If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew.

An explanation why You are appealing the initial determination.Īs part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.Īfter MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim.

Whether the appeal is the first or second appeal of the initial determination.Appeals must be in writing and must include at least the following information: You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision.

Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. If MetLife denies Your claim, You may take two appeals of the initial determination. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based.

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