Citi Benefits Handbook
Claims and Appeals for the MetLife PDP
The amount of time MetLife will take to make a decision on a claim will depend on the type of claim.
1 The time period allowed to make a decision is suspended pending receipt of additional information.
You have the right to request a reconsideration of the denied claim by calling or writing to MetLife. Any additional information that you feel would support the claim should be provided to MetLife.
If, after the review, it is determined that the initial denial can be reversed and the claim paid, normal processing steps are followed. If, after the review, it is determined that the original denial stands, a denial letter is written to you.
Responses to an appeal are conducted by an individual of higher authority than the person who originally denied the claim. The response includes:
- An explanation in plain language of why the charges are denied in plain language and
- A reference to the wording from this Plan document that justifies the denial.
The appeal request must be submitted in writing to MetLife within 180 days of receipt of the denial letter. As part of this review, you or your legal representative has the right to review all pertinent documents and submit issues and comments in writing to a committee selected by MetLife. The committee consists of senior representatives of MetLife Dental Claim Management and a Dental Consultant.
For preservice, post-service and concurrent claim appeals, Citi has delegated to MetLife as Claims Administrator the exclusive right to interpret and administer the provisions of the Dental Benefit Plan. The Claims Administrator's decisions are conclusive and binding. The Claims Administrator's decision is based only on whether or not benefits are available under the plan for the proposed treatment or procedure. The determination as to whether the pending health service is necessary or appropriate is between you and your physician.
If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to bring a civil action under Section 502(a) of ERISA, provided that you file any lawsuit or similar enforcement proceeding, commenced in any forum, within 12 consecutive months after the date of receiving a final determination on review of your claim or, if earlier, within two years from the date on which you were aware, or should have been aware, of the claim at issue in the suit.
The two-year limitation shall be increased by any time a claim or appeal on the issue is under consideration by the appropriate fiduciary. If any different period to begin suit is specified in an insurance contract forming part of the Plans or any shorter period is specified in the rules of the Claims Administrator, that period will apply to proceedings against the insurer or with regard to the ruling of that Claims Administrator, respectively