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Appealing a Denied Claim
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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
a claim for medical benefits
under the Keystone Point of Service Program is denied, in whole or in part, you
may file a written appeal with Keystone (referred care) or QCC (self-referred
care), subsidiaries of Independence Blue Cross.
If a claim for life insurance or AD&D benefits is denied, in whole
or in part, you may file a written appeal with Standard Insurance Company.
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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