PGR » Topics » CLAIMS PROCEDURES

This excerpt taken from the PGR 10-K filed Mar 1, 2010.

CLAIMS PROCEDURES

8.1 Establishment of Claims Procedure.

The Committee shall establish reasonable procedures under which a claimant, who may be a Participant, or Beneficiary, or his/her duly authorized representative, may present a claim for benefits under this Plan.

8.2 Claims Denials.

Unless such claim is allowed in full by the Committee, written notice of the denial shall be furnished to the claimant within ninety (90) days (which may be extended by a period not to exceed an additional ninety (90) days if special circumstances so require and written notice to the claimant is given prior to the expiration of the initial ninety (90) day period describing such circumstances and indicating the date by which the Committee expects to render its determination) setting forth the following in a manner calculated to be understood by the claimant:

 

  (i) The specific reason(s) for the denial;

 

  (ii) Specific reference(s) to any pertinent provision(s) of the Plan or rules promulgated pursuant thereto on which the denial is based;

 

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  (iii) A description of any additional information or material as may be necessary to perfect the claim, together with an explanation of why it is necessary;

 

  (iv) A description of the Plan’s claims review procedures and the time limits applicable to such procedures, 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; and

 

  (v) An explanation of the steps to be taken if the claimant wishes to resubmit his/her claim for review.

8.3 Appeals of Denied Claims.

Within a reasonable period of time after the denial of the claim, but in any event, not to be more than sixty (60) days, the claimant or his/her duly authorized representative may make written application to the Committee for a review of such denial. The claimant or his/her representative, may, upon request and free of charge, review or receive copies of documents, records and other information relevant to the claimant’s claim for benefits, and may submit written comments, documents, records and other information relating to the claim for benefits.

8.4 Review of Appeals.

If an appeal is timely filed, the Committee shall conduct a full and fair review of the claim and mail or deliver to the claimant its written decision within sixty (60) days after the claimant’s request for review (which may be extended by a period not to exceed an additional sixty (60) days if special circumstances or a hearing so require and written notice to the claimant is given prior to the expiration of the initial sixty (60) day period describing such special circumstances and indicating the date by which the Committee expects to render its determination). In conducting its review, the Committee shall take into account all comments, documents, records and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. The Committee’s decision on review shall:

 

  (i) Be written in a manner calculated to be understood by the claimant;

 

  (ii) State the specific reason(s) for the decision;

 

  (iii) Make specific reference to pertinent provision(s) of the Plan;

 

  (iv) State that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claimant’s claim for benefits; and

 

  (v) Include a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA.

 

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  8.5 Extensions.

If a period of time is extended, as permitted under Sections 8.2 and 8.4 above, due to a claimant’s failure to submit information to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

8.6 Disability Claims.

Claims involving a determination of Disability or payments related to Disability shall comply with and follow the applicable Department of Labor regulations. Upon the filing of an initial Disability-related claim, the Committee will make a decision regarding a Participant’s claim within 45 days of such Participant’s request, unless special circumstances would make rendering a decision within the 45-day period unfeasible. The Committee will notify the Participant of its need to extend the decision deadline and may extend the deadline for up to two additional 30-day periods, if necessary. The Participant will be permitted to appeal any adverse initial determination up to 180 days after the determination is issued. The Committee will make a decision within a reasonable period of time after receiving any appeal but in no event later than 45 days after a Participant’s appeal is received unless special circumstances would make rendering a decision within the 45-day period unfeasible. The Committee will notify a Participant of any need to extend the decision deadline and may extend the deadline for no more than an additional 45 days. More details about the Disability retirement procedure are available from the Committee.

This excerpt taken from the PGR 10-K filed Feb 25, 2009.

CLAIMS PROCEDURES

8.1 Establishment of Claims Procedures

The Committee shall establish reasonable procedures under which a claimant, who may be a Participant, or Beneficiary, or his/her duly authorized representative, may present a claim for benefits under this Plan.

8.2 Claims Denials

Unless such claim is allowed in full by the Committee, written notice of the denial shall be furnished to the claimant within ninety (90) days (which may be extended by a period not to exceed an additional ninety (90) days if special circumstances so require and written notice to the claimant is given prior to the expiration of the initial ninety (90) day period describing such circumstances and indicating the date by which the Committee expects to render its determination) setting forth the following in a manner calculated to be understood by the claimant:

 

  (i) The specific reason(s) for the denial;

 

  (ii) Specific reference(s) to any pertinent provision(s) of the Plan or rules promulgated pursuant thereto on which the denial is based;

 

  (iii) A description of any additional information or material as may be necessary to perfect the claim, together with an explanation of why it is necessary;

 

  (iv) A description of the Plan’s claims review procedures and the time limits applicable to such procedures, 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; and

 

  (v) An explanation of the steps to be taken if the claimant wishes to resubmit his/her claim for review.

8.3 Appeals of Denied Claims

Within a reasonable period of time after the denial of the claim, but in any event, not to be more than sixty (60) days, the claimant or his/her duly authorized representative may make written application to the Committee for a review of such denial. The claimant or his/her representative, may, upon request and free of charge, review or receive copies of documents, records and other information relevant to the claimant’s claim for benefits, and may submit written comments, documents, records and other information relating to the claim for benefits.

 

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8.4 Review of Appeals

If an appeal is timely filed, the Committee shall conduct a full and fair review of the claim and mail or deliver to the claimant its written decision within sixty (60) days after the claimant’s request for review (which may be extended by a period not to exceed an additional sixty (60) days if special circumstances or a hearing so require and written notice to the claimant is given prior to the expiration of the initial sixty (60) day period describing such special circumstances and indicating the date by which the Committee expects to render its determination). In conducting its review, the Committee shall take into account all comments, documents, records and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. The Committee’s decision on review shall:

 

  (i) Be written in a manner calculated to be understood by the claimant;

 

  (ii) State the specific reason(s) for the decision;

 

  (iii) Make specific reference to pertinent provision(s) of the Plan;

 

  (iv) State that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claimant’s claim for benefits; and

 

  (v) Include a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA.

8.5 Extensions

If a period of time is extended, as permitted under Sections 8.2 and 8.4 above, due to a claimant’s failure to submit information to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

EXCERPTS ON THIS PAGE:

10-K
Mar 1, 2010
10-K
Feb 25, 2009

"CLAIMS PROCEDURES" elsewhere:

Horace Mann Educators (HMN)
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