Visa Inc. MetLife Life and AD&D Insurance Plan. Summary of Benefits for Employees

Transcription

1 Visa Inc. MetLife Life and AD&D Insurance Plan Summary of Benefits for Employees Effective January 1, 2013

2 MetLife Life and AD&D Insurance Plan 1 Table of Contents BENEFITS UNDER THE LIFE AND AD&D PLAN... 1 Automatic Benefits For Eligible Employees... 1 Eligibility Under Severance Agreement... 1 Optional Benefits For Eligible Employees and Eligible Dependents... 2 ELIGIBLE DEPENDENTS... 2 OPTIONAL LIFE INSURANCE FOR ELIGIBLE EMPLOYEES... 3 OPTIONAL AD&D INSURANCE FOR ELIGIBLE EMPLOYEES... 4 FAMILY AD&D INSURANCE... 4 ENROLLING IN OPTIONAL LIFE AND AD&D INSURANCE:... 5 Paying for Optional Coverage... 6 Naming a Beneficiary... 6 Evidence of Insurability... 7 LIFE INSURANCE BENEFIT PROVISIONS... 8 Accelerated Benefits... 8 Reduction of Coverage Conversion to an Individual Policy Unpaid Leaves of Absence AD&D INSURANCE BENEFIT PROVISIONS AD&D Benefits Limitations on AD&D Benefits No Individual Policy Conversion For AD&D Coverage... 15

3 MetLife Life and AD&D Insurance Plan 2 Unpaid Leaves of Absence TERMINATION OF DEPENDENT COVERAGE CLAIM PROCEDURES Filing a Claim If You Receive an Adverse Benefit Determination Procedures for Appealing an Adverse Benefit Determination... 17

4 MetLife Life and AD&D Insurance Plan 1 This document summarizes the main provisions of the MetLife Life and Accidental Death & Dismemberment (AD&D) Insurance plan ( Life and AD&D plan ) effective January 1, 2013, for eligible employees. The plan is offered under the Visa Welfare Benefits and Cafeteria Plan. Please refer to the SPD for the Visa Welfare Benefits and Cafeteria Plan for information regarding your eligibility, making changes during the year, your rights under ERISA, and general administrative information. BENEFITS UNDER THE LIFE AND AD&D PLAN The Life and AD&D plan is designed to offer protection for your and your family s financial well-being in case of your death or disability. Automatic Benefits For Eligible Employees An eligible employee (as defined in the SPD for the Visa Welfare Benefits and Cafeteria Plan) is automatically enrolled in the following benefits under the Life and AD&D plan, at no cost, on his first active day at work: $50,000 of basic life insurance; and $50,000 of basic AD&D insurance. Eligible employees dependents are not covered under basic life and basic AD&D insurance (see below for optional coverages for your dependents). Eligibility Under Severance Agreement In addition, former employees who have a severance agreement with Visa may be eligible to continue participation in the Life plan, for the term of their severance period, not to exceed one year, under the terms of that severance agreement. Actively at Work Employees must be actively at work to enroll for insurance coverage or receive any increase in insurance coverage.

5 MetLife Life and AD&D Insurance Plan 2 Optional Benefits For Eligible Employees and Eligible Dependents The following additional benefits are available under the Plan and are described below: optional life, dependent life, optional AD&D, and family AD&D insurance. ELIGIBLE DEPENDENTS For the purposes of the Life and AD&D plan, eligible dependents include: Your spouse or domestic partner ( spouse and domestic partner are defined in the SPD for the Visa Welfare Benefits and Cafeteria Plan); Your or your domestic partner s unmarried dependent child who is under age 19 (under age 25 if a full-time student with at least 8 credits at an accredited educational institution) supported by you, unmarried and not working full-time. You can only elect coverage for your domestic partner s children if you have a domestic partner on file with Visa and if the child meets the criteria for an eligible dependent; Your or your domestic partner s unmarried dependent child, regardless of age, who is mentally or physically disabled and incapable of earning his/her own living. Proof of disability or incapacity must be sent to MetLife within 31 days after the child attains age 19. The child must have insurance coverage prior to reaching age 19. A child for whom you have a Qualified Medical Child Support Order (QMCSO); and A child under age 18 for whom you or your spouse/domestic partner is a court appointed guardian. Your children include: Your biological children; Your legally adopted children (effective when placed in your custody and during the period You are party to a suit in which You are seeking the adoption of the child.);

