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• About Initiating Claims

About Initiating Claims

When the time comes for you to use the benefits you selected, the last thing you need is a complicated claims process.

The Federal Program allows you or your representative to initiate a claim within 12 months after the date you incurred charges for covered services, or by April 1 of the year following the year you incurred charges for covered services, whichever is later. We will send you written notice of our claim determination as soon as possible after we receive all the information we need. In general, that means within 10 business days.

What happens if my claim is denied?

If we deny your claim, in whole or in part, you or your representative may request a review of the denial by sending a written request to us no later than 60 days after the date of the denial. We then send you written notice of our decision no later than 60 days after the date we receive your request.

If the initial denial is upheld on review, you can appeal by sending us a written request 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 provides 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, our written notice lets you know how to request such an appeal.
 

Independent third party claims 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, 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.
 

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. See the Limits on Legal Actions section of the Benefit Booklet for more information.