Filing Claims

To obtain a claim form, notify Unum within 90 days of receiving a critical illness diagnosis. If it is not reasonably possible to notify Unum within this period, it must be done no later than one year after notice is required.

Proof of claim must include documentation furnished by a physician and supported by clinical, radiological, histological, pathological, and/or laboratory evidence. It may also include the hospital or physician's bill or other proof of charges. Unum may require you or your dependents to be examined by a physician of their choice at their expense. If you do not obtain the exam or provide information Unum requests to complete your claim, benefits may be denied.

Unum has the right to recover any overpayments due to fraud or errors made when processing the claim.

Send claims to Unum Life Insurance Company at the address shown on the claim form.

Appeal Procedures

You have 180 days from the date you receive notice of a denied claim to file an appeal for that claim. Send your written appeal to the address specified in the claim denial. A decision will be made within 45 days following Unum's receipt of your appeal request. If Unum determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Unum will notify you in writing if an additional 45-day extension is needed.

If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will have at least 45 days to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information.

You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the claim denial will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination.

A person who is not involved in the initial claim determination will conduct the appeal review and such person will not work under the original decision maker's authority. In the case of a claim denied on the grounds of a medical judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Unum will provide you with the names of each such expert, regardless of whether the advice was relied upon.

A notice that your request on appeal is denied will contain the following information:

The specific reason(s) for the determination;
A reference to the specific Plan provision(s) on which the determination is based;
A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request);
A statement describing your right to bring a lawsuit under Section 502(a) of ERISA if you disagree with the decision;
The statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and
The statement that "You or your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency".

Notice of the determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.

Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim.