CLAIMS AND APPEALS PROCEDURES

This section describes the procedures under which you can make a claim for benefits and appeal a denied claim for benefits. As you will see, there are different procedures that apply if you are filing a claim or appeal that does not involve health benefits (in other words, a claim or appeal under the Short-Term Disability Plan, Long-Term Disability Plan, Life Insurance Plan, Business Travel Accident and Seat Belt Plan, the Unisys Income Assistance Plan and/or the Dependent Care Flexible Spending Account) versus a claim or appeal that does involve health benefits (in other words, a claim or appeal under the Unisys Medical Plan – Aetna Choice POS II (formerly the PPO Options), the Prescription Drug Plan, the Unisys Dental Plan, the Health Care Flexible Spending Account and/or the Unisys Vision Plan).

Note that this section does not cover the claims and appeals procedure for the Unisys Medical Plan Self-Insured HMO Options or the insured HMO options: the applicable claims and appeals procedures for those Medical Plan options are found in the applicable Supplements or HMO certificates of insurance, depending on the plan.

What Is a Claim?

A request for benefits is a “claim” subject to these procedures only if it is filed by you or your authorized representative in accordance with the plans’ claim filing guidelines. If you obtain services from a network provider (for example, a network provider under the Unisys Medical Plan or Dental Plan), the provider will submit a claim for all services they perform.

In general, your claims must be filed in writing (except for an “urgent care” claim for health benefits, described below, which may be made orally) with the Claims Administrator for Processing Benefits Requests (the “Claims Administrator”) listed below. Any claim that does not relate to a specific benefit under a Plan (for example, a general eligibility claim or a dispute involving a mid-year election change) must be filed with:

UnisysBenefitsServiceCenter

P.O. Box 785048

Orlando, Fla.32878-5048

1-877-864-7972

A casual inquiry about benefits or the circumstances under which benefits will be paid is not a “claim” under these rules, unless it is determined that your inquiry is an attempt to file a claim.

If you want to bring a claim for benefits under one of the plans, you may designate an authorized representative to act on your behalf as long as you provide written notice of such designation to the Claims Administrator or the Appeals Administrator identifying such authorized representative. (In the case of a claim for medical benefits involving urgent care, a healthcare professional who has knowledge of your condition may act as your authorized representative.)

A.Claims and Appeals That Don’t Involve Health Benefits – Procedures for the Short-Term Disability Plan, Long-Term Disability Plan, Life Insurance Plan, Business Travel Accident and Seat Belt Plan, the Unisys Income Assistance Plan and Unisys Dependent Care Flexible Spending Account

Filing Your Claim

You need to file your written claim for benefits with the appropriate Claims Administrator noted below. Please contact the appropriate Claims Administrator for claim forms and other information that may be useful in filing your claim for benefits or check online at the Unisys U.S. Benefits Web site (User ID: Unisys; Password: usbenefits).

Claims Administrator for Processing Benefits Requests

For the Short-Term Disability Plan and the Long-Term Disability Plan:

Broadspire Services, Inc.
P.O. Box 189093
Plantation, Florida33318-9093
1-866-269-6239

For the Life Insurance Plan:

Marsh@Work Solutions
P.O. Box 9122
Des Moines, IA50306
1-800-222-1617

For the Business Travel Accident and Seat Belt Plan:

CIGNA
1601 Chestnut St.
Philadelphia, PA19192

For the Unisys Income Assistance Plan:

Employee and Labor Relations
Unisys Corporation
Unisys Way
Township Line and Union Meeting Roads
M.S. E8-114
Blue Bell, PA19424

For the Unisys Dependent Care Flexible Spending Account

Benefits Payment Office - FSA, C/OAetna

PO Box 843

Blue Bell, Pa19422-0843

Response from Claims Administrator

You will receive a response to a request for benefits within 90 days (45 days in the case of a claim for short-term or long-term disability benefits). For claims other than claims involving disability benefits, if the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 90-day period that the Claims Administrator needs up to an additional 90 days to review your claim. In the case of a claim for short-term or long-term disability benefits, if the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 45-day period that the Claims Administrator needs up to an additional 30 days to review your claim.

If there is not enough information to allow the Claims Administrator to process your claim, you will be given an opportunity to supply the missing information.

