8. CLAIM PROVISIONS written request with us for an external grievance review. Upon receipt of the written request, the following steps will be taken: · We will select a different independent review organization for each filed external grievance, from the list of independent review organizations certified by the Indiana Department of Insurance. · We will rotate the choice of an independent review organization among all certified independent review organizations before repeating a selection. · The independent review organization shall make a determination to uphold or reverse our appeal resolution within 15 business days after the external grievance is filed. · The independent review organization shall notify you and us of the determination made within 72 hours after making the determination. Such determination is binding on us. You shall not pay any of the costs associated with the services of an independent review organization. Should you submit information to us that is relevant to the resolution of the appeal of the grievance, and was not previously considered or reviewed by us: · We may reconsider the prior resolution. If we elect to reconsider, the independent review organization shall cease the external review process until the reconsideration is completed. · We shall notify you of a decision within 72 hours after the information is submitted, for a reconsideration, if making a decision in the standard timeline would seriously jeopardize the Insured’s life or health, or his or her ability to reach and maintain maximum function. · Under any other circumstances, we shall notify you within 15 days after the information is submitted. · If you do not agree with our decision, you may request that the independent review organization resume the external review process. · If we choose to not reconsider our initial resolution after receipt of the relevant new information, we shall forward such submitted information to the independent review organization not more than 2 business days after we receive it. Documents and other information created or received by the independent review organization or the medical review professional in connection with an external grievance review are not considered public records to which access is granted and will be treated in accordance with confidentiality requirements of state and federal law. · An independent review organization is immune from civil liability for actions taken in good faith in connection with an external review and its work product and/or determination are admissible in a judicial or administrative proceeding. However, the work product and/or determination do not, without other supporting evidence, satisfy a party’s burden of proof or persuasion concerning any material issue of fact or law. If you have the right to an external review of a grievance under Medicare, you may not request an external review of the same grievance under this process. Pursuing a resolution through the grievance process does not add to or otherwise change the terms of coverage included in this Policy. For further information, you may contact us at the phone number or address listed on the front cover of this Certificate. To whom are benefits payable? Benefits payable for loss of life will be payable in accordance with the beneficiary designation. Unless you otherwise specify, if more than one beneficiary survives you, all surviving beneficiaries will share equally. The beneficiary designation must be in Writing, Signed by you and in a form acceptable to us. If no beneficiary is alive on the date of your death or you do not elect a beneficiary, we, at our option, may make payments as follows: · to your spouse, if living; or · if there is no surviving spouse, to your surviving children in equal shares; or · if there is no surviving spouse or children, to your surviving parents in equal shares; or · if there is no surviving spouse, children or parents, to your surviving brothers and sisters in equal shares; or · if none of the above, to your estate. Benefits payable for loss of life of your Spouse or a Dependent Child will be payable to you. If you are not living or are disqualified by operation of law, we will pay the deceased Dependent’s estate. 16-AC-C-01 Page34