ARIZONA- IF YOU HAVE ADDITIONAL INFORMATION TO SUBMIT, PLEASE DO SO. YOU HAVE THE RIGHT TO APPEAL THIS DECISION. IF YOU FEEL THERE ARE OTHER FACTS THAT WE SHOULD CONSIDER, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF  8:00 A.M AND 4:30 P.M. CST OR WRITE TO US AT THE ADDRESS SHOWN IN THE CONTACT SECTION.

 

CALIFORNIA-THE RULES AND REGULATION OF THE CALIFORNIA DEPARTMENT OF INSURANCE REQUIRE THAT OUR COMPANY ADVISE YOU THAT IF YOU WISH TO TAKE THIS MATTER UP WITH THE CALIFORNIA DEPARTMENT OF INSURANCE, IT MAINTAINS AN OFFICE IN LOS ANGELES AT 300 S. SPRING STREET, LOS ANGELES, CALIFORNIA 90013. THE PHONE NUMBER IN CALFORNIA IS 1-800-927-4357; OUT OF CALIFORNIA IS 213-897-8921.

 

THE INTERNET WEBSITE ADDRESS THAT HANDLES THE REVIEW OF DENIED CLAIMS IS  http://www.insurance.ca.gov/01-consumers/101-help/

 

DELAWARE-YOU HAVE THE RIGHT TO SEEK REVIEW OF A CLAIM DENIAL THROUGH THE DELAWARE INSURANCE DEPARTMENT. THE DELAWARE INSURANCE DEPARTMENT ALSO PROVIDES FREE INFORMAL MEDIATION SERVICES WHICH ARE IN ADDITION TO, BUT DO NOT REPLACE, YOUR RIGHT TO REVIEW OF THIS DECISION.

 

YOU CAN CONTACT THE DELAWARE INSURANCE DEPARTMENT FOR INFORMATION ABOUT CLAIM DENIAL REVIEW OR MEDIATION BY CALLING THE CONSUMER SERVICES DIVISION AT 800-282-8611 OR 302-739-4251. YOU MAY GO TO THE DELAWARE INSURANCE DEPARTMENT AT THE RODNEY BUILDING, 841 SILVER LAKE BLVD., DOVER, DE 19904 BETWEEN THE HOURS OF 8:30 A.M. AND 4:00 P.M. TO PERSONALLY DISCUSS THE REVIEW OR MEDIATION PROCESS.

 

ALL REQUESTS FOR REVIEW THROUGH PROCEDURES ESTABLISHED BY THE DELAWARE INSURANCE DEPARTMENT MUST BE FILED WITHIN 60 DAYS FROM THE DATE YOU RECEIVE THIS NOTICE; OTHERWISE, THIS DECISION WILL BE FINAL.

 

ILLINOIS- IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00A.M. AND 4:30P.M. CST.

 

PART 919 OF THE RULES OF THE ILLINOIS DEPARTMENT OF INSURANCE REQUIRES THAT OUR COMPANY ADVISE YOU IF YOU WISH TO TAKE THIS MATTER UP WITH THE ILLINOIS DEPARTMENT OF INSURANCE, IT MAINTAINS A CONSUMER DIVISION IN CHICAGO AT 122 S. MICHIGAN AVENUE, 19TH FOOR, CHICAGO, ILLINOIS 60603 AND IN SPRINGFIELD AT 320 WEST WASHINGTON, SPRINGFIELD, ILLINOIS 62767.

 

MARYLAND - You have 180 days following receipt of this notice to request an appeal in writing regarding benefit determination, by writing the company at the address listed IN THE CONTACT SECTION. If you believe this claim was denied in error please submit written comments, documents, records, and other information relating to the claim for benefits. WE will consider your appeal and will contact you upon conclusion of the review.     

 

MINNESOTA-IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00A.M. AND 4:30P.M. CST.

 

NEBRASKA- IF YOU HAVE ADDITIONAL INFORMATION TO SUBMIT, PLEASE DO SO. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00 A.M. AND 4:30 P.M. CST. THE FOLLOWING INFORMATION IS BEING FURNISHED TO YOU. IF YOU DO NOT AGREE WITH OUR POSITION YOU MAY HAVE THIS MATTER REVIEWED BY: NEBRASKA DEPARTMENT OF INSURANCE PO BOX 82089 LINCOLN, NE 68501-2089 PHONE 877-564-7323.

