CPlus, A Medicare Select Plan

Review and Appeal, Arbitration Procedures

 

If we accept your application for C Plus Select Plan B or Plan F, you will have the right to seek and obtain full and fair review by us of any determination we make under your C Plus contract. The following is a summary of the review and appeal procedures you must use to do this. More detailed information about these procedures is included in the C Plus contract.

 

Requesting a Review

If you believe that we incorrectly denied all or part of your benefits or made an incorrect decision relating to anything else under your C Plus contract, and you want us to review our determination, you should submit to us a written request for review at the address set forth in your C Plus contract. Your written request must state your full name and subscriber identification number. If your request relates to a claim, you must state the number of the claim that you want reviewed and include a copy of the C Plus Claim Report. Your envelope should be marked "C Plus Request for Review." We will send you a copy of our determination upon review with the reason for it.

 

Dispute Resolution Procedures:

If you have a complaint or dispute that has not been adequately addressed under the review procedures just described, you may submit an appeal to us at the address set forth in your C Plus contract. Your appeal must be submitted to us in writing within 30 days. Your envelope should be marked C Plus Dispute Resolution. Upon receipt of your appeal, we will examine the facts fully and fairly. You will receive a written decision from us within 30 days.

 

Arbitration

In consideration of coverage under the contract and payment of the premiums, you (and we) agree to binding arbitration. This means that any and all claims whether in contract, tort, or otherwise, whether arising before, on, or after the date of your contract, and including without limitation any statutory, common law, intentional tort, or equitable claims will be settled by arbitration - not a court. The arbitrator's decision is final and binding and cannot be reviewed by a court.

As outlined more fully in the contract, the arbitration will be conducted in accordance with the American Arbitration Association's dispute resolution procedures for insurance claims (a copy of which may be obtained by written request to us), except as modified in the contract. The claimant is responsible for starting the arbitration proceedings. We will bear all costs of arbitration other than your costs of representation. If you initiate arbitration, and if the arbitrator finds that the dispute is without substantial justification, the arbitrator has the authority to order that the cost of the arbitration proceedings be borne by you.

The arbitration will be conducted before a single arbitrator in the county in which you reside unless you and we agree to conduct the arbitration in some other county. Prior to the arbitration, if all parties consent to mediate the claim, the arbitrator will refer the claim to a separate mediator, but arbitration will follow if no settlement is reached. A claimant's claim(s) must be arbitrated separately from the claims of others, and may not be consolidated with the claims of others or arbitrated on a class-wide basis.