Plan Information - Appeals

Claims and Appeal Procedures

Filing a Claim

Your claim will be considered filed when your application is received by the Fund Office, without regard to whether all the information necessary to make a benefit determination accompanies your application. If all necessary information does not accompany your application, the Fund Office will notify you, in writing, of:

The standards on which entitlement to benefits is based;
The unresolved issues that prevent a decision on the claim; and
The additional information needed to resolve those issues.

Determining Initial Claim

Benefits Other Than Disability Benefits:

The initial determination of benefits will be made within a reasonable period of time but not longer than 90 calendar days after the Fund Office receives your application for benefits and all required information. (If all required information is not received with your application, and you are notified of this by the Fund Office, the 90-day period for making the initial determination will be suspended during the time you are obtaining the additional information).

If the Fund Office determines that special circumstances require an extension of time for processing your claim, the Fund Office will notify you, in writing, prior to the expiration of the 90 days of the circumstances requiring the extension of time and the date by which the Plan expects to make a determination. The extension cannot be more than 90 calendar days from the end of the initial 90-day period.

Disability Benefits:

The initial determination of benefits will be made within a reasonable period of time but not longer than 45 calendar days after the Fund Office receives your application for benefits and all required information. (If all required information is not received with your application, and you are notified of this by the Fund Office, the 45-day period for making the initial determination will be suspended during the time you are obtaining the additional information).

The initial 45-day period may be extended for up to 30 calendar days, to a total of 75 calendar days, if an extension is necessary due to matters beyond the Plan’s control. The Fund Office will notify you, in writing, prior to the expiration of the initial 45-day period of the circumstances requiring the extension of time and the date by which the Plan expects to make a determination.

If the Plan needs a second extension of time to make a determination due to circumstances beyond its control, you will be notified of an extension of up to 30 calendar days, or a maximum of 105 calendar days after the initial receipt of your application. Before the end of the first 30-day extension period, the Fund Office will notify you, in writing, of the circumstances requiring the extension and will give you a new date by which a determination will be made.

If an application for benefits is not acted on within these time periods, you may proceed to the appeal procedures as if your claim has been denied.

Notice of Claim Denial

If the Plan denies your application for benefits, in whole or in part, you will be notified in writing of the determination and be given the opportunity for a full and fair review of the benefit decision. The written notice of denial shall include:

The specific reason(s) for the denial;
The specific reference to pertinent Plan provision(s) on which the denial is based;
A description of any additional material or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review; and
For a claim for disability benefits only, if an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination, a statement that such rule, guideline, protocol or other similar criterion was relied upon and that a copy of that document will be provided to you free of charge upon request.

Right to Appeal

If you apply for benefits and your claim is denied, or if you believe that you did not receive the full amount of benefits to which you are entitled, you have the right to petition the Board of Trustees for reconsideration of its decision. Your petition for reconsideration:

Must be in writing; and
Must state in clear and concise terms the reason(s) for your disagreement with the decision of the Board of Trustees; and
May include documents, records, and other information related to your claim for benefits; and
Must be filed by you or your duly authorized representative with the Fund Office within 60 calendar days after you received notice of denial. In the case of a claim for disability benefits, your petition for reconsideration must be filed with the Fund Office within 180 calendar days after you received notice of denial. Failure to file an appeal within these time limits will constitute a waiver of your right to a review of the denial of your claim. A late application may be considered if the Board of Trustees finds that the delay in filing was for reasonable causes.

By participating in the Plan, you and your beneficiary agree to waive your right to participant in a class, collective, or representative action relating to the Plan. Any dispute, claim, or controversy may only be initiated or maintained and decided on an individual basis.

Review of Appeal

A properly filed appeal will be reviewed by the Board of Trustees (or by a committee authorized to act on behalf of the Board of Trustees) at its next regularly scheduled quarterly meeting. However, if the appeal is received within 30 calendar days prior to such meeting, the appeal may be reviewed at the second quarterly meeting following the receipt of your appeal. If special circumstances require an extension of time, the Board of Trustees will render a decision at the third scheduled quarterly meeting following the receipt of your appeal. The Fund Office will notify you, in writing, before the beginning of the extension of the special circumstances and the date that the Board of Trustees will make its decision.

The Board of Trustees will review all submitted comments, documents, records and other information related to your claim, regardless of whether the information was submitted or considered in the initial benefit determination. The Board of Trustees will not afford any deference to the initial benefit determination. If the adverse benefit determination is based in whole or in part on a medical judgment, the Board of Trustees shall consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment. Such consultant shall be different from any individual consulted in connection with the initial determination and shall not be the subordinate of any such person.

You will receive written notification of the benefit determination on appeal no later than 5 calendar days after the benefit determination is made.

The written notification will include the reason(s) for the determination, including references to the specific Plan provisions on which the determination is based. The written notification will also include 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 for benefits. The written notification of a benefit determination in regard to disability benefits will also include the specific rule, guideline, protocol or other similar criterion relied upon in making the determination.

The denial of a claim to which the right to review has been waived, or a decision by the Board of Trustees or its designated committee with respect to a petition for review, is final and binding upon all parties, subject only to any civil action you may bring under ERISA within two (2) years from the date your appeal has been denied. Following issuance of the written decision of the Board of Trustees on an appeal, there is no further right of appeal to the Board of Trustees or right to arbitration.