6 MetLife Life and AD&D Insurance Plan 3 Your stepchildren that are supported by you and are your tax dependents. The definition of dependent also includes stepchildren of an eligible employee, provided that the child also qualifies as the eligible employee's Code Section 152 dependent. If you and your spouse (or domestic partner) both work for Visa and are eligible for benefits, Visa will provide each of you with Basic Life and Accidental Death and Dismemberment. You each have the option to enroll in Optional Life and Optional AD&D. Neither can cover the other under Spouse Life or Optional AD&D. No person may be insured as a Dependent of more than one employee; i.e., only one of you can cover your eligible children as dependents. OPTIONAL LIFE INSURANCE FOR ELIGIBLE EMPLOYEES An eligible employee may buy optional life insurance coverage for himself, as follows: One times your annual salary (rounded up to the next $1,000) Two times your annual salary (rounded up to the next $1,000) Three times your annual salary (rounded up to the next $1,000) Four times your annual salary (rounded up to the next $1,000) Five times your annual salary (rounded up to the next $1,000) Six times your annual salary (rounded up to the next $1,000). The maximum amount of basic and optional life insurance coverage that an eligible employee may purchase for himself is $2,500,000. In addition, for certain coverage amounts, you may need to provide evidence of insurability, as described below. Important note: For the purpose of optional life insurance, the amount of coverage is based on your annual base salary or wages excluding overtime, shift differentials, bonuses, or additional compensation as of September 30 of the previous year. For sales employees the amount of coverage is based on your annual base salary (excluding overtime, shift differentials, bonuses, or additional compensation) plus average annual commissions as of September 30 of the previous year. The amount

7 MetLife Life and AD&D Insurance Plan 4 of optional life insurance that you select does not increase if your salary increases during the year. OPTIONAL AD&D INSURANCE FOR ELIGIBLE EMPLOYEES You have the option to buy optional AD&D insurance coverage for yourself. You can choose from the following options: One times your annual salary (rounded up to the next $1,000) Two times your annual salary (rounded up to the next $1,000) Three times your annual salary (rounded up to the next $1,000) Four times your annual salary (rounded up to the next $1,000) Five times your annual salary (rounded up to the next $1,000) Six times your annual salary (rounded up to the next $1,000). The maximum amount of optional AD&D insurance coverage that you can purchase is $950,000 For the purpose of optional AD&D insurance, including any family AD&D insurance that you elect to purchase, the amount of coverage is based on your base salary or for sales people salary plus average annual commissions as of September 30 of the previous year. The amount of optional AD&D insurance that you select does not increase if your salary increases during the year. Your AD&D insurance benefit will be based on your salary in effect as of September 30 of the previous year. FAMILY AD&D INSURANCE You have the option to buy family AD&D insurance coverage for yourself, your spouse or domestic partner and/or your domestic partner s dependent children. If you elect family AD&D coverage, your family members are covered at the following amounts: Family Member Spouse or domestic partner only Child(ren) only Coverage Amount 60% of your benefit 20% of your benefit for each child

8 MetLife Life and AD&D Insurance Plan 5 Family Member Coverage Amount Spouse or domestic partner and child(ren) 50% for your spouse or domestic partner 15% of your benefit for each child You must identify each family member you wish to cover under family AD&D. Important note: For the purpose of optional AD&D insurance, including any family AD&D insurance that you elect to purchase, the amount of coverage is based on your base salary or for sales people salary plus average annual commissions as of September 30 of the previous year. The amount of optional AD&D insurance that you select does not increase if your salary increases during the year. Your AD&D insurance benefit will be based on your salary in effect as of September 30 of the previous year or your date of hire if you are enrolling for the first time. In addition, if you and your dependent spouse or domestic partner die within one year of sustaining injuries in the same accident, the optional AD&D benefits amount which applies to your dependent spouse or domestic partner will be increased to equal the amount set forth on page 13 that applies to you, the employee. Enrolling in Optional Life and AD&D Insurance: You have 31 days from your date of hire to enroll online ( in optional life, dependent life, optional AD&D, and family AD&D insurance. Unless you are required to provide evidence of insurability, your coverage will begin retroactively from your date of hire and through December 31. If you do not enroll within 31 days of your date of hire, you must wait until a subsequent open enrollment period during which you may elect to participate for the next following calendar year. If you are required to provide evidence of insurability (see below), your coverage will be effective on the first day of the calendar month after your evidence of insurability is approved. If you are not actively at work on the date insurance would otherwise take effect, the insurance will take effect on the day you resume work.