 

THE RULES AND REGULATIONS OF THE NEBRASKA DEPARTMENT OF INSURANCE REQUIRE THAT OUR COMPANY ADVISE YOU THAT IF YOU WISH TO TAKE THIS MATTER UP WITH THE NEBRASKA DEPARTMENT OF INSURANCE, IT MAINTAINS AN OFFICE AT TERMINAL BUILDING, 941 O' STREET SUITE 400, LINCOLN, NE 68508.

 

NEVADA-IF YOU DISAGREE WITH OUR DECISION TO DENY YOUR CLAIM, YOU HAVE THE RIGHT TO FILE A WRITTEN COMPLAINT WITH US AT THE ADDRESS SHOWN IN THE CONTACT SECTION.

 

IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS SHOWN IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00A.M. AND 4:30P.M. CST.

 

IF YOU WISH TO DISPUTE THE COMPANY'S DECISION ON THIS CLAIM, YOU MAY REGISTER A COMPLAINT BY WRITING OR CALLING CUSTOMER SERVICE AT THE ADDRESS AND PHONE NUMBER DISPLAYED IN THE CONTACT SECTION. IN REVIEWING YOUR COMPLAINT, THE COMPANY WILL FOLLOW THE COMPLAINT PROCEDURE DESCRIBED IN YOUR BENEFITS PLAN.

 

NEW HAMPSHIRE- IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, OR WOULD LIKE TO APPEAL THIS DECISION, PLEASE WRITE TO US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00A.M. AND 4:30P.M.

 

WE WILL, OF COURSE, BE AVAILABLE TO YOU TO DISCUSS THE POSITION WE HAVE TAKEN. SHOULD YOU, HOWEVER, WISH TO TAKE THIS MATTER UP WITH THE NEW HAMPSHIRE INSURANCE DEPARTMENT IT MAINTAINS A SERVICE DIVISION TO INVESTIGATE COMPLAINTS AT 21 SOUTH FRUIT STREET, SUITE 14, CONCORD, NEW HAMPSHIRE 03301. THE NEW HAMPSHIRE INSURANCE DEPARTMENT CAN BE REACHED, TOLL-FREE, BY DIALING 1-800-852-3416.

 

NEW JERSEY-THE STATE OF NEW JERSEY REQUIRES US TO INFORM YOU THAT THE UNIFORM PROVISIONS OF YOUR POLICY, UNDER LEGAL ACTIONS, STATE THAT NO LEGAL ACTION SHALL BE BROUGHT AFTER THE EXPIRATION OF THREE YEARS FROM THE TIME WRITTEN PROOF OF LOSS IS REQUIRED TO BE FURNISHED.

 

IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-800-525-7662 BETWEEN THE HOURS OF 8:00A.M. AND 4:30P.M. CST.

 

This is to advise you that there is a procedure in place for claim appeals.  If you wish to appeal a claim, please contact Customer Service at the address and phone number DISPLAYED IN THE CONTACT SECTION.  Once a claim appeal is received, our claim committee will review all documents available and we will complete our determination within 10 business days.  You will be sent a response within three business days.

 

NEW YORK- IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE CONTACT US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION OR AT 1-800-525-7662 BETWEEN THE HOURS OF 8:00 A.M. AND 4:30 P.M. CST.  

                   

PLEASE NOTE THAT YOUR POLICY OR CERTIFICATE CONTAINS A PROVISION THAT STATES THAT NO LEGAL ACTION MAY BE BROUGHT TO RECOVER ON THIS POLICY OR CERTIFICATE WITHIN 60 DAYS AFTER WRITTEN PROOF OF LOSS HAS BEEN GIVEN AS REQUIRED BY THIS POLICY OR CERTIFICATE. NO LEGAL ACTION MAY BE BROUGHT AFTER 3 YEARS FROM THE TIME WRITTEN PROOF OF LOSS IS REQUIRED TO BE GIVEN.

