CCP 12-13-2004 - Laserfiche WebLink

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. . . Citv of Arden Hills SUmmary Plan Description 1245 West Hwy 96 Arden Hills, MN 55112 Telephone: 651-634-5125 Employer Identification Number: 41-6008992 The Plan Administrator has contracted with Acclaim Benefits to perform third party administration services for the Plan. Claim forms are available from the Assistant to the City Administrator. The Employer (and persons to whom it has delegated powers, to the extent of such delegations) has total and complete authority to (I) detenninc conclusively for all parties all questions arising in the administration of the Plan, (2) interpret and construe the terms of the Plan, and (3) detennine all questions of eligibility and status of Employees, participants, and beneficiaries under the Plan and their respective intcrests. Such detenninations are binding on all persons, subject to the claims procedures under the Plan. CLAIMS FOR BENEFITS Claims under the health insurance or dental insurance are described in the Certificates of Coverage for those benefits. Unless otherwise proved in this document, the Certificates of Coverage or other documents governing a particular benefit plan, the following procedure will apply to claims for benefits under the Plan. You or your beneficiary may file a written claim with the Employer requesting a benefit under the Plan or objecting to the detennination of your benefit. You must file a claim on the form or forms available for that purpose in order for a claim to be valid. Forms are available from the sources referenced in this booklet, or you may obtain the form you need from the Plan Administrator. The Plan Administrator will notify you in writing within 30 days after your written application for benefits of your eligibility or non-eligibility for benefits under the Plan. If the Plan Administrator needs additional time to evaluate your claim, it will notify you within the first 30 days how much additional time is needed, but not more than another 15 days. If the Plan Administrator requests additional information, you will have 45 days to provide that information. The review period will be suspended until the specified information is received. Ifthe Plan Administrator determines that you are not eligible for benefits or full benefits, the notice will tell you: (I) the specific reasons for the denial, (2) the specific provision of the Plan on which denial is based, (3) a description of any additional information or material necessary for you to perfect your claim (and an explanation of why such information or material is necessary), and (4) an explanation of the Plan's claim review procedure, including the time limits applicable to the review procedure and your right to bring a civil action under ERISA following an adverse benefit determination on review. If the Plan Administrator delermines that you are not eligible for benefits, or if you believe that you are entitled to greater or different benefits, you will have the opportunity to have your claim reviewed by the SPD-17