Appealing a Denial of Claims for Benefits

When you apply for benefits, there are time periods within which you must receive a decision on your claim for benefits. If you or your beneficiary applies for benefits and either part or all of the request is denied, you have the right to appeal that deci­sion, provided the appeal is made in accordance with the provisions of the plan and applicable laws (e.g., appeals must be filed within required time periods).

Appeals are generally decided by the pro­vider of the benefit involved, which is the insurance carrier, claims administrator, or vendor for most benefits, or the University or its Plan Administration Committee for some benefits.

Appeals to Insurance Carriers/Claims Administrators/Other Vendors

Appeals regarding benefits or other issues affecting plan participants or other persons for The Travel Accident Insurance Plan, Personal and Family Accident Insurance Plan, Group Supplemental Life Insurance Plan, and Basic Life Insurance  Plans should be made to the applicable provider under the Plan.

The claims filing procedures are set forth in the separate written document, insurance certificate or contract, benefit summary, or other governing document for each Plan.

If a claim for benefits is either wholly or partially denied, you will be notified in writing within 90 days (45 days in the case of a claim for disability benefits). If special circumstances require an extension of time to process the claim, written notice of the extension and an explanation of the special circumstances requiring an extension will be provided to you prior to the termination of the initial 90-day period (45-day period in the case of a claim for disability benefits).

Every notice of an adverse benefit determination will include:

  • the specific reason or reasons for the adverse determination;
  • reference to the specific plan provisions on which the determination is based;
  • a description of any additional information or material needed to support the claim and an explanation why the information or material, if any, is necessary;
  • a description of the plan’s review procedures and the applicable time limits, including a statement of your right to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on review; and
  • if the claim is for disability benefits, the following:
    • a discussion of the decision, including an explanation of the basis for disagreeing with or not following (as applicable) the views of health care professionals treating you and vocational professionals who evaluated you; the views of medical or vocational experts whose advice was obtained on behalf of the plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and any disability determination made by the Social Security Administration;
    • 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 claim, 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; and
    • a statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records and information relevant to your claim.

Your appeal of a denied claim must be filed with the insurance carrier, claims administrator, or vendor for the applicable benefit within 60 days (or 180 days in the case of a claim for disability benefits) after you receive written notice of the decision. Your written request for review must contain all additional information that you want the claim administrator to consider.

Appeals may be submitted to the following providers:

  • The Group Life Insurance Plan and the Group Supplemental Life Insurance Plan,

Standard Insurance Company
1100 SW Sixth Avenue
Portland, OR 97204
1-888-937-4783

  • Travel Accident Insurance Plan and the Personal and Family Accident Insurance Plans

The Hartford Group Benefits
P.O. Box 2999
Hartford, CT 06104-2999
1-888-747-8819

If a claim is for disability benefits, before issuing an adverse determination on review, the claim administrator will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated in connection with the claim, as well as a description of any new or additional rationale on which the denial is based. This information will be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided to give you a reasonable opportunity to respond prior to that date.

You will be notified of the decision on review within 60 days (45 days in the case of a claim for disability benefits). If special circumstances require an extension of time to process the claim, written notice of the extension and explanation of the special circumstances requiring an extension will be provided prior to the termination of the initial 60-day period (45-day period in the case of a claim for disability benefits).

Every notice of an adverse benefit determination on review will include:

  • the specific reason or reasons for the adverse determination;
  • reference to the specific plan provisions 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 relevant information as defined above;
  • a statement of your right to bring a civil action under section 502(a) of ERISA and a description of the limitations period provided by the plan, including the date on which the limitations period will expire; and
  • if the claim is for disability benefits, the following:
  • a discussion of the decision, including an explanation of the basis for disagreeing with or not following (as applicable) the views of health care professionals treating you and vocational professionals who evaluated you; the views of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and any disability determination made by the Social Security Administration; and 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, 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.