 

OHIO-IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS SHOWN IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL OUR CUSTOMER SERVICE REPRESENTATIVES AT 1-800-525-7662 BETWEEN THE HOURS OF 8:00 A.M. AND 4:30 P.M. CST.    

                        

IF YOU WISH TO DISPUTE THE COMPANY'S DECISION ON THIS CLAIM, YOU MAY REGISTER A COMPLAINT BY WRITING TO US AT THE ADDRESS SHOWN IN THE CONTACT SECTION, OR BY CALLING 1-800-525-7662. IN REVIEWING YOUR COMPLAINT, THE COMPANY WILL FOLLOW THE COMPLAINT PROCEDURES DESCRIBED IN YOUR BENEFITS PLAN.  

     

RHODE ISLAND-THE FOLLOWING INFORMATION IS BEING FURNISHED TO YOU. IF YOU DO NOT AGREE WITH OUR POSITION YOU HAVE THE RIGHT TO HAVE THIS MATTER REVIEWED BY: STATE OF RHODE ISLAND INSURANCE DIVISION 233 RICHMOND STREET PROVIDENCE, RI 02903-4233.

 

UTAH- IF YOU FEEL THERE ARE OTHER FACTS THAT WE SHOULD CONSIDER, PLEASE WRITE OR CALL CUSTOMER SERVICE AT THE ADDRESS AND PHONE NUMBER DISPLAYED IN THE CONTACT SECTION.

 

VERMONT-IF YOU WOULD LIKE US TO REVIEW ANY ADDITIONAL INFORMATION, PLEASE WRITE TO US AT THE ADDRESS DISPLAYED IN THE CONTACT SECTION. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT CUSTOMER SERVICE AT 1-800-525-7662 BETWEEN THE HOURS OF 8:00 A.M. AND 4:30 P.M. CST.     

 

IF YOU FEEL THERE ARE OTHER FACTS THAT WE SHOULD CONSIDER, PLEASE WRITE OR CALL CUSTOMER SERVICE AT THE ADDRESS AND PHONE NUMBER DISPLAYED IN THE CONTACT SECTION.    

 

WASHINGTON DC-    IF YOU WISH TO APPEAL THIS DECISION, PLEASE WRITE OR CALL CUSTOMER SERVICE AT THE ADDRESS AND PHONE NUMBER DISPLAYED IN THE CONTACT SECTION. IF YOU DISAGREE WITH OUR CLAIM DECISION, YOU ALSO HAVE THE RIGHT TO CONTACT THE OFFICE OF HEALTH CARE OMBUDSMAN AND BILL OF RIGHTS BY WRITING THEM AT: 899 NORTH CAPITOL STREET NE, 6TH FLOOR, WASHINGTON D.C. 20002, OR CALLING 877-685-6391.

 

YOU HAVE THE RIGHT TO RECEIVE COPIES OF ALL DOCUMENTS FREE OF CHARGE RELEVANT TO THIS CLAIM.

 

WEST VIRGINIA- THE RULES AND REGULATIONS OF THE WEST VIRGINIA INSURANCE DIVISION REQUIRE THAT OUR COMPANY ADVISE YOU THAT IF YOU WISH TO TAKE THIS MATTER UP WITH THE WEST VIRGINIA INSURANCE COMISSIONER, IT MAINTAINS AN OFFICE AT PO BOX 11685, CHARLESTON, WEST VIRGINIA 25339-1685, PHONE NUMBER 1-888-879-9842 EXT 3864, OR EMAIL CONSUMER.ADVOCATE@WVINSURANCE.GOV.      

                                       

WISCONSIN-A DENIAL OF BENEFITS ALLOWS YOU TO FILE A GRIEVANCE WITH THE COMPANY. YOUR POLICY CONTAINS AN AMENDMENT, FORM NUMBER 16290B-WI, PROVIDING YOU WITH THE DEFINITION OF AND PROCEDURES FOR FILING A GRIEVANCE. YOU OR YOUR REPRESENTATIVE MUST SUBMIT THE GRIEVANCE IN WRITING TO THE ADDRESS LISTED IN THE CONTACT SECTION OR CALL THE NUMBER LISTED IN THE CONTACT SECTION FOR A DUPLICATE AMENDMENT TO BE MAILED.