Res05 14665 - Laserfiche WebLink

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(i) If a Participant fails to submit a claim within the 90 day period immediately following the end of the Plan Year, those claims shall not be considered for reimbursement by the Administrator. ARTICLE Vlll BENEFITS AND RIGHTS 8.1 CLAIM FOR BENEFITS (a) Any claim for Benefits underwritten by Insurance or Administrative Services Contracts shall be made to the City. If the City denies any claim, the Participant or beneficiary shall follow the City's claims review procedure. Any other claim for Benefits shall be made to the Administrator. If the Administrator denies a claim, the Administrator may provide notice to the Participant or beneficiary, in writing, within 90 days after the claim is filed unless special circumstances require an extension of time for processing the claim. If the Administrator does not notify the Participant of the denial of the claim within the 90 day period specified above, then the claim shall be deemed denied. The notice of a denial of a claim shall be written in a manner calculated to be understood by the claimant and shall set forth: (1) specific references to the pertinent Plan provisions on which the denial is based; (2) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation as to why such information is necessary; and (3) an explanation of the Plan's claim procedure. (b) Within 60 days after receipt of the above material, the claimant shall have a reasonable opportunity to appeal the claim denial to the Administrator for a full and fair review. The claimant or his duly authorized representative may: (1) request a review upon written notice to the Administrator; (2) review pertinent documents; and (3) submit issues and comments in writing. (c) A decision on the review by the Administrator will be made not later than 60 days after receipt of a request for review, unless special circumstances require an extension of time for processing (such as the need to hold a hearing), in which event a decision should be rendered as soon as possible, but in no event later than 120 days after such receipt. The decision of the Administrator shall be written and shall include specific reasons for the decision, written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on which the decision is based. (d) Any balance remaining in the Participant's Dependent Care Assistance Program or Health Care Reimbursement Plan as of the end of each Plan Year shall be forfeited and deposited in the benefit plan surplus of the City 20