MMC Benefits Handbook
This section applies to the following plans:
- Marsh & McLennan Companies Basic Long Term Disability Plan
- Marsh & McLennan Companies Optional Long Term Disability Plan
- Marsh & McLennan Companies Long Term Disability Bonus Income Plan
- Marsh & McLennan Companies Individual Disability Insurance Plan
Unless otherwise provided in the applicable insurance policy/evidence of coverage, your claim for benefits or your appeal will be processed under the procedures described below.
Timing of Notification of Claim for Disability Benefits Determinations
In the case of a claim for disability benefits, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 45 days after your claim was properly filed and received. This period may be extended one time by the Claims Administrator for up to 30 days, provided that the extension is necessary due to matters beyond the control of the Claims Administrator and you are notified prior to the expiration of the initial 45-day period of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. If prior to the end of the first 30-day extension period, the administrator determines that, due to matters beyond the control of the plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days, provided that the Plan Administrator notifies the claimant, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the plan expects to render a decision.
If additional information is needed to process the claim, the Claims Administrator will notify you of the information needed within this 45-day period and may request a one-time extension not longer than 45 days and suspend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day timeframe, the Claims Administrator will notify you of the determination within 30 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied.
Timing of Appeal of Claim for Disability Benefits Determinations
If you believe your claim for disability benefits under the plan was denied improperly, you may file a written claim for the unpaid amount within 180 days of receipt of the denial. The written claim should specify the amount of the claim and any other written comments, documents, records or other information that may be pertinent and should be sent to the Claims Administrator. Your appeal will be conducted by a person different from the person who made the initial decision. No deference will be afforded to the initial determination. The Claims Administrator's review on appeal shall take into account all comments, documents, records and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. You have a right to review and respond to new or additional evidence or rationales developed by the Claims Administrator during the pendency of your appeal.
The first level appeal will be conducted, and you will be notified by the Claims Administrator of the decision within 45 days from receipt of a request for appeal of a denied claim. This period may be extended one time by the Claims Administrator for up to 45 days, provided that you are notified prior to the expiration of the initial 45-day period of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision.
If you are not satisfied with the first level appeal decision of the Claims Administrator, you have the right to request a second level appeal from the Claims Administrator. Your second level appeal request must be submitted to the Claims Administrator within 180 days from receipt of the first level appeal decision. The second level appeal will be conducted, and you will be notified by the Claims Administrator of the decision within 45 days from receipt of a request for review of the first level appeal decision.
If you do not file a written request for appeal of a denied claim within 180 days from the date you received your claim denial, your claim will be closed and your right to appeal will terminate. Appeals that are submitted after this timeframe cannot be considered.
Notice of Determination
If your claim or appeal is in part or wholly denied, you will receive notice of an adverse benefit determination that will:
- state specific reason(s) of the adverse determination
- reference specific plan provision(s) on which the benefit determination is based
- describe additional material or information, if any, needed to perfect the claim and the reasons such material or information is necessary (initial claim only)
- describe the plan's claims review procedures and the time limits applicable to such procedures (initial claim only)
- include a statement of (a) your right to bring a civil action under section 502(a) of ERISA following appeal and (b) describing any contractual limitations period that applies to your right to bring such an action, including the calendar date on which the contractual limitations period expires for the claim
- discussion of the decision, including an explanation of the basis for disagreeing or not with the following:
- the views presented by you to the Claims Administrator of health care professionals treating you and vocational professionals who evaluated you
- the views presented of medical or vocational experts whose advice was obtained on behalf of the Claims Administrator in connection with the adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination, and
- a disability determination regarding you presented by you to the Claims Administrator made by the Social Security Administration
- state 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 the claim for benefits (appeal only)
- disclose any specific internal rules, guidelines, standards, protocols or other similar criteria of the Claims Administrator relied upon in making the adverse determination or, alternatively, a statement that such rules, guidelines, protocols, standards, or other similar criteria of the Claims Administrator do not exist (or a statement that such information will be provided free of charge upon request)
- if the denial is based on a medical necessity or experimental treatment or similar limit, explain the scientific or clinical judgment for the determination, applying the terms to the plan to your medical circumstances, or a statement that such information will be provided free of charge upon request
- describe any voluntary appeal procedures offered by the plan and your right to obtain information about such procedures (appeal only)
- a statement prominently displayed in an applicable non-English language clearly indicating how to access the language services provided by the Claims Administrator
- any other notice(s), statement(s) or information required by applicable law.