9 MetLife Life and AD&D Insurance Plan 6 Paying for Optional Coverage You pay the full cost of any optional life, dependent life, optional AD&D and family AD&D insurance you elect based on the group rates obtained by Visa. Your cost for coverage will depend on how much coverage you elect to purchase and your age on January 1 or your date of hire for new hires or when you first enroll. Rates are published each year during annual enrollment. Please refer to the Benefits Book on for the optional life, dependent life, and optional AD&D rates. Your contributions are deducted each payroll period on an after-tax basis, that is, after federal and state income taxes and FICA taxes are applied. Naming a Beneficiary You must name one (or more) beneficiary(ies) to receive insurance payments in the event of your death. You will be asked to do this in writing when you first enroll. You can name more than one beneficiary, and you can change your beneficiary designation at any time. To designate or update a beneficiary, complete and return the Life and AD&D Beneficiary Designation Form to your Benefits Department. Forms are available online in the forms section of Note: It is advisable to update your beneficiary designation on an annual basis. For example, if you get married or divorced, you may want to name a new beneficiary, or if your beneficiary moves, you will need to update his/her address. If you fail to name a beneficiary, your life and AD&D insurance benefits will be paid automatically to any surviving spouse, then in equal parts to any surviving children, then to any surviving parents and then to any surviving siblings in that order. However, all or a part of your benefit may be paid to your estate. You are automatically the beneficiary for any family AD&D coverage you elect for your spouse or domestic partner and/or for your or your domestic partner s children.

10 MetLife Life and AD&D Insurance Plan 7 Evidence of Insurability In certain circumstances, you may be asked to provide evidence of insurability (EOI) before life insurance coverage can be effective. For example, if your basic and optional life insurance coverage exceeds two times your salary, or if you previously waived coverage, you will be asked to provide EOI. This may include a physical examination at your expense. Your increased or excess coverage will not go into effect until the insurance company has approved your application. Please refer to Evidence of Insurability Chart below. EOI does not apply to optional AD&D coverage. Evidence of Insurability (EOI) Chart Description EOI Requirement - If the Employee / Dependent... Then... Is a new hire or his/her dependent Requests coverage for the very first time Timely Entrant EOI required for amounts in excess of the levels below. If EOI is not approved, the coverage amount will be equal to the following: Optional Life: 2x Basic Annual Earnings Spouse Life: $25,000 Is a current employee or his/her dependent previously waived coverage Late Entrant EOI required for any amounts of insurance requested. If EOI is not approved, he/she will not be insured for any amount of coverage. Is a current participant - requests a one-level increase in the level of coverage at Open Enrollment Employee & Dependents: current enrollees and their dependents may increase coverage by one level/increment annually without EOI..

11 MetLife Life and AD&D Insurance Plan 8 Is a current participant requests an increase of more than one level or greater than 2x at Open Enrollment Increases of more than one level, or where the resulting amount is greater than 2x, will require EOI. If EOI is not approved, the coverage amount will be the current benefit amount in place. Below are some examples: If enrollee is at 1x and requests a two-increment increase to 3x and fails the required EOI, the coverage amount will be 2x (one increment increase under the EOI level). If enrollee is at 1x and requests a 2x, then EOI is not required If enrollee is at 2x and requests 3x, EOI is required and until EOI is approved enroll will be held at 2X If enrollee is at 3x and requests 4x, EOI is not required If enrollee is at 3x and requests 5x, EOI is required and until EOI is approved enrollee will be held at 4x. Experiences a Change in Family Status: If previously waived coverage Late Entrant Current participant EOI required for any amounts of insurance requested Current enrollees and dependents may increase coverage by one level/increment without EOI. Increases of more than one level, or where the resulting amount is greater than the 2x, will require EOI. If EOI is not approved, the coverage amount will be the current benefit amount Exception: If enrollee is at 1x and requests a two-increment increase to 3x and fails the required EOI, the coverage amount will be 2x (one increment increase under the EOI level). New spouse or new child Is Not Actively at Work Subject to Actively-at-Work requirement Mirrors rules for new hires Effective date of coverage is delayed until return to active work. Requested changes in benefits do not take place until return to active work. Any increase in salary that results in an increase of benefit, does not take place until return to active work. LIFE INSURANCE BENEFIT PROVISIONS Accelerated Benefits If a doctor certifies that you are terminally ill and have a life expectancy of less than 12 months, you can receive up to 80% of your Basic Life coverage to a maximum of $40,000 and up to 80% of your Supplemental life coverage up to $500,000. Your beneficiary will receive the remainder of your life insurance benefit after you die. The benefit that is paid at death will be reduced by the amount you receive in advance. To qualify for this benefit you must provide MetLife proof of your terminal illness. If your

