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When used throughout this document "Company", "Our", "We", or "Us" means:
<br />0 United States Fire Insurance Company
<br />GRIEVANCE PROCEDURES
<br />When you submit a claim and that claim is denied, we will provide a written statement containing the reasons for
<br />the Adverse Determination. You have the right to request a review of any Company decision or action pertaining to
<br />our contractual relationship and to appeal any adverse claim determination we've made by filing a Grievance.
<br />These procedures have been developed to ensure a full investigation of a Grievance through a formal process.
<br />DEFINITIONS
<br />A "Grievance" is a written complaint requesting a change to a previous claim decision, claims payment, the
<br />handling or reimbursement of health care services, or other matters pertaining to your coverage and our contractual
<br />relationship.
<br />An "Adverse Determination" is a determination by the Company or its designated utilization review organization
<br />that (i) a service, treatment, drug, or device, is experimental, investigational, specifically limited or excluded by your
<br />coverage; or (ii) a facility admission; the availability of care, continued stay -or other health care services proposed
<br />or furnished have been reviewed and, based upon the information provided, does not meet the contractual
<br />requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and
<br />therefore, the benefit coverage is denied, reduced or terminated in whole or in part.
<br />INFORMAL GRIEVANCE PROCEDURE
<br />You, your authorized representative, or a provider acting on your behalf may submit an oral complaint to us within
<br />60-days after an event that causes a dispute. Telephoning allows you to discuss your complaint or concerns and
<br />gives us the opportunity to immediately resolve the problem.
<br />If we don't have all the information necessary to review your complaint, we will request any additional
<br />information within 6 business days of receiving your complaint. After we receive all the necessary
<br />information, we will provide you, your authorized representative, or a provider acting on your behalf with
<br />our written decision within 30-days after receiving the complaint and all necessary information.
<br />If the problem cannot be resolved in this manner, you still have the right to submit a written request for the
<br />complaint to be reviewed through the Formal Grievance Procedure, as outlined below.
<br />FORMAL GRIEVANCE PROCEDURE
<br />A formal Grievance may be submitted by you, your authorized representative, or in the event of an Adverse
<br />Determination, by a provider acting on your behalf.
<br />If you file a formal Grievance, you will have the opportunity to submit written comments, documents,
<br />records and other information you feel are relevant to the Grievance, regardless of whether those materials
<br />were considered in the initial Adverse Determination.
<br />First Level Review
<br />Within 3 working business days after receiving the Grievance, we must acknowledge the Grievance and provide
<br />you, your authorized representative or a provider with the name, address, and telephone number of the coordinator
<br />handling the Grievance and information on how to submit written material. The person(s) who reviews the
<br />Grievance will not be the same person(s) who made the initial Adverse Determination. During the review, all
<br />information, documents, and other materials submitted relating to the claim will be considered, regardless of
<br />whether they were considered in making the previous claim decision. The Insured will not be allowed to attend, or
<br />have a representative attend, a First Level Review, The Insured may, however, submit written material for
<br />consideration by the reviewer(s).
<br />Grievance
<br />When the Grievance is based in whole or in part on a medical judgment, the review will be conducted by, or in
<br />consultation with, a medical doctor with appropriate training and expertise to evaluate the matter.
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