Sound Shore Medical Center of Westchester SSMC Active EE Health Final SPD Page 87
SSMC Employee Health Benefit Plan
81
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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
No action at law or inequity shall be brought to recover under the Plan before the expiration of 30 days after
the exhaustion of all appeal rights under this section of the Plan, nor shall any such action be brought at all
unless commenced within three years from the date the Covered service or supply was Incurred. However, in
the event this self-funded Plan is being canceled and the Covered Person is notified of the cancellation, no
action to recover under this Plan shall be brought unless commenced before the later of 30 days after the date
of the notification, or 90 days from the date of the Plan cancellation. The agent for service of legal process is
the human resources manager, Sound Shore Medical Center of Westchester, 16 Guion Place, New Rochelle,
NY 10802, Tel.: (914) 632-5000.