If the Claims Administrator denies your claim in whole or in part, the Claims Administrator will provide you with a written notice of the denial. This notice will include:

  • the reason for the denial
  • references to relevant plan provisions
  • a description, if applicable, of any additional material or information necessary for you to perfect your claim and an explanation as to why such information is necessary
  • a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the appeal determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to you free of charge at your request
  • a description of the plan’s appeal procedure, including a statement that you are entitled to bring a civil action in Federal court under Section 502 of ERISA to pursue your claim for benefits once you have exhausted the Plan’s appeal process

How to Appeal the Denial of a Claim not Involving Health Benefits

Informal Complaint Procedure

If you disagree with the determination made on a benefit request, you may be able to satisfactorily resolve the disagreement by calling the Claims Administrator that issued the determination. If you are not successful in arriving at a satisfactory resolution, you may file a formal appeal with the appropriate Appeals Administrator, as noted below. Note that you are not required to follow this informal complaint procedure before filing a formal appeal under the “Formal Appeal Procedures” described below.

Formal Appeals Procedure

If you disagree with the determination of the Claims Administrator, you must submit a written appeal to the appropriate Appeals Administrator, as noted below, within 60 days (or 180 days in the case of a claim for short-term or long-term disability benefits) after the date you receive your benefit determination.

Your written appeal should state the reasons why you feel your benefit should have been granted and you may submit documents, records and other information relating to your claim for benefits (regardless of whether such information was considered in your initial claim for benefits) to the Appeals Administrator for review and consideration. You will also be entitled to receive, upon request and free of charge, access to and copies of, all documents, records and other information that is relevant to your appeal.

Appeals Administrators

For the Unisys Short-Term Disability Plan,Unisys Long-Term Disability Plan for disabilities that started before January 1, 1994, Dependent Care Flexible Spending Account,Business Travel Accident and Seat Belt Insurance, Unisys Income Assistance Plan

The Appeals Administrator responsible for determining appeals under these plans, and for determining appeals for claims that are not related to any specific benefit under a Plan, is the Unisys Employee Benefits Administrative Committee. Your written appeal should be sent to the Claims Administrator that initially handled your claim; the Claims Administrator will forward your appeal to the Unisys Employee Benefits Administrative Committee. The response to your initial claim for benefits will provide details on how and where to file your appeal.

For the Unisys Long-Term Disability Plan for disabilities that started on or after January 1, 2003

The Appeals Administrator for the Unisys Long-Term Disability Plan for disabilities that started on after January 1, 2003 is:

Broadspire Services, Inc.

P.O. Box 189151

Plantation, Florida 33318-9151

1-866-269-6239

The response to your initial claim for LTD benefits will provide further details on how and where to file your appeal.

Response from Appeals Administrator

You will be notified of a decision within 60 days (45 days in the case of a claim involving short-term or long-term disability benefits) after your appeal is received. If the Appeals Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Appeals Administrator will notify you within the initial 60-day period (or within the initial 45-day period in the case of a claim for short-term or long-term disability benefits) that the Appeals Administrator needs up to an additional 60 days (45 days in the case of a claim for short-term or long-term disability benefits) to review your appeal.

If the Appeals Administrator denies your claim in whole or in part, the Appeals Administrator will provide you with a written notice of the denial. This notice will include:

  • the reason for the denial
  • references to relevant plan provisions
  • a statement that you are entitled to receive, upon request and free of charge, access to and copies of, all documents, records and other information that is relevant to your claim for benefits
  • a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the appeal determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to you free of charge at your request
  • a statement that you are entitled to bring a civil action in Federal court under Section 502 of ERISA to pursue your claim for benefits

The decision of the Appeals Administrator is final and conclusive on all persons claiming benefits under the Plan, subject to applicable law.

If you challenge the decision of the Appeals Administrator, a review by a court of law will be limited to the facts, evidence and issues presented during the Formal Appeals Procedure noted above. The Formal Appeals Procedure described above must be exhausted before you can pursue the claim in Federal court. Facts and evidence that become known to you after having exhausted the appeals procedure may be submitted for reconsideration of the appeal in accordance with the time limits established above. Submit this new information to the Claims Administrator that handled your initial claim. Issues not raised during the Formal Appeals Procedure will be deemed waived.

B.Claims and Appeals for Health Benefits – Procedures for the Unisys Medical Plan Aetna Choice POS II (formerly the PPO) Options, the Prescription Drug Program, the Unisys Dental Plan, the Unisys Health Care Flexible Spending Account and the Unisys Vision Plan

Different Types of Claims for Health Benefits

There are several different types of claims that you may bring for health benefits. The procedures for evaluating claims (for example, the time limits for responding to claims and appeals) depend upon the particular type of claim. The types of claims that you may generally bring under the plans are as follows:

Pre-Service Claim -- A “pre-service claim” is a claim for a particular benefit that is conditioned upon you receiving prior approval in advance of receiving the benefit. A pre-service claim must contain, at a minimum, the name of the individual for whom benefits are being claimed, a specific medical condition or symptom, and a specific treatment, service or product for which approval is being requested.

