Teamsters Local 170 Health and Welfare Fund

Claims Procedure

Claims Procedures For The Plan

 
Group Health Plan Claim Processing

Your claims under the Plan’s group health plan will be processed under the following procedures, except to the extent inconsistent with the insurers’ or claim administrator’s claims procedures as set forth in an attachment hereto, in which case the insurers’ or claims administrator’s claims procedures will apply as long as such other claims procedures comply with the Affordable Care Act and DOL Regulations.   For more detailed information, you should review the insurance carriers’ certificate of coverage or benefit booklets, or you may contact the insurance carriers or claims administrators directly to obtain specific claim/appeal processes.

Medical, Pharmacy, Dental and Vision Claim Processing

Initial Claim Processing

Post-Service Claims

Post-Service Claims are those claims that are filed for payment of benefits after health care has been received.  If your Post-Service Claim is denied, you will receive a written notice from the insurer within 30 days of receipt of the claim, as long as all needed information was provided with the claim.  The insurer will notify you within this 30-day period if additional information is needed to process the claim, and may request a one-time extension not longer than 15 days and hold your claim until all information is received.

Once notified of the extension, you then have 45 days to provide this information.  If all of the needed information is received within the 45-day time frame and the claim is denied, the insurer will notify you of the denial within 15 days after the information is received.  If you don’t provide the needed information within the 45-day period, your claim will be denied.

A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide information about applicable appeal procedures.

Pre-Service Claims

Pre-Service Claims are those claims that require notification or approval prior to receiving health care.  If your claim was a Pre-Service Claim, and was submitted properly with all needed information, you will receive written notice of the claim decision from the claims administrator within 15 days of receipt of the claim.  The claims administrator will notify you within this 15-day period if additional information is needed to process the claim, and may request a one-time extension not longer than 15 days and hold your claim until all information is received.  Once notified of the extension, you then have 45 days to provide this information.  If all of the needed information is received within the 45-day time frame, the claims administrator will notify you of the determination within 15 days after the information is received.  If you don’t provide the needed information within the 45-day period, your claim will be denied.  A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide information about the applicable appeal procedures.

Urgent Claims That Require Immediate Action

Urgent Care Claims are those claims that require notification or approval prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your health condition, could cause severe pain.  In these situations:

  • you will receive notice of the benefit determination in writing or electronically within 72 hours after the claims administrator receives all necessary information, taking into account the seriousness of your condition.
  • notice of denial may be oral with a written or electronic confirmation to follow within 3 days.

If you filed an Urgent Care Claim improperly, the claims administrator will notify you of the improper filing and how to correct it within 24 hours after the Urgent Care Claim was received.  If additional information is needed to process the claim, the claims administrator will notify you of the information needed within 24 hours after the claim was received.  You then have 48 hours to provide the requested information.

You will be notified of a determination no later than 48 hours after:

  • the claims administrator’s receipt of the requested information; or
  • the end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time.

A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide information about applicable appeal procedures.

Concurrent Care Claims

If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an Urgent Care Claim as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment.  The claims administrator will make a determination on your request for the extended treatment within 24 hours from receipt of your request.  If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an Urgent Care Claim and decided according to the timeframes described above.

If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to post-service or pre-service timeframes, whichever applies.

If the insurance company denies any part or all of a benefit claim, it will provide you with a written notice.  The written notice will include the specific reason or reasons for the denial and a reference to the Plan provisions on which the denial is based. The notice will also give the name and address of the entity to which you can appeal, and a description of the Plan’s appeal procedures.

Appealing the Denial of a Claim

If your claim is denied, you may appeal that decision.  To appeal, you must submit a written request to the insurance company within 180 days of receiving the initial claim denial.  Along with the written request for appeal, you may submit any additional facts, documents or proof you believe will show why the claim should not be denied. If the written request for appeal is not submitted within 180 days of receiving the initial claim denial, you lose the right to appeal under the Plan.

