[Name of person who wrote denial letter]
[Name of company that person works for]
RE: Claimant : John Doe
Claim No. : XXXXXX
Name of Plan : Costco Wholesale Corporation Employee [type of plan] Plan
I am writing as a result of your company’s denial of my claim for [put in what you are making a claim for under the Plan].
Pursuant to 29 CFR 2560.503-1(g)(v)(A); 503-1(h)(2)(iii); and 503-1(h)(3)(iii) -(v), please provide the following information to me upon receipt of this letter:
1) a copy of the specific rule, guideline, protocol, or other similar criterion relied upon in making the adverse benefit determination; and
2) a copy of all documents, records, and other information relevant to my claim for [what you are making claim for]; and
3) the name and curriculum vitae of all health care professionals with whom [your company] consulted prior to the adverse benefit determination. This information should also include reference to the health care professionals’ experience and training in [the particular specialty under which your claim is being made], including a list of all peer review articles authored by these professionals; and
4) the identification of all medical or vocational experts whose advice was obtained on behalf of the plan in connection with my adverse benefit determination, without regard to whether the advice was relied upon in making the determination.
Pursuant to 29 CFR 2560.503-1(m)(8), a document, record, or other information shall be considered “relevant” to a claimant’s claim if such document, record, or other information:
(i) Was relied upon in making the benefit determination;
(ii) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;
(iii) Demonstrates compliance with the administrative processes and safeguards required pursuant to paragraph (b)(5) of this section in making the benefit determination; or
(iv) In the case of a group health plan or a plan providing disability benefits, constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.
In addition, please forward as well the Trust Document (commonly known as the “Plan Document”), Summary Plan Description (SPD) (and any amendments thereto since the inception of the Plan), and Form 5500. The authority for this request is found at 29 U.S.C.A. §1024(b)(4).
Very truly yours,
John Doe (insured/claimant)
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