319 Appealing Denied Benefit Claims
The Benefits Office maintains and provides documents that explain the limits of coverage for benefit programs. If a participant or beneficiary feels that a claim for a benefit payment has been improperly rejected, he or she may appeal the decision. The appeals procedure is available to any active employee, retired employee, or beneficiary of an employee.
The general claims procedures outlined below apply to claims regarding benefits under a welfare plan (health, dental, life insurance, disability, business travel and accident insurance, accidental death and dismemberment and salary continuation). Participants or beneficiaries contemplating a claim should consult the specific provisions of the particular plan(s) which take precedence for purposes of claims procedures in the event of a conflict with the general claims procedures. If a particular welfare plan does not have a specific claims procedure in its plan document, the general claims procedure set forth in the University's Master Welfare Plan document applies. Copies of specific plan documents and the Master Welfare Plan document are maintained and amended at the Benefits Office.
The participant or beneficiary must file a claim with the Benefits Office. The Benefits Office will supply the necessary form, help fill it out, and send it to the appropriate department or insurance company.
If the claim is denied, the Benefits Office will, within 30 working days of the date it receives notice to that effect, send the participant or beneficiary the information necessary to determine the basis for denial.
Any participant or beneficiary whose claim for benefits is denied has the right to request a review within 60 calendar days after receipt of notice of denial.
When a claim is denied solely by an insurance company, that company will determine the procedure for appeal. The Benefits Office, if requested to do so, will assist in arranging to have the appeal receive due consideration.
When a claim is denied by a department of Yale, the participant or beneficiary may appeal by going to the Benefits Office and completing a Request for Review form within 60 calendar days of notification. The Benefits Office will schedule a hearing at which the participant, the beneficiary, or a representative of the participant or beneficiary may explain the basis for appeal and submit supporting documents and written statements.