Pre-Service and Post-Service Claim Appeals

You will be provided with written or electronic notification of the decision on your appeal as follows:

For appeals of Pre-Service Claims (as defined above), you will be notified by the claims administrator of the decision within 15 days from receipt of a request for appeal of a denied claim.  If you are not satisfied with the first level appeal decision of the claims administrator, you have the right to request a second level appeal from the claims administrator.  Your second level appeal request must be submitted to the claims administrator within 60 days from receipt of first level appeal decision.  You will be notified by the claims administrator of the decision within 15 days from receipt of a request for review of the first level appeal decision.

For appeals of Post-Service Claims (as defined above), the first level appeal will be conducted by the claims administrator and you will be notified by the claims administrator of the decision within 30 days from receipt of a request for appeal of a denied claim.  If you are not satisfied with the first level appeal decision of the claims administrator, you have the right to request a second level appeal from the claims administrator.  Your second level appeal request must be submitted to the claims administrator within 60 days from receipt of the first level appeal decision.  You will be notified by the claims administrator of the decision within 30 days from receipt of a request for review of the first level appeal decision.

For procedures associated with Urgent Claims, see “Urgent Claim Appeals That Require Immediate Action” below.

For appeals of denials of a claim based on a determination of medical necessity or experimental or investigational services, as those terms are defined in each certificate of coverage, the claims administrator will notify you of the decision within 60 days from receipt of a request for appeal of a denied claim.  The decision of the claims administrator regarding this type of denial of a claim is final, conclusive and binding.  There is no second level of appeal for this type of denial.

Please note that the claims administrator’s decision is based only on whether or not benefits are available under the medical, dental or vision plans for the proposed treatment or procedure.  The determination as to whether the pending health service is necessary or appropriate is between you and your doctor.

Urgent Claim Appeals That Require Immediate Action

Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain.  In these urgent situations, the appeal does not need to be submitted in writing.  You or your doctor should call the claims administrator as soon as possible, and provide the claims administrator with the information identified above under “How to Appeal a Claim Decision.”  The claims administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination taking into account the seriousness of your condition.  There is no second level of appeal for this type of denial.

If the insurance company denies all or part of your appeal, it will provide you with a written notice.  The written notice will include the specific reason or reasons for the denial, a reference to the Plan provision on which the denial is based, and a statement providing you with reasonable access to documents and other information related to your claim.  The written notice will also advise you of your rights to bring a lawsuit under ERISA.  Note that you may not bring a lawsuit unless you have exhausted your rights to appeal.

Voluntary External Review

If you are enrolled in a non-grandfathered group health plan, your internal appeal of a claim for health benefits under such plan is denied, you will have the right to request an external (i.e. independent) review if you do so within four months after receiving notice of an adverse benefit determination or final internal adverse benefit determination.  Within five business days after receiving your request, a preliminary review will be completed to determine whether: (i) you are/were covered under the Plan, (ii) the denial was based on your ineligibility under the terms of the Plan, (iii) you exhausted the Plan’s internal process, if required, and (iv) you provided all information necessary to process the external review.  Within one business day after completing the preliminary review, you will be notified in writing if your appeal is not eligible for an external review or if it is incomplete.  If your appeal is complete but not eligible, the notice will include the reason(s) for ineligibility.  If your appeal is not complete, the notice will describe any information needed to complete the appeal.  You will have the remainder of the four month filing period or 48 hours after receiving the notice, whichever is greater, to cure any defect.  If eligible for an external review, your appeal will be assigned to an independent review organization (IRO).  If the IRO reverses the Plan’s denial, the IRO will provide you written notice of its determination.

In addition, you will have the right to an expedited external review in the following situations:

  • following an adverse benefit determination involving a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal; and
  • following a final internal adverse benefit determination involving (i) a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function or (ii) an admission, availability of care, continued stay, or health care item or service for which you received emergency services but have not been discharged from a facility.

The IRO will provide notice of its final external review decision as expeditiously as your medical condition or circumstances require, but not more than 72 hours after the IRO receives the request.

Group Welfare Plan Claims Processing: Spousal Burial, Dependent Life Benefits and certain Wellness Benefits/Programs

Under Department of Labor (DOL) regulations, claimants are entitled to a full and fair review of any claim made under the Plan. The procedures described in this document are intended to comply with DOL regulations by providing reasonable procedures governing the filing of benefit claims, notification of benefit decisions, and appeal of adverse benefit decisions.