Post-Service Claim – A “post-service claim” is a claim for payment for a particular benefit or for a particular service after the benefit or service has been provided. A post-service claim must contain the information requested on a claim form provided by the applicable provider.

Urgent Care Claim – An “urgent care claim” is a claim for benefits or services involving a sudden and urgent need for such benefits or services. A claim will be considered to involve urgent care if the Claims Administrator or a physician with knowledge of your condition determines that the application of the claims review procedure for non-urgent claims

  • could seriously jeopardize your life or your health, or your ability to regain maximum function, or
  • in your physician’s opinion, would subject you to severe pain that cannot adequately be managed without the care or treatment that is subject of the claim.

Concurrent Claim Review – A “concurrent claim review” is a claim relating to the continuation/reduction of an ongoing course of treatment.

Filing Your Claim

You need to file your written claim for benefits with the appropriate Claims Administrator noted below. If you obtain services from a network provider (for example, a network provider under the Unisys Medical Plan or Dental Plan), the provider will submit a claim for all services they perform. For Prescription Drug Program claims for prescription drugs that you purchase at a retail pharmacy, your retail pharmacist will file your claim for benefits. Please contact the appropriate Claims Administrator for claim forms and other information that may be useful in filing your claim for benefits or check online at the Unisys U.S. Benefits Web site (User ID: Unisys; Password: usbenefits).

Claims Administrator for Processing Benefits Requests

For the Unisys Medical Plan -- Aetna Choice POS II (formerly known as the PPO) options:

Aetna
PO Box 981107
El Paso, TX 79998-1107

For the Dental Plan:

MetLife Dental
P.O. Box 14093
Lexington, KY 40512-4093

For the Prescription Drug Program:

Medco Health
P.O. Box 2201
Pittsburgh, PA 15230-2201

For the Unisys Heath Care Flexible Spending Account:

Benefits Payment Office - FSA, C/OAetna

PO Box 843

Blue Bell, Pa 19422-0843

For the Unisys Vision Plan:

Spectera Claims Department
P.O. Box 26618
Baltimore, MD 21207-6618
RESPONSE FROM CLAIMS ADMINISTRATOR

You will receive a response to a request for benefits within the following:

  • Post-Service Claim - In the case of a post-service claim, the Claims Administrator will respond to you within 30 days after receipt of the claim. If the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 30-day period that the Claims Administrator needs up to an additional 15 days to review your claim. If such an extension is necessary because you failed to provide the information necessary to evaluate your claim, the notice of extension will describe the information that you need to provide to the Claims Administrator. You will have no less than 45 days from the date you receive the notice to provide the requested information.
  • Pre-Service Claim - In the case of a pre-service claim, the Claims Administrator will respond to you within 15 days after receipt of the claim. If the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 15-day period that the Claims Administrator needs up to an additional 15 days to review your claim. If such an extension is because you failed to provide the information necessary to evaluate your claim, the notice of extension will describe the information that you need to provide to the Claims Administrator. You will have no less than 45 days from the date you receive the notice to provide the requested information.
  • Urgent Care Claim - In the case of an urgent care claim, the Claims Administrator will respond to you within 72 hours after receipt of the claim. If the Claims Administrator determines that it needs additional information to review your claim, the Claims Administrator will notify you within 24 hours after receipt of the claim and provide you with a description of the additional information that it needs to evaluate your claim. Youwill have no less than 48 hours from the time you receive this notice to provide the requested information. Once you provide the requested information, the Claims Administrator will evaluate your claim within 48 hours after the earlier of the Claims Administrator’s receipt of the requested information, or the end of the extension period given to you to provide the requested information. There is a special time period for responding to a request to extend an ongoing course of treatment if the request is an urgent care claim. For these types of claims, the Claims Administrator must respond to you within 24 hours after receipt of the claim by the Plan (provided, that you make the claim at least 24 hours prior to the expiration of the ongoing course of treatment).
  • Concurrent Care Review Claim - If the Plan has already approved an ongoing course of treatment for you and contemplates reducing or terminating the treatment, the Claims Administrator will notify you sufficiently in advance of the reduction or termination of treatment to allow you to appeal the Claims Administrator’s decision and obtain a determination on review before the treatment is reduced or terminated.

If there is not enough information to allow the Claims Administrator to process your claim, you will be given an opportunity to supply the missing information.