Notice of Adverse Decision on Appeal

Every notice of an adverse determination on appeal will be provided in a culturally and linguistically appropriate manner and will include:

• the specific reason or reasons for the adverse determination, and reference to the specific plan language on which the determination is based;
• a statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim;
• upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding the appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit;
• a description of the claims procedures for any additional level of appeal and the applicable time limits, external review rights, the right to obtain information about the claims procedures, and a statement of your right to bring a civil action under Section 502(a) of ERISA after exhausting the Plan’s claims procedures; and
• The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”

External Review

You may have the right to request an external review of a group health plan claim involving medical judgment, as determined by the external reviewer, or a coverage rescission. See the “Right to an External Review of Claims” provision above for additional information.

Exhaustion

If you do not exercise your appeal right within the timeframe set forth in the claims procedures described in the applicable document, insurance certificate or contract, benefit summary, or other governing document for the applicable health plan option, or, alternatively, as described above, you may lose your right to file suit in a state or federal court.

Limitations Period

Unless expressly stated otherwise in the applicable document, insurance certificate or contract, benefit summary, or other governing document for the applicable health plan option, any lawsuit on a claim for benefits under the Health Plan must be initiated within 12 months after the date of final disposition of the claim.