Notice of Claim

The following claims procedures shall apply to welfare benefits provided by the Fund for spousal death benefits, dependent death benefits and certain Wellness Benefits/Programs. The initial benefit determination of spousal burial benefits and dependent death benefits will be made by the Fund. The initial benefit determination in certain wellness programs is made by Blue Cross Blue Shield, who administers these wellness programs.  If a participant or dependent receives an adverse benefit determination for a wellness program provided by Blue Cross Blue Shield, then the following claims procedure shall apply to the participant or their dependent.

Written Notice of Claim Must be Given to the Fund Office Written Notice of Claim given by or on behalf of the Participant or Dependent to the Fund with sufficient information to identify the Participant or Dependent will be considered notice to the Fund. “Notice of Claim” is defined as the first (1st) time that the Fund is made aware that a claim was incurred on a specific date.

  • Authorized Representative An Authorized Representative of a Participant or Dependent may act on behalf of such Participant or Dependent in pursuing a benefit claim or appeal of an Adverse Benefit Determination. A Participant’s spouse or a parent of a minor Participant or Dependent may serve as the Participant or Dependent’s representative without prior notice to the Fund Office. A Participant or Dependent must submit a written designation of any other representative to the Fund.
  • Failure to Follow Plan Procedures In the case of a failure by a Participant or Dependent or an Authorized Representative of a Participant or Dependent to follow the Plan’s procedures for filing a “claim”, the Participant or Dependent or representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Participant or Dependent or Authorized Representative, as appropriate. Notification may be oral, unless written notification is requested by the Participant or Dependent or Authorized Representative.
Short Term Disability Income Benefits, Spousal Burial and Dependent Life Benefits Claim Processing

Claim Review Procedure

  • Manner and Content of Notification of Benefit Determination The Fund shall provide a Participant or Dependent with written notification of any Adverse Benefit Determination. The notification shall set forth, in a manner calculated to be understood by the Participant or Dependent:
      • The specific reason or reasons for the Adverse Benefit Determination;
      • Reference to the specific Plan provisions on which the determination is based;
      • A description of any additional material or information necessary for the Participant or Dependent to perfect the 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 the Participant or Dependent’s right to bring a civil action under ERISA Section 502(a) if your claim is denied (you receive Adverse Benefit Determination on appeal);
      • The identity of any medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a Participant or Dependent’s Adverse Benefit Determination, without regard to whether the advice was relied upon in making the benefit determination;
      • If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the Participant or Dependent upon request;
      • If the Adverse Benefit Determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Participant or Dependent’s medical circumstances, or a statement that such explanation will be provided free of charge upon request;
      • A statement “you and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out may be available is to contact your local U.S. Department of Labor Office and your State Insurance Regulatory Agency.”

    Timing of Notification of Benefit Determination

    The Fund shall notify a Participant or Dependent of a benefit determination in accordance with the following schedule:

    The Fund shall notify the Participant or Dependent of an Adverse Benefit Determination

    within a reasonable period of time, but not later than forty-five (45) days after receipt of the claim by the Plan. This period may be extended by the Plan for up to thirty (30) days, provided that the Fund determines that such an extension is necessary due to matters beyond the control of the Plan and notifies the Participant or Dependent, prior to the expiration of the initial forty-five (45) day period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If, prior to the end of the first (1st) thirty (30) day extension period, the Fund determines that, due to matters beyond the control of the Plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional thirty (30) days, provided that the Fund notifies the Participant or Dependent, prior to the expiration of the first (1st) thirty (30) day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to render a decision. In the case of any extension, the notice of extension shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and the Participant or Dependent shall be afforded at least forty-five (45) days within which to provide the specified information.

    Calculating Time Periods

    The period of time within which a benefit determination is required to be made shall begin at the time a claim is received by the Fund, without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended due to a Participant or Dependent’s failure to submit information necessary to decide a claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Participant or Dependent until the date on which the Participant or Dependent responds to the request for additional information.

