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Appeals
As stated in the Notice and Review of Benefit Eligibility Decision subsection of the Eligibility for Benefits section, and the Notice and Review of Claim Determination subsection of the Claims section, the Federal Long Term Care Insurance Program (FLTCIP) includes an appeals process. This section explains your right to appeal in the event we initially deny your eligibility for benefits or your claim and then, on review, we uphold our denial.
If you choose to appeal our eligibility for benefits or claim decision, you must send a Written request to us, with any additional information that you wish to have us consider, no later than 60 days after the date of our review decision. Your appeal will be reviewed by an appeals committee composed of: one or more representatives of John Hancock Life & Health Insurance Company, and other person(s) if mutually agreed upon by OPM and us.
The appeals committee will provide you with Written notice of its final decision no later than 60 days after the date we receive your Written request for appeal. If the appeals committee upholds the denial and that denial is eligible for appeal to an independent third party (as explained below), our Written notice will let you know how to request such an appeal.
If the appeals committee upholds a denial of your eligibility for benefits or your claim due to its evaluation of your medical condition/functional capacity, (such as your ability to perform Activities of Daily Living or your cognitive status), you may request to appeal that decision to an independent third party mutually agreed to by OPM and us. You must make this request in Writing no later than 60 days after the date of our notice informing you of the appeals committee’s decision.
The independent third party will provide you with Written notice of its final decision no later than 60 days after we receive your request for appeal to the independent third party. The decision of the independent third party is final and binding on us.
The following is an example of when a denial by the appeals committee will be eligible for appeal to an independent third party: the appeals committee upholds a denial of your eligibility for benefits because its review indicates that you can perform 5 out of 6 Activities of Daily Living.
The following is an example of when a denial by the appeals committee will not be eligible for appeal to an independent third party: the appeals committee upholds a denial of your claim for benefits for Nursing Home services because you exhausted your Maximum Lifetime Benefit.
Exhaustion of the Appeals Process
Once you have exhausted this appeals process, you may seek judicial review of a final denial of eligibility for benefits or a claim. Please see the Limits on Legal Actions subsection of the General Provisions section for more information.
| Call: 1-800-LTC-FEDS (1-800-582-3337) (TTY: 1-800-843-3557) |
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