12 MetLife Life and AD&D Insurance Plan 9 Life Insurance is scheduled to reduce within 12 months of the Accelerated Benefit Option (ABO) request, the accelerated benefit will be based on the reduced amount of insurance. If your Life Insurance benefit is scheduled to end within 12 months, an accelerated benefit will not be paid. Total Disability and Life Insurance Under Age 60 Basic Life Insurance If you become disabled and eligible for benefits under Visa's disability plans while you are a Visa employee, your basic life insurance will continue at no cost to you for up to 12 months from the start of your disability. If you become totally disabled prior to age 60, after nine months of disability you may be able to continue basic coverage at no cost to you by applying for a Premium of Waiver from MetLife and providing the insurance company with satisfactory proof of your total disability. This would need to be provided to MetLife at least three months before your coverage would otherwise end in other words, three months before the first-year anniversary date of the start of your disability. If approved, your coverage will then continue (with all premiums being waived) until age 65. If your Premium of Waiver is denied, your coverage will end 12 months from the start of your disability. You may apply for an individual conversion policy. Under Age 60 Optional Life Insurance If you become disabled and eligible for benefits under Visa's disability plans while you are a Visa employee, your optional life insurance will continue at no cost to you for up to 12 months from the start of your disability. If you become totally disabled prior to age 60, after nine months of disability you may be able to continue optional coverage you have had for at least one year at no cost to you by applying for a Premium of Waiver from MetLife and providing the insurance company with satisfactory proof of your total disability. This would need to be provided to MetLife at least three months before your coverage would otherwise end in other words, three months before the first-year anniversary date of the start of your disability. If approved, your coverage will then continue (with all premiums being waived) until age 65. If your Premium of Waiver is

13 MetLife Life and AD&D Insurance Plan 10 denied, your optional life insurance will end 12 months from your date of disability and you may apply for an individual conversion policy. Over Age 60 If you become disabled and eligible for benefits under Visa's disability plans while you are a Visa employee and over age 60, your basic and optional life insurance will continue at no cost to you for up to 12 months from the start of your disability You must submit a conversion form within 31 days of your life insurance end date to continue coverage under an individual policy. Reduction of Coverage at Age 70 When you reach age 70 your basic life insurance benefit will be reduced to 65% of the original benefit; your optional life insurance benefit is not subject to reduction. Conversion to an Individual Policy If your Life Insurance ends, you can convert part or all of your basic and optional life insurance coverage to an individual policy within 31 days of your termination date or life insurance coverage end date without providing evidence of good health. The rates you pay will be based on your class of risk, your age at that time, the type of policy and the amount of insurance coverage. If you die within the 31-day application period, MetLife will pay the amount of eligible life insurance you were entitled to convert. Suicide Limitations For Optional & Dependent Life Insurance Coverage If you die as the result of suicide, your beneficiary will receive your basic life insurance benefit of $50,000. If you purchased optional life insurance and you die as the result of suicide, your beneficiary will only receive your optional life insurance benefit if you have had this level of coverage for more than two years. If you have been covered less than two years, your beneficiary will receive your basic life insurance benefit of $50,000 plus a refund of your contributions for your optional life insurance coverage (without interest). Similarly, if you increase the level of coverage and die as the result of suicide within two years of that increase, the plan will pay only the prior coverage amount plus the cost

14 MetLife Life and AD&D Insurance Plan 11 difference in contributions you paid for the increased level of coverage. If you die as the result of suicide after you have had the increased level of coverage for more than two years, your beneficiary will receive the full benefit. Unpaid Leaves of Absence If you take an unpaid personal leave of absence, your life insurance coverage will continue to the end of the month following one month of unpaid leave. If your personal leave follows a family or medical leave, your life coverage will end at the end of the month in which the family or medical leave ends.. After this period, your coverage will end unless you convert to an individual policy within 31 days. AD&D INSURANCE BENEFIT PROVISIONS AD&D Benefits The amount of your benefit (or your beneficiary s if you die) depends on the extent of your injury as follows: If you lose Your life Both speech and hearing Movement in both your upper and lower limbs Any combination of a hand, foot or sight of an eye A hand A foot Sight in one eye Speech or hearing in both ears Paralysis of both legs Paralysis of both the arm and leg on one side of the body The plan will pay 100% of your benefit 50% of your benefit A thumb and index finger on the same hand 25% of your benefit Note: If the same accident causes more than one of these losses, the insurance paid will not exceed 100% of your benefit.