    Appeal Procedure for Denied Claim or Adverse Benefit Determination

    If you wish to appeal an adverse benefit determination or a denial of a claim for welfare benefits, you or your authorized representative must file a written appeal with the Board of Trustees (also known as the Plan Administrator) within 180 days after receipt of written notice of denial or otherwise known as adverse benefit decision. You or your authorized representative may submit a written statement, documents, records, and other information relating to the claim for benefits. You may also, free of charge upon request, have reasonable access to and copies of Relevant Documents relating to the claim for benefits. Relevant Document means any document, record or other information that:

    • Was relied upon in making a benefit determination including a decision to deny benefits;
    • Was submitted, considered, or generated in the course of making the decision to deny benefits, whether or not it was relied upon in making the decision to deny benefits;
    • Demonstrates compliance with any administrative processes and safeguard designed to confirm that the benefit determination was in accord with the Fund and that the Fund provisions, where appropriate, have been applied consistently regarding similarly situated individuals; or

    Constitutes a statement of policy or guidance to the Plan concerning a denied treatment option or benefit for your diagnosis, whether or not it was relied upon in making the decision to deny benefits.

    Standard of Review

    The review will consider all statements, documents, and other information submitted by you or your authorized representative, whether or not such information was submitted or considered under the initial denial decision. Claim determinations are made in accordance with Plan Documents and, where appropriate, Plan provisions are applied consistently to similarly situated claimants.

    In addition, the following procedures apply:

    • The appeal decision will not defer to the initial decision denying your disability claim (the adverse benefit determination) and will be made by the Board of Trustees who are not persons who made the initial decision, nor subordinates of such person;
    • If the initial denial decision was based in whole or in part on a medical judgment, the Board of Trustees will consult with health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;
    • Any health care professional engaged for such consultation will not be a person consulted in the initial decision, nor a subordinate of any such person; and
    • Any medical or vocational expert whose advise was obtained in connection with the decision to deny your disability claim will be identified upon request, whether or not the advice was relied upon.

    The Board of Trustees will review all appeals of denied claims and makes final determinations. The Board of Trustees has full discretionary authority, including power to administer, construe and interpret the terms and provisions of the Plan, Summary Plan Description and Trust Agreement and to determine eligibility for benefits under the Plan.  The Board of Trustees has the exclusive right to interpret the provisions of the Plan. Decisions of the Board of Trustees are final, conclusive and binding.  The Board of Trustees has final claims adjudication authority under the Plan.

    Timing and Appeal of Decision

    Your appeal generally will be addressed at the next regularly scheduled quarterly meeting of the Board of Trustees after an appeal is received. If, however, your appeal is received within 30 days prior to such a meeting, it will be considered by the second regularly scheduled quarterly meeting after it is received. In addition, if special circumstances require an extension of time for processing your appeal, a decision will be rendered no later than the third regularly scheduled quarterly meeting after your appeal is received. Written notice of any extension of time will be sent before it commences explaining the reason for the extension and the expected date of the appeal determination. Notice of the appeal decision will be provided not later that five days after the decision is made.

    Contents of Appeal Decision

    If your appeal a denied claim, the decision on review will be in writing and will include the following information:

    • The specific reason or reasons for the decision; and
    • Reference to the specific Plan provisions on which the decision is based; and
    • A statement of your right to receive, upon request free of charge, reasonable access to and copies of Relevant Documents; and
    • A statement of your right to bring a civil action under Section 502(a) of ERISA, if your claim is denied or you receive an adverse benefit decision; and
    • Any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits or review, or a statement that such was relied upon and a copy will be provided free of charge upon request; and
    • If the decision or review was based on medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination applying Plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request; and
    • The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office or the States Insurance Regulatory Agency.”
Group Welfare Plan Claims Processing; Short Term Disability Income Benefits

Under Department of Labor (DOL) regulations, claimants are entitled to a full and fair review of any claim made under the Plan. The procedures described in this document are intended to comply with DOL regulation 29 C.F.R section 2560-503-1 by providing reasonable procedures governing the filing of short term disability income benefits filed under the plan on or after January 1, 2018.

Notice of Claim

The following claims procedures shall apply to short term disability income benefits filed under the plan on or after January 1, 2018.  The initial benefit determination of short term disability income benefit claims will be made by the Fund.  The following claims procedure will apply specifically to claims made for short term disability income benefits under one or more Plan features, including any rescission of disability coverage under such Plan features with respect to an active employee or beneficiary (whether or not, in connection with the rescission, there is an adverse effect on any particular benefit at that time).  For this purpose, rescission means a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

Written Notice of Claim Must be Given to the Fund Office Written Notice of Claim given by or on behalf of the Participant or Dependent to the Fund with sufficient information to identify the Participant or Dependent will be considered notice to the Fund. “Notice of Claim” is defined as the first (1st) time that the Fund is made aware that a claim was incurred on a specific date.

  • Authorized Representative An Authorized Representative of a Participant or Dependent may act on behalf of such Participant or Dependent in pursuing a benefit claim or appeal of an Adverse Benefit Determination. A Participant’s spouse or a parent of a minor Participant or Dependent may serve as the Participant or Dependent’s representative without prior notice to the Fund Office. A Participant or Dependent must submit a written designation of any other representative to the Fund.

Failure to Follow Plan Procedures In the case of a failure by a Participant or Dependent or an Authorized Representative of a Participant or Dependent to follow the Plan’s procedures for filing a “claim”, the Participant or Dependent or representative shall be notified of the failure and the proper procedures to be followed in filing a claim for benefits. This notification shall be provided to the Participant or Dependent or Authorized Representative, as appropriate. Notification may be oral, unless written notification is requested by the Participant or Dependent or Authorized Representative.

Timing of Notice of Adverse Benefits Determination

The Fund shall notify an active employee or his representative of a benefit determination in accordance with the following schedule:

If a claim under the Plan is denied in a whole or in part, you or your representative will receive written notification of the adverse benefit determination within a reasonable period of time, but no later than 45 days after the Fund’s receipt of the claim. The Fund may extend this period for up to 30 additional days provided the Fund determines that the extension is necessary due to matters beyond the Fund’s control and the claimant is notified of the extension before the end of the initial 45-day period and is also notified of the date the by which the Fund expects to render a decision. The 30-day extension can be extended by an additional 30 days if the Fund determines that, due to matters beyond its control, it cannot make the decision within the original extended period. In that event, you will be notified before the end of the initial 30-day extension of the circumstances requiring the extension and the date by which the Fund expects to render a decision. The extension notice will explain the standards on which your entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information, if any, you must submit. If you must provide additional information, you will be provided with at least 45 days to provide the additional information. The period from which you are notified of the additional information. The period from which you are notified of the additional required information to the date you respond is not counted as part of the determination period.

Adverse Benefits Determination Notice

A denial notice will include:

  • The specific reason(s) for your adverse benefit determination;
  • Reference to the specific Plan provision on which the determination is based;
  • A description of any additional material or information necessary for you to fix your claim and an explanation of why such material or information is necessary;
  • A description of the review procedures, including a statement of your right to bring a lawsuit following an adverse benefit determination on review;
  • A discussion of the decision, including, an explanation of the basis for disagreeing with or not following:
    1. The views presented by the health care professional treating you and vocational professionals who evaluated you;
    2. The views of medical or vocational experts who advice was obtained on behalf of the Plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and
    3. A disability determination regarding you presented by you to the Plan made by the Social Security Administration;
  • If the adverse benefit determination is based on medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgement for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request;
  • Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the plan relied upon in make the adverse determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria of the plan do not exist; and
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of the entire claim file and all documents, records, and other information relevant to your claim for benefits. A document, record, or other information will be considered “relevant” to your claim if such document, record, or other information:
  1. Was relied upon in making the benefit determination:
  2. Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the determination:
  3. Demonstrates compliance with the administrative processes and safeguards designed to ensure and verify that benefit determinations are made in accordance with governing plan documents and that, where appropriate, the Plan provisions have been applied consistently with respect to similarly satiated claims; or
  4. Constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit for your diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Appeal process

If you disagree with a claim determination, you can contact the Board of Trustees (also known as the Plan Administrator) in writing to formerly request an appeal. If the appeal relates to claim for payment, your request should include:

  • The subject individual’s name and the identification number from the ID card, if any.
  • The reason you believe the claim should be paid.
  • Any documentation or other written information to support your request for claim payment.

Your appeal request must be submitted to the Board of Trustees within 180 days after you receive the claim denial.

The Board of Trustees, who were not involved in the decision being appealed will decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination. The Board of Trustees may consult with, or seek the participation of, medical experts as part of the appeal resolution process. You consent to this referral and the sharing of pertinent health claim information. Upon request and free of charge you have the right to reasonable access to and copies of your entire claim file and all documents, records, and other information relevant to your claim for benefits.

In addition, prior to the appeal determination noted below, the Board of Trustees will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan, insurer, or other person making the benefit determination (or at the direction of the Plan, insurer or such other person) in connection with the claim as soon as possible and sufficiently in advance of the date on which the appeal determination is required to be provided to give you a reasonable opportunity to respond prior to the date. Before an adverse benefit determination on appeal based on a new or additional rationale, the Board of Trustees will provide you, free of charge, with the rationale; the rationale will provide as soon as possible and sufficiently in advance of the date on which the appeal determination is required to be provided to give you a reasonable opportunity to respond prior to that date.

Timing of Appeal Determination

You will be notified of the Board of Trustees decision upon review within a reasonable period of time, but no later than 45 days after the Board of Trustees receives your appeal request. The 45-day period may be extended for an additional 45-day period if the Board of Trustees determines that special circumstances (such as the need to hold a hearing) require an extension of time. You will be provided with written notice prior to the expiration of the initial 45-day period. Such notice will state the special circumstances requiring the extension and the date by which the Board of Trustees expects to render a decision.

Avoiding Conflicts of Interest

The Fund will ensure that short term disability income benefit claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. For example, a claims adjudicator or medical or vocational expert will not be hired, promoted, terminated or compensated based on the likelihood of the persons denying short term disability income benefit claims.

Appeal Determination Notice

If denied, your review decision on appeal will include the following:

  • The specific reason(s) for the adverse determination;
  • Reference to the specific Plan provision on which the benefit determination is based;
  • A statement that you are entitled to receive, without charge, reasonable access to any documentation (i) relied on in making the determination, (ii) submitted, considered or generated in the course of making the benefit determination, (iii) that demonstrates compliance with the administrative process and safeguards required in making the determination, or (iv) that constitutes a statement of policy or guidance with respect to the Plan concerning the claim without regard to whether the statement was relied on;
  • Either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of charge upon request;
  • If the adverse determination is based on medical necessity or experimental treatment or a similar exclusion or limit, either an explanation of the scientific or clinical judgement applying the terms of the Plan to your medical condition, or a statement that such explanation will be provided without charge on request;
  • A statement describing the Plan’s optional appeals procedures, if any, and your right to receive information about such procedures, as well as your right to bring a lawsuit and any applicable contractual limitation period that applies to your right to bring such an action, including the calendar date on which the contractual limitations period expires for the claim;
  • The following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency;” and
  • A discussion of the decision, including, an explanation of the basis for disagreeing with or not following:
    1. The views presented by the health care professionals treating you and vocational professionals who evaluated you;

 

  1. The views of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and
  • A disability determination regarding you presented by you to the Plan made by the Social Security Administration;
  • If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgement for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request;
  • Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the plan relied upon in making the adverse determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria of the plan do not exist.

The Board of Trustees has the exclusive right to interpret the provisions of the Plan. Decisions of the Board of Trustees are final, conclusive, and binding. The Board of Trustees has final claims adjudication authority under the Plan.

Group Welfare Plan Claims: Processing Life Insurance, Accidental Death and Dismemberment

Life Insurance and AD&D
The life insurance claims and accidental death and dismemberment claims are to be administered by the Hartford Life and Accident Insurance Company. Claims filed regarding life insurance and the accidental death and dismemberment benefit shall be forwarded to the Hartford for benefit determination in accordance with the Hartford Life Insurance Company’s procedures found in Attachments #10, #11 to this Summary Plan Description. The Hartford Life and Accident Insurance Company has sole and complete discretion and authority to administer and interpret the provisions of the plans it insures. The Hartford Life and Accident Insurance Company shall follow the claims procedures contained in the policies, contracts, summary plan descriptions or other written materials as long as these claims procedures comply with all ERISA requirements and DOL regulations including but not limited to 29 C.F.R. section 2560-503-1.

ERISA RIGHTS FOLLOWING REVIEW

A claimant has the right to sue in Federal Court but only if the claimant has exhausted all claims procedures. You shall be deemed to have exhausted the Fund’s administrative procedures if the Fund fails to strictly fulfill all applicable claims and appeals procedural requirements, regardless of whether the compliance defect materially impacted the outcome of the claims appeal decision. In such a circumstance a claimant may pursue remedies under Section 502 of ERISA, as applicable, which include judicial review of the Plan determination to recover benefits due to him under the terms of the Plan, to enforce his rights under the terms of the Plan, or to clarify his rights to future benefits under the Plan. Additional information may be available from the local U.S. Department of Labor office.

MISCELLANEOUS

Right of Recovery; Termination of Coverage for Cause, Including Fraud or Intentional Misrepresentation.

There are times that you will be required to furnish information or proof necessary to determine your or a dependent’s right to a Plan benefit.  When inaccurate information and/or proof is provided, this ultimately can result in the improper use of Plan assets, which adversely affects the ability of the Plan to provide the highest possible level of benefits.

Accordingly, the Plan Administrator reserves the right to terminate your coverage under the Plan and/or your Eligible Dependent(s) coverage prospectively without notice for cause, as determined by the Plan Administrator, and/or if you and/or your Eligible Dependents are otherwise determined to be ineligible for coverage under the Plan.  In addition, if you or an Eligible Dependent commits fraud or intentional misrepresentation in an application for coverage under the Plan, in a claim or appeal for benefits, or in response to any request for information by the Plan Administrator (or its delegate), or a Claims or Appeals Administrator, the Administrator may terminate your coverage retroactively upon 30 days notice.  Failure to inform the Plan Administrator, or a claims or appeals administrator, as applicable, that you or your Eligible Dependent is covered under another group health plan or knowingly providing false information to obtain coverage for an ineligible dependent are examples of actions that constitute fraud under the Plan.  Of course, if the Plan pays benefits of expenses actually incurred or in excess of allowable amounts, due to error (including for example, a clerical error) or for any other reason (including, for example, your failure to notify the Plan Administrator or its delegates regarding a change in family status), the Plan Administer reserves the right to recover such overpayment through whatever means are necessary, including, without limitation, deduction of the excess amounts from future claims and/or legal action.

Subrogation and Reimbursement
Were you or your dependent injured in an accident for which someone else is liable? If so, that person or his/her insurance may be responsible for paying your or your dependent’s related medical and accident & sickness expenses and these expenses would not be covered under the Plan. However, waiting for a third party to pay for those injuries may be difficult; recovery from a third party may take a long time (you may have to go to court) and your creditors may not wait patiently. Because of this, as a service to you, the Fund will advance you or your dependent benefit payments related to such an accident based on the Fund’s rights of reimbursement and subrogation. You must reimburse the Fund if you obtain any recovery from any person or entity.

The Fund must be repaid out of any proceeds you or your dependents receive from the other party if:

  • Benefits are paid under this Fund; and
  • You or your dependent has a claim against another party who may be responsible

The Fund Office will require the participant assign or transfer his or her rights to any recoveries, settlements or judgments, and that the Plan be paid for such recoveries, settlements or judgments as a first right of recovery (i.e., ahead of participant, his or her attorneys, and any other person, and without reduction for attorneys’ fees or other costs or expenses). Such recoveries, settlements or judgments shall constitute Plan assets to the extent of the benefits paid or to be paid by the Plan, and any person who handles such assets shall hold them in trust for the Plan. The participant shall be required to sign a Subrogation, Assignment of Rights and Reimbursement Agreement to be eligible for benefits arising out of this injury. However, the failure of any participant to sign this form shall in no way affect the Fund’s right to enforce these provisions and to obtain proceeds of any recoveries, settlements or judgments, no matter how characterized, as described above. Any participant who has the Plan pay his or her claims does so with the understanding that these Assignment and Subrogation rules are binding upon the participant, his or her attorneys, or the agents, assigns or heirs and executors of the participant. The participant is required to pay his or her own legal expenses and the participant is required to notify his or her attorney of these provisions and assignment. Any amounts recovered by the participant in excess of the full amount expended by the Fund may be retained by the participant or used to pay legal expenses.

You and/or the dependent are required to notify the Fund within ten days of any accident or injury for which someone else may be liable. Further, the Fund must be notified within ten days of the initiation of any lawsuit arising out of the accident and of the conclusion of any settlement, judgment of payment relating to the accident in any lawsuit initiated to protect the Fund’s claims.

If you or your dependent receive any benefit payments from the Fund for an injury or sickness and you or your dependent recover any amount from any third party or parties in connection with such injury or sickness, you or your dependent must reimburse the Fund from that recovery the total amount of all benefit payments the Fund made or will make on your or your dependent’s behalf in connection with such injury or sickness.

In addition, if you or your dependent receive any benefit payments from the Fund for any injury or sickness, the Fund is subrogated to all rights of recovery available to you or your dependent arising out of any claim, demand, cause of action or right of recovery which has accrued, may accrue or which is asserted in connection with such injury or sickness, to the extent of any and all related benefit payments made or to be made by the Fund on your or your dependent’s behalf. This means that the Fund has an independent right to bring an action in connection with such injury or sickness in your or your dependent’s name and also has a right to intervene in any such action brought by you or your dependent, including any action against an insurance carrier under any uninsured or underinsured motor vehicle policy.

The Fund’s rights of reimbursement and subrogation apply regardless of the terms of the claim, demand, right of recovery, cause of action, judgment, award settlement, and compromise, insurance or order, regardless of whether the third party is found responsible or liable for the illness or sickness, and regardless of whether you or your dependent actually obtain the full amount of such judgment, award, settlement, compromise, insurance or order. The Fund’s rights of reimbursement and subrogation provide the Fund with first priority to any and all recovery in connection with the injury and sickness whether such recovery is full or partial and no matter how such recovery is characterized why or by whom it is paid, or the type of expense for which it is specified. Such recovery includes amounts payable under your or your dependent’s own uninsured motorist insurance, under-insured motorist insurance, or any medical pay or no-fault benefits payable. The ‘make-whole’ doctrine does not apply to the Fund’s right of reimbursement, and subrogation. The Fund’s rights of reimbursement and subrogation are for the full amount of all related benefits payments; this amount is not offset by legal costs, attorneys’ fees or other expenses incurred by you or your dependent in obtaining recovery. The Fund shall have a lien on any amount received by you, your dependent or a representative of you or your dependent (including an attorney) that is due to Fund under this section, and any such amount shall be deemed to be held in trust by you or your dependent for the benefit of the Fund until paid to the Fund.

Consistent with the Fund’s rights set forth in this section, if you or your dependent submit claims for or receive any benefit payments from the Fund for an injury or sickness that may give rise to any claim against any third-party, you and/or your dependent will be required to execute a “Subrogation, Assignment of Rights and Reimbursement Agreement” affirming the Fund’s rights of reimbursement and subrogation with respect to such benefit payments and claims. This Agreement must also be executed by your or your dependents attorney, if applicable. In the event of any failure or refusal by you or your dependent to execute this agreement or to take any action requested by the Fund, the Fund may withhold payment of benefits or deduct the amount of any payments from future claims of the participant or his or her dependents.

Because benefit payments are not payable unless you sign a Subrogation, Assignment of Rights and Reimbursement Agreement, your or your dependent’s claims will not be considered filed and will not be paid until the fully signed Agreement is received by the Fund. This means that, if you file a claim and your Subrogation, Assignment of Rights and Reimbursement Agreement is not received promptly, the claim will be untimely and will not be paid if the period for filing claims passes before your Subrogation