Adverse Benefit Determination definition

Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in the Plan; and including
Adverse Benefit Determination means any of the following:
Adverse Benefit Determination means a decision by a health plan issuer:

Examples of Adverse Benefit Determination in a sentence

  • Notice to Insured of Adverse Benefit Determination Adverse benefit determination means a denial, reduction, termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination or failure to provide or make payment that is based on a determination of a participant’s eligibility to participate in the plan.


More Definitions of Adverse Benefit Determination

Adverse Benefit Determination means any of the following: a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a claimant’s eligibility to participate in a plan and with respect to a claim for benefits due to Executive being Permanently Disabled, shall also mean any rescission of disability coverage with respect to a Participant or Beneficiary (whether or not there is an adverse effect on any particular benefit at that time), where rescission means a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.
Adverse Benefit Determination means a denial, reduction, or
Adverse Benefit Determination means a rescission of coverage; a decision by the CO-OP to deny, reduce, terminate, fail to provide, or make payment for a benefit, including a denial, reduction termination, or failure to provide, or make a payment for a benefit that is based on: an individual’s eligibility; a determination that a benefit is not a Covered Service; the limitation on an otherwise Covered Service; or a determination that a benefit is experimental, investigational, or not Medically Necessary or appropriate. A denial of coverage in an initial eligibility determination for individual coverage is an Adverse Benefit Determination.
Adverse Benefit Determination means an insurer’s denial, reduction or termination of a
Adverse Benefit Determination means a rescission of coverage; a decision by SHL to deny, reduce, terminate, fail to provide, or make payment for a benefit, including a denial, reduction termination, or failure to provide, or make a payment for a benefit that is based on:
Adverse Benefit Determination means an insurer’s denial, reduction or termination of a health care item or service, or an insurer’s failure or re- fusal to provide or to make a payment in whole or in part for a health care item or service, that is based on the insurer’s:
Adverse Benefit Determination means a denial, reduction or termination of, or a failure to make payment (in whole or in part) for, a benefit, including a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because the Carrier determines the item or service to be experimental or investigational, cosmetic, dental rather than medical, excluded as a pre-existing condition or because the Carrier has rescinded the coverage.