15 MetLife Life and AD&D Insurance Plan 12 Definitions Loss of speech the total and irrevocable loss of audible communication which continues for 6 consecutive months following injury/accident. Loss of hearing permanent and total deafness in both ears which continues for 6 consecutive months following injury/accident Loss of a hand or foot the complete severance through or above the wrist or ankle joint. Loss of sight in one eye the permanent and uncorrectable loss of sight in the eye. Loss of a thumb or index finger severance through or above the joints between the fingers and the hand (metacarpophalangeal joints). Paralysis- means loss of use of a limb, without severance. A physician must determine the paralysis to be permanent, complete and irreversible. The plan may also pay the following benefits as consistent with the circumstances outlined below: Exposure Benefit The plan will pay your beneficiary the full AD&D benefit if: You die from unavoidable exposure to the elements and After one year, your body has not been found after a disappearance, forced landing, sinking or wreckage. Seat Belt Benefit The plan will pay up to an additional 10% up to $25,000, if you or a covered dependent are wearing a properly fastened seat belt or child restraint device (meets the required state law) and die as a result of accidental injuries suffered while driving or riding in a private passenger car. Before benefits are paid, the police report must be submitted with the claim.

16 MetLife Life and AD&D Insurance Plan 13 Hospital Benefit If as a result of an accident, you or a covered dependent are confined in a hospital, the plan will pay the lesser of 1% or $2,500 for each full month of hospital confinement. Benefits will not be paid for the first four days of hospital confinement or for more than 12 months. Training Benefit for a Dependent Spouse If you die as a result of an accident while your dependent spouse is enrolled full time in an accredited school or if your spouse enrolls within 12 months of your death for the purpose of training or refreshing employment skills, the plan will pay the cost of enrolling for one year of school, up to an academic year maximum of $5,000 (overall maximum of 2% of the full amount of insurance). Education Benefit for Dependent Children If you die as a result of an accident, the plan will pay up to an academic year maximum up of $5,000 (overall maximum of 2% of the full amount of insurance) per dependent child if on the date of the accident, the child was: Enrolled as a full-time student in a college, university or vocational school above the 12 th grade or Enrolled as a full-time student in a college, university or vocational school within 365 days following the date of the accident. Each dependent child can receive this benefit for up to four consecutive years as long as he/she remains a full-time student. If you have no dependent children who qualify for the benefit upon your death, the plan will pay an additional $1,000 to your beneficiary. Child Care Benefit If you die as a result of an accident, the plan will pay up to $5,000 per year for four consecutive years (overall maximum of 3% of the full amount of insurance) to each of your dependent children that is under age 12 and enrolled in a licensed child care at the time of the accident or enrolls within 12 months of your accidental death. If you have no

17 MetLife Life and AD&D Insurance Plan 14 dependent children who qualify for the benefit upon your death, the plan will pay an additional $1,000 to your beneficiary. Limitations on AD&D Benefits AD&D benefits will not be paid if the loss results from or is caused by: Any diagnosis or treatment of a physical or mental illness An infection, unless it is caused by a visible external wound that was sustained by an accident Suicide or attempted suicide (see the Suicide Limitations section on page 18) A self inflicted or intentional injury The use of any drug, alcohol or medicine unless it is taken as prescribed by a Physician or an over-the-counter medication taken as directed A war, or a warlike action in time of peace, including terrorist acts Committing or attempting to commit a felony or serious crime Any voluntarily taken, administered or absorbed poison, gas, or fumes Service in the armed forces of any country or international authority, except the United States National Guard Operating, learning to operate or serving as a member of a crew of an aircraft that is: Operated by or under any military authority Being used for test or experimental purposes Used or designed to go beyond the Earth s atmosphere For the purpose of descent while in flight (except for self-preservation) Parachuting or exiting an aircraft while in flight (except for self-preservation)

18 MetLife Life and AD&D Insurance Plan 15 Driving a vehicle while intoxicated as defined by the laws of the jurisdiction in which the vehicle was being operated. Reduction of Coverage at Age 70 When you reach age 70, your basic and optional AD&D insurance benefits will be reduced as follows: On or after you reach Age Age Age Age 85 or older Your coverage will equal 70% of the original benefit 45% of the original benefit 30% of the original benefit 15% of the original benefit No Individual Policy Conversion For AD&D Coverage Your basic and optional AD&D insurance coverage cannot be converted to an individual policy. Unpaid Leaves of Absence If you take an unpaid personal leave of absence, your life insurance coverage will continue to the end of the month following one month of unpaid leave. If your personal leave follows a family or medical leave, your life coverage will end at the end of the month in which the family or medical leave ends.. After this period, your coverage will end. Total Disability and AD&D Your AD&D coverage will end effective the first day of your disability. TERMINATION OF DEPENDENT COVERAGE Dependent coverage ends on the date the policy ends or coverage under the policy ends, the employee dies, or retires, the dependent ceases to be a dependent; the

19 MetLife Life and AD&D Insurance Plan 16 end of the period for which premium has been paid; or the last day of the calendar month in which employment ends. CLAIM PROCEDURES Filing a Claim You or your beneficiary will not receive life and/or AD&D benefits until a claim is filed. A claim for life insurance benefits should be sent as soon as reasonably possible after the death of one insured. MetLife s claim process is described below for Basic or Optional Life and Accidental Death & Dismemberment: Within 20 days of the loss, you or your beneficiary must provide MetLife written notice of the loss Within 90 days of the loss, you or your beneficiary must provide MetLife written proof of the loss; if you do not receive forms from MetLife within 15 days of providing notice, you can provide written proof of loss by sending MetLife a written description of the event and the justification for your benefits eligibility. If You Receive an Adverse Benefit Determination The claim administrator will provide you with a notification of any adverse benefit determination, which will set forth: The specific reason(s) for the adverse benefit determination Reference to the specific plan provisions on which the benefit determination is based A description of any additional material or information necessary for you to perfect the claim and an explanation of why that material or information is necessary A description of the plan s appeal procedures and time limits applicable to such procedures, including a statement of your right to bring a civil action under ERISA after an adverse determination on appeal.

20 MetLife Life and AD&D Insurance Plan 17 If you receive an adverse benefit determination (e.g., any denial, reduction, or termination of a benefit or a failure to provide or make a payment), the plan s claim administrator will notify you within a reasonable period of time, but not later than 90 days after receiving the claim. This 90-day period may be extended for up to an additional 90 days, if the claim administrator both determines that special circumstances require an extension of time for processing the claim, and notifies you, before the initial 90-day period expires, of the special circumstances requiring the extension and the date by which the plan expects to render a determination. In the event an extension is necessary due to your failure to submit necessary information, the plan s time frame for making a benefit determination on review is tolled (i.e., stopped) from the date the claim administrator sends you the extension notification until the date you respond to the request for additional information. Procedures for Appealing an Adverse Benefit Determination You, or your authorized representative, have 60 or 180 (for claims involving a disability determination) days following the receipt of a notification of an adverse benefit determination within which to appeal the determination. You have the right to: Submit written comments, documents, records and other information relating to the claim for benefits Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits Request a review that takes into account all comments, documents, records and other information submitted by you relating to the claim, regardless of whether such information was submitted or considered in the initial benefit determination. The claim administrator will notify you of the plan s benefit determination on review within a reasonable period of time, but not later than 60 days after receipt of your request for review by the plan. This 60-day period may be extended for up to an additional 60 days, if the claim administrator both determines that special circumstances require an extension of time for processing the claim, and notifies you,

21 MetLife Life and AD&D Insurance Plan 18 before the initial 60-day period expires, of the special circumstances requiring the extension and the date by which the plan expects to render a determination on review. In the event an extension is necessary due to your failure to submit necessary information, the plan s time frame for making a benefit determination on review is tolled (i.e., stopped) from the date the plan administrator sends you the extension notification until the date you respond to the request for additional information. The claim administrator s notice of an adverse benefit determination on appeal will be provided in writing and will contain all of the following information: The specific reason(s) for the adverse benefit determination Reference to the specific plan provisions on which the benefit determination is based A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records and other information relevant to your claim and A statement describing any voluntary appeal procedures offered by the plan and your right to obtain the information about such procedures, and a statement of your right to bring an action under ERISA.