[Code of Federal Regulations]
[Title 5, Volume 2]
[Revised as of January 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 5CFR875.104]

[Page 434-435]
 
                    TITLE 5--ADMINISTRATIVE PERSONNEL
 
          CHAPTER I--OFFICE OF PERSONNEL MANAGEMENT (CONTINUED)
 
PART 875_FEDERAL LONG TERM CARE INSURANCE PROGRAM--Table of Contents
 
             Subpart A_Administration and General Provisions
 
Sec.  875.104  What are the steps required to resolve a dispute involving 

benefit eligibility or payment of a claim?

    (a) If you dispute the Carrier's denial of your eligibility for 
benefits or your claim for payment of benefits, you must first send a 
written request for reconsideration to the Carrier no later than 60 days 
from the date of its decision.
    (b) The Carrier must provide you with written notice of its review 
decision no later than 60 days after the date it receives your 
reconsideration request.
    (c) If the Carrier upholds its denial (or does not respond within 60 
days), you have the right to appeal its reconsideration decision 
directly to the Carrier. You must make this appeal in writing within 60 
days from the date of the Carrier's notice upholding its decision. You 
will be notified of the decision on your appeal in writing no later than 
60 days from receipt of your appeal request.
    (d) If a denial of your eligibility for benefits or a denial of your 
claim is upheld upon appeal due to the evaluation of your medical 
condition/functional capacity, the Carrier will inform you that you may 
request that an independent third party, mutually agreed to by OPM and 
the Carrier, review the decision. You must make this request in writing 
within 60 days from the date of the notice informing you of the appeal 
decision. The independent third party must notify you in writing of its 
decision no later than 60 days from the Carrier's or its designee's 
receipt of your request for appeal to the third party. This is the final 
administrative remedy available to you. The decision

[[Page 435]]

of the independent third party is final and binding on the Carrier.
    (e) You may seek judicial review of the final administrative denial 
of a claim. Such action may not be brought prior to exhaustion of the 
administrative process provided in this section. To pursue such judicial 
review, you must bring legal action against the Carrier in an 
appropriate United States district court within 2 years from the date of 
the final decision. You may not sue OPM, the independent reviewer, or 
any other entity. If you prevail in court, your recovery is limited to 
the amount of benefits payable under your benefit booklet and schedule 
of benefits.
    (f) The procedures described in paragraphs (a), (b), (c), (d), and 
(e) of this section apply only if you have valid coverage under the 
FLTCIP. If the Carrier determines that your coverage was based on an 
erroneous application and voids the coverage as described in Sec.  
875.408 of this part, these provisions do not apply. The Carrier will 
provide you with information on your review rights in its rescission 
letter (letter voiding your coverage).

[68 FR 5534, Feb. 4, 2003, as amended at 70 FR 30607, May 27, 2005; 72 
FR 12037, Mar. 15, 2007]