Aetna and CIGNA, the Life Insurance and AD&D Insurance carriers, consider requests for an appeal of a denied claim when you or your duly authorized representative makes a written request for review. You may review pertinent documents and submit to Aetnaand/or CIGNA a written statement of issues and comments. Review of claim denials and final decisions on appeal are Reliastar’s and/or CIGNA’s responsibility for the Life Insurance and AD&D Insurance Plans, respectively.
Aetnaand CIGNA serve as the claims review ﬁduciary with respect to the Life Insurance and AD&D insurance policies and Plans. For both the Life Insurance and AD&D Insurance Plans, the claims review ﬁduciary has the final discretionary authority to interpret the Plan and the insurance policy and to determine eligibility for benefits. Decisions by the claims review ﬁduciary will be complete, final and binding on all parties.
Life Insurance Claims
If Aetnadenies payment of your claim, you will receive written notice within 90 days of the date the insurance company receives your claim or physician’s statement, if filed later. An extension of 90 days will be allowed for processing your claim if special circumstances are involved. Aetnawill notify you in writing of any extension it requires to review your claim, including the special circumstances involved and the date by which it expects to reach a decision.
If Aetnadenies your claim, the notice will be written in an understandable manner and will include:
· The specific reasons for the denial;
· Specific references to the plan provision on which the denial is based; and
· An explanation of the claim review procedure.
You may request an appeal at any time during the 60-day period following the date you receive the notice of denial.
No civil action may be brought unless you exhaust your internal appeals with Reliastar. If your appeal to Aetnais denied, you have the legal right to bring a civil action under section 502(a) of ERISA within three years of the date proof of loss must be submitted.
CIGNA has 90 days from the date it receives your claim, to determine whether or not benefits are payable in accordance with the terms and provisions of the Policy. The Insurance Company may require more time to review your claim, if necessary, due to circumstances beyond its control. If this happens, CIGNA will notify you in writing that its review period has been extended for up to two additional periods of 30 days (in the case of a claim for disability benefits), or one additional period of 90 days (in the case of any other benefit). If this extension is made because you must furnish additional information, these extension periods will begin when the additional information is received. You have up to 45 days to furnish the requested information.
If your claim is denied, in whole or in part, you will receive a written notice from CIGNA within the review period. CIGNA’s written notice must include the following information:
1. The specific reason(s) the claim was denied;
2. Specific reference to the policy provision(s) on which the denial was based;
3. Any additional information required for your claim to be reconsidered, and the reason this information is necessary;
4. In the case of any claim for a disability benefit, identification of any internal rule, guideline or protocol relied on in making the claim decision, and an explanation of any medically-related exclusion or limitation involved in the decision; and
5. A statement informing you of your right to appeal the decision, and an explanation of the appeal procedure, as outlined below.
If CIGNA denies payment of your claim, or if you think that the amount paid is not correct, you may appeal CIGNA’s decision:
You (or your duly authorized representative) must make a written request for appeal to CIGNA within 60 days (180 days in the case of any claim for disability benefits) from the date you receive the denial. If you do not make this request within that time, you will have waived your right to appeal.
Once CIGNA receives your request, a prompt and complete review of your claim will take place. This review will give no deference to the original claim decision, and will not be made by the person who made the initial claim decision. During the review, you (or your duly authorized representative) have the right to review any documents that have a bearing on the claim, including the documents that establish and control the Plan. Any medical or vocational experts consulted by CIGNA will be identified. You may also submit issues and comments that you feel might affect the outcome of the review.
CIGNA has 60 days from the date it receives your request to review your claim and notify you of its decision (45 days, in the case of any claim for disability benefits). Under special circumstances, CIGNA may require more time to review your claim. If this happens, CIGNA will notify you, in writing, that its review period has been extended for an additional 60 days (or 45 days, in the case of any claim for disability benefits). Once its review is complete, CIGNA will notify you, in writing, of the results of the review and indicate the Plan provisions upon which it based its decision.
No civil action may be brought unless you exhaust your internal appeals with CIGNA. If your appeal to CIGNA is denied, you have the legal right to bring a civil action under section 502(a) of ERISA within three years of the date of the letter informing you of the denial of the appeal by CIGNA.