Does anybody have a "sample" claims procedure or know where I might be able to find some good language? I have to update a large number of H&W SPDs and I know the old claims language is inadequate.

Thanks again and have a great day!

You might consider this:




All insured claims should be made directly to the insurance carrier or company that provides the coverage.



All claims for reimbursement under the Plan other than insured claims should be directed to the Claims Administrator. So too, all claims regarding eligibility for or the payment per this Plan for the cost of coverage (insurance or other), such as the payment of insurance premiums, should be made to the Claims Administrator. A form for making a claim is available from the Claims Administrator. The claimant (or his or her authorized representative) may submit the claim and any documents, materials or other information the claimant wishes in support of the claim. The claimant may review any or all prior written claims determinations, which are kept by the Claims Administrator, indexed on the basis of Plan provision and type of expense involved. No claimant will be charged a fee or any other cost by or on behalf of the Plan for making a claim. There will be no hearing before the Claims Administrator as part of the initial determination proceedings. See the section hereinabove entitled Annual Flex Accounts for more information on the timing and process of making a claim for reimbursement. See the section hereinabove entitled Employer Reimbursement of Certain Health Expenses for more information on the timing and process of making a claim for reimbursement.



If such a claim under the Plan is denied in whole or in part by the Claims Administrator, the claimant (or his or her authorized representative) will receive a written notification. The notification will include specification of each of the reasons for denial, with references to the specific provisions of and internal rules of the Plan on which the denial was based, an explanation of any scientific or clinical judgment upon which the initial determination was made if it was based on a medical necessity or other similar exclusion or limit (or statement that the claimant can obtain such an explanation free of charge upon request), a description of any additional information needed to complete the claim (and an explanation of why such additional information is needed), an explanation of the claims review procedure and applicable time limits, and a statement about the claimant’s right to file a lawsuit under section 502(a) of Title I of the Employee Retirement Income Security Act of 1974 after the claims review procedure.



If the Claims Administrator fails to respond within thirty (30) days after the claim is filed (forty-five (45) days if the claimant received notice of the need for an extension of up to fifteen (15) days before the first thirty (30) days runs out), the claim cannot be denied.



Within one hundred eighty (180) days after denial, the claimant (or his or her authorized representative) may submit a written request for a full and fair review to any member of the Review Board (as listed in Basic Plan Information above). The Review Board will provide a notice to the claimant (or his or her authorized representative) explaining that, upon request and free of charge, the claimant can have access to and copies of all documents, records and other information relevant to the claim, and such notice will also identify any medical or vocational experts that advised the Claims Administrator regarding the claim. As part of the review process, the claimant may submit any comments, documents, records or other information relating to the claim, even if such was not submitted to the Claims Administrator. The Review Board will, without a hearing unless the Review Board deems such advisable under the circumstances, review the initial denial by the Claims Administrator, as requested by the claimant.



If such a claim under the Plan is denied in whole or in part by the Reviewing Board, the claimant (or his or her authorized representative) will receive a written notification. The notification will include specification of each of the reasons for denial, with references to the specific provisions and any internal rules of the Plan on which the denial was based, a description of any additional information needed to complete the claim (and an explanation of why such additional information is needed), an explanation of any scientific or clinical judgment upon which the review determination was made if it was based on a medical necessity or other similar exclusion or limit (or statement that the claimant can obtain such an explanation free of charge upon request), a statement that the claimant is entitled, upon request and free of charge, to reasonable access and copies of documents, records, and other information relevant to the claim, an explanation that there are other dispute resolution options (such as mediation) that might be available from or through the local US Dept of Labor office or the State’s insurance regulatory agency, and a statement about the claimant’s right to file a lawsuit under section 502(a) of Title I of the Employee Retirement Income Security Act of 1974 after the claims review procedure.



If the Review Board fails to respond within sixty (60) days after the claimant’s request for review of the initial denial, the claim will be honored in its entirety.