If a claim for medical benefits under the
Personal Choice Program is denied, in whole or in part, you may file a written
appeal with Independence Blue Cross.
If you are not satisfied with the final decision with respect to your
claim, you may file a written appeal to the Fund Administrator as provided below. Please
note, however, that any
claim directly relating solely to eligibility to participate in the Fund or one
of its programs should be appealed to the Fund Administrator as provided below.
If your claim for any other benefit is denied,
in whole or in part, or if you dispute whether or not you are eligible to
participate in any program under the Fund, you may file a written appeal to the
Fund Administrator within 90 days of the date of the notice of denial.
The Fund Administrator will respond with a
written notice within 60 days of receipt of your appeal, stating whether the appeal
is approved or denied. This notification
will include the specific reasons for the decision, the Plan provisions on
which the decision is based, the information needed to complete the claim, and
the reasons why this information is needed.
The notice will also explain the Plan's claim review procedures.
If you are not satisfied with the Fund
Administrator's decision regarding your claim appeal, you may request a review
of the Fund Administrator's denial. The review will take place at the next regularly scheduled Board of Trustees'
meeting, if possible. However, the
review must take place within 120 days after the Board receives your written
request for a review. You or your
representative has the right to review pertinent Plan documents and submit a
written statement in support of your claim.
However, the Board of Trustees has discretionary power and authority to
make benefit eligibility determinations, to construe the terms of the Plan, and
to determine your rights under the Plan.
Its decisions are entitled to the maximum deference permitted by law. The Board's decision on your appeal
will be made in writing and is final and binding.
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