Claim Procedures

To report a claim, you (or your beneficiary) must contact your local Human Resources representative within 30 days* of the covered loss, or as soon as reasonably possible.

* Claims under the AD&D Insurance Plan will not be accepted beyond one year of the date of the accident that caused the loss.

Back to Top

Terminal Illness Benefit (Accelerated Death Benefit) Claims

If, while covered under the Employee (or Dependent) Life Insurance Plan, you (or your spouse/domestic partner) become terminally ill, you may request that the Insurance Company pay an Accelerated Death Benefit (ADB).*

* Throughout the remainder of this section, references to "you" also refer to your spouse/domestic partner, as applicable.

For the purposes of this provision, you will be considered "terminally ill" if you...

  • Suffer from an incurable, progressive and medically recognized disease or condition; and,

  • Are not expected to live more than 12 months (based on a reasonable medical probability and generally accepted prognostic protocol).

You may request an ADB at any time by completing the applicable form and submitting it to the Insurance Company. The request must include a statement of your terminal illness prepared by a currently licensed U.S. physician. This statement must include all medical test results, lab reports, and any other information on which the statement is based, including the generally accepted prognostic protocol used by the physician to determine your remaining life span.

To process your request, the Insurance Company may require you to submit to an independent medical exam by a physician chosen by the Insurance Company.

You may apply for an ADB payment of up to 50% of the coverage amount in force.* The payment will be made in a lump sum. Only one ADB payment will be made on behalf of the covered individual's lifetime.

* Under the Employee Life Insurance Plan, there is a maximum ADB benefit of $150,000.

If an ADB payment is made, your coverage amount will be reduced accordingly so that the amount of this payment will be deducted from the benefit paid upon your death. (The amount by which the life insurance coverage is reduced due to an ADB payment cannot be converted to an individual life insurance policy.)

Your request for an ADB may be denied if, before the Insurance Company approves the request,...

  • You are no longer eligible under the group contract,

  • The group contract ends, or

  • Your coverage under the Plan ends for any reason.

Your request for an ADB payment will also be denied if you die before receiving payment.

If Your Claim Is Denied

If your claim is denied, the insurance company will notify you of the adverse decision within a reasonable period of time, but not later than 90 days after receiving the claim, unless the insurance company determines that special circumstances requiring an extension of time and the date by which the insurance company expects to render the decision.

The claim determination time frames begin when a claim is filed, without regard to whether all the information necessary to make a claim determination accompanies the filing.

The insurance company’s notice of denial shall include:

  • The specific reason or reasons for denial with reference to those specific Plan provisions on which the denial is based,

  • A description of any additional material or information necessary to perfect the claim and an explanation of why that material or information is necessary, and

  • A description of the Plan’s appeal procedures and time frames, including a statement of the claimant’s right to bring a civil action under ERISA following an adverse decision on appeal.

Appeals

You, or your authorized representative, may appeal a denied claim within 60 days after you receive the insurance’s notice of denial. You have the right to:

  • Submit to the insurance company, for review, written comments, documents, records and other information relating to the claims;

  • Request, free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim; and

  • A review on appeal that takes into account all comments, documents, records, and other information submitted by you, without regard to whether such information was submitted or considered in the initial claim decision.

The Insurance Company will make a full and fair review of your appeal and may require additional documents as it deems necessary in making such a review. A final decision on review shall be made within a reasonable period of time, but not later than 60 days following receipt of the written request for review, unless the Insurance Company determines that special circumstances require an extension. In such case, a written extension notice will be sent to you before the end of the initial 60-day period. The extension notice shall indicate the special circumstances and the date by which the Insurance Company expects to render the appeal decision. The extension cannot exceed a period of 60 days.

The appeal time frames begin when an appeal is filed, without regard to whether all the information necessary to make an appeal decision accompanies the filing.If an extension is necessary because you failed to submit necessary information, the days from the date the Insurance Company sends you the extension notice until you respond to the request for additional information are not counted as part of the appeal determination period.

The Insurance Company’s notice of denial on appeal shall include:

  • The specific reason or reasons for denial with reference to those Plan provisions on which the denial 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; and

  • A statement describing any voluntary appeal procedures offered by the Plan and your right to obtain the information about such procedures, and a statement of your right to bring an action under ERISA.

Back to Top