Appeals

If Your Claim is Denied

If any claim under the Plan is denied, you will receive written notice of the decision of the right to appeal the denial. The notice will include a description of (1) the specific reasons for the denial and reference to the specific Plan provisions on which the denial is based; (2) a description of any additional information required and why that information is required to perfect your claim; (3) the Plan’s appeal procedures, including applicable time limits and your right to submit written comments, documents, and other information relating to the claim and to request in writing to review or receive copies, free of charge, of Plan documents, records, or other relevant and non-privileged information; and (4) your right to file suit if your claim is denied on appeal.

In addition, if your claim is for medical, dental or disability benefits, you will be notified if an internal rule, guideline, or similar criterion was relied on by the Plan Administrator and, at your request, will be provided with a copy, free of charge, of such rule, guideline, or similar criterion. If your claim is denied based on a medical necessity or other similar exclusion or limit, you will be notified that you may request, free of charge, an explanation of how that exclusion or limit and any clinical judgments apply to your medical circumstances. In the case of a denial of an urgent care claim, a description of the expedited review process applicable to such claims will be included.

Appealing a Denied Claim

If you want to file an appeal of a claim denial, it is important that you do so within the applicable time period specified below. If you do not appeal on time, you may lose your right to file suit in a state or federal court, because you have not exhausted your internal administrative appeal rights (which is generally a requirement before you can sue in state or federal court).

• Health and Disability Benefit Appeals

You (or your authorized representative) may appeal a complete or partial denial of the claim by filing with the Plan’s Administrative Office a written appeal within 180 days after your receipt of the claim denial.

• Life Insurance and AD&D Benefit Appeals

You (or your authorized representative) may appeal a complete or partial denial of the claim by filing a written appeal within 60 days after your receipt of the claim denial.

You should include the reasons you believe the claim was improperly denied and all additional facts and documents you consider relevant in support of your appeal. As you prepare your appeal, you may request, free of charge, reasonable access to all documents, records, and other information relevant to your claim. You may also request the identity of any medical and/or vocational experts whose advice was obtained in connection with the adverse benefit determination, even if that advice was not relied upon in the claim denial.

The following chart summarizes which entity is responsible for reviewing different types of appeals.

How an Appeal is Decided

As indicated in the chart above, the members of the Plan’s Board of Trustees will decide appeals related to eligibility, and coverage for time loss and Self-Funded medical and dental benefits. If you are enrolled in an HMO option, whether medical, dental, or otherwise, the HMO is the final decision maker on appeal. When deciding appeals, the Trustees will not defer to the initial adverse benefit determination and will consider all comments, documents, and records and other information you submit, even if they were not submitted or considered during the initial claim decision. Their decision on your appeal will be made based on the record, including any additional documents and comments you submit.

If your claim was denied on the basis of a medical judgment (such as the absence of medical necessity or the use of an experimental or investigational treatment), the Board will consult a health care professional with training and experience applicable to the relevant field of medicine. The professional shall not have been involved in the claim denial nor be the subordinate of any person involved in the denial. Upon request, you can obtain the name of any professional consulted and the advice (if any) given concerning your claim (even if the Board did not rely on this advice in making its decision).

The time for the Board to issue its decision depends on the type of claim:

Pre-Service & Urgent Care Health Claims

You will receive notice of the decision on your appeal within 30 days for Pre-Service Claims. You may request expedited review of urgent care claim denials by telephone or in writing and submit information in support of your appeal by facsimile and/or telephone, as appropriate. You will receive notice of the decision within 72 hours of receipt of the appeal.

All Other Claims

Appeals of Post-Service Claims will be decided at the next regularly scheduled meeting of the Board of Trustees following receipt of the appeal. If, however, your request for review is received within 30 days of the next regularly scheduled Board meeting, your appeal will be decided at the second regularly scheduled Board meeting following receipt of your appeal. In special circumstances, review of your appeal may be delayed until the third regularly scheduled Board meeting following receipt of your appeal. You will be notified in writing if an extension is necessary. You will be notified of the decision on your appeal as soon as possible but no later than five days after a decision on your appeal is reached.

Denial of a Claim on Appeal

If your claim is denied on appeal, you will receive a written notice stating (1) the specific reasons for the decision and specific references to the relevant Plan provisions on which the Trustees’ decision is based; (2) your right to receive, on request and free of charge, access to and copies of all documents, records, and other relevant information; and (3) your right to file suit under section 502(a) of ERISA. If your claim is for medical, dental or disability benefits, you will be notified if an internal rule, guideline, or other similar criterion was relied on by the Trustees and will be provided with a copy of such rule, guideline, or other criterion free of charge at your request. If your claim is denied based on a medical necessity or other similar exclusion or limit, you will be provided, free of charge at your request, an explanation of how that exclusion or limit and any clinical judgments apply to your medical circumstances, including information relating to medical or vocational experts whose advice was obtained on behalf of the Trustees in connection with the denial, without regard to whether the advice was relied upon in making the benefit determination.