such other matters as the Company deems relevant. If the claim has not been granted and written notice is not provided within the time period specified above, the appeal shall be deemed denied. If the claimant does not follow the procedures set forth above, the claimant shall be deemed to have waived his right to appeal benefit determinations under the Agreement. In addition, the decisions, actions, and records of the Company shall be conclusive and binding upon all persons having or claiming to have any right or interests in or under the Agreement.