SSMC Employee Health Benefit Plan
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A statement describing any voluntary appeal procedures offered by the Plan and the Claimant's
right to obtain the information about such procedures and a statement of the Claimant's right to
bring civil action in a court to clarify their right to benefits.
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If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the
adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a
statement that such rule, guideline, protocol, or other similar criterion was relied upon in making
the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion
will be provided free of charge to the Claimant upon request; and
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If the Adverse Benefit Determination is based on a Medical Necessity or Experimental treatment
or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the Claimant's medical circumstances, or a
statement that such explanation will be provided free of charge upon request.
G. Legal Proceedings
