To determine initial eligibility for benefits, you or someone acting on your behalf, must call the Claims Administrator (refer to the number on your identification card) to inform to inform of your request for a determination of eligibility for benefits and the reasons for the request. You will be certified as Chronically Ill (as defined by the Claims Administrator), only if the Claims Administrator is provided with proof, satisfactory to the Licensed Health Care Practitioner employed or retained by the Claims Administrator that you are Chronically Ill. If we require more information: we or a person designated by us may contact you, your representative, your Physician or other persons familiar with your condition; and we or a person designated by the Claims Administrator may need to access your medical records to obtain information about your condition (the Licensed Health Care Practitioner employed or retained by the Claims Administrator cannot certify you as Chronically Ill if we are denied access to your medical records); and we have the right to have you examined, at our expense, by a healthcare provider and to conduct an on-site assessment.

If you are certified as Chronically Ill, you are eligible for benefits. We will send written notice of the certification decision as soon as reasonably possible. We will send this notice no later than 10 business days after we have received all the information we need to assess your condition. The notice will state the date as of which you have been certified as Chronically Ill. When we notify you that you are eligible for benefits, we will provide you or your representative with forms to be used to submit proof of a claim for benefits. Contact the Claims Administrator for the claims submission requirements.

If you are not certified as Chronically Ill, you are not eligible for benefits. The Claims Administrator will send written notice of their decision no later than 10 business days after we have received all the information we need to assess your condition. You or your representative may ask us to more fully explain the denial. Within 60 days of the date the Claims Administrator receives such a written request: (a) the Claims Administrator will provide a written explanation of the reasons for the denial; and (b) make available all information directly relating to such denial.

If you believe your claim for benefits under the plan was denied improperly, you or your representative may appeal the denial of eligibility for benefits. Contact the Claims Administrator for the "Appeals of Eligibility for Benefits or Claims Decisions" instructions.