5.3. ERMUSR 02-09-2010 - Laserfiche WebLink

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(4) an explanation of the Plan's claims review procedure and other appropriate information as to the steps to be taken if the Participant wishes to have the claim reviewed. If the Plan Administrator, or Plan Administrator's designee, determines that there are special circumstances requiring additional time to make a decision, the Plan Administrator, or Plan Administrator's designee, shall notify the Participant of the special circumstances and the date by which a decision is expected to be made, and may extend the time for up to an additional fifteen (15) days. (b) Appeals. If a Participant is determined by the Plan Administrator, or Plan Administrator's designee, not to be eligible for benefits, or if the Participant believes that he or she is entitled to greater or different benefits, the Participant shall have the opportunity to have the claim reviewed by the Plan Administrator, or Plan Administrator's designee, by filing an appeal within one hundred eighty (180) days after receipt by the Participant of the notice issued by the Employer, or the Employer's designee. The appeal shall state the specific reasons the Participant believes he or she is entitled to benefits or greater or different benefits. Within sixty (60) days after receipt of the appeal, the Plan Administrator, or Plan Administrator's designee, shall afford the Participant (and the Participants counsel, if any) an opportunity to present the Participants position to the Plan Administrator, or Plan Administrator's designee, orally or in writing, and the Participant (or the Participants counsel) shall have the right to review the pertinent documents. (c) Decision on Appeal. The Plan Administrator shall notify the Participant of its decision on appeal in writing within said sixty (60) day period stating specifically the basis of said decision. If it is determined that a person is not eligible for benefits or for full benefits, the notice shall set forth: (1) the specific reasons for the denial; (2) a specific reference to the provision of the Plan on which the denial is based; (3) a statement of the Participant's right to review (on request and at no charge) relevant documents and other information; (4) if the Plan Administrator relied on an "internal rule, guideline, protocol, or other similar criterion" in making the decision, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other similar criterion will be provided free of charge to Participant upon request; and In the event of the death of a Participant, the same procedure shall be applicable to the Participants beneficiaries. 19