SPD (14800-7)
If the claim on appeal is denied in whole or in part, you will receive a written notification
from Prudential of the denial. The notice will be written in a manner calculated to be
understood by the applicant and shall include:
(a) the specific reason(s) for the adverse determination,
(b) references to the specific plan provisions on which the determination was based,
(c) a statement that you are entitled to receive upon request and free of charge
reasonable access to, and make copies of, all records, documents and other
information relevant to your benefit claim upon request,
(d) a description of Prudential’s review procedures and applicable time limits,
(e) a statement that you have the right to obtain upon request and free of charge, a copy
of internal rules or guidelines relied upon in making this determination, and
(f) a statement describing any appeals procedures offered by the plan.
If a decision on appeal is not furnished to you within the time frames mentioned above, the
claim shall be deemed denied on appeal.
If the appeal of your benefit claim is denied or if you do not receive a response to your
appeal within the appropriate time frame (in which case the appeal is deemed to have been
denied), you or your representative may make a second, voluntary appeal of your denial in
writing to Prudential within 180 days of the receipt of the written notice of denial or 180 days
from the date such claim is deemed denied. You may submit with your second appeal any
written comments, documents, records and any other information relating to your claim.
Upon your request, you will also have access to, and the right to obtain copies of, all
documents, records and information relevant to your claim free of charge.
Prudential shall make a determination on your second claim appeal within 45 days of the
receipt of your appeal request. This period may be extended by up to an additional 45 days
if Prudential determines that special circumstances require an extension of time. A written
notice of the extension, the reason for the extension and the date by which Prudential
expects to render a decision shall be furnished to you within the initial 45-day period.
However, if the period of time is extended due to your failure to submit information
necessary to decide the appeal, the period for making the benefit determination will be
tolled from the date on which the notification of the extension is sent to you until the date on
which you respond to the request for additional information.
Your decision to submit a benefit dispute to this voluntary second level of appeal has no
effect on your right to any other benefits under this plan. If you elect to initiate a lawsuit
without submitting to a second level of appeal, the plan waives any right to assert that you
failed to exhaust administrative remedies. If you elect to submit the dispute to the second
level of appeal, the plan agrees that any statute of limitations or other defense based on
timeliness is tolled during the time that the appeal is pending.
If the claim on appeal is denied in whole or in part for a second time, you will receive a
written notification from Prudential of the denial. The notice will be written in a manner
calculated to be understood by the applicant and shall include the same information that
was included in the first adverse determination letter. If a decision on appeal is not
furnished to you within the time frames mentioned above, the claim shall be deemed denied
on appeal.