Processing LTD Claims

If your claim is denied, the insurance company will, within a reasonable period of time (not exceeding 90 days), provide you with a written denial. If your claim is denied, the insurance company will notify you of the adverse decision within a reasonable period of time, but not later than forty-five days after receiving the claim. This forty-five-day period may be extended for up to thirty days, if the insurance company: (1) determines the extension is necessary because of matters beyond the Plan's control, and (2) notifies you, before the end of the forty-five-day period, why the extension is needed and the expected decision date. If, before the end of the first thirty-day extension, the insurance company determines, due to matters beyond the Plan's control, a decision cannot be rendered within that extension period, the determination period may be extended for up to an additional thirty days, provided the insurance company notifies you, before the end of the first 30-day extension period, why the extension is needed and the expected decision date.

The notice of extension shall explain: (1) the standards on which benefit entitlement is based, (2) the unresolved issues that prevent a claim decision, and (3) the additional information needed. You have at least forty-five days to provide the information.

The claim determination time frames begin when a claim is filed, without regard to whether all the information necessary to make a claim determination accompanies the filing.

If an extension is necessary because you failed to submit necessary information, the days from the date the insurance company sends you the extension notice until you respond to the request for additional information are not counted as part of the claim determination period.

Any denial will include specific reasons for the denial, and the provisions of the insurance company contract on which the denial is based. It will also explain how to apply for a review of the denied claim. Where appropriate, it will also include a description of any material that is needed to complete or perfect your claim, and will explain why such material is necessary.

The insurance company is solely responsible for determining what constitutes a covered claim under this plan. If the insurance company denies your claim for benefits, in whole or in part, you have a right to appeal the denial. Consult the Benefits Section of the Office of Human Resources for information about the procedure to appeal a denial.

Additional information about appealing a denial of benefits is included in the Administrative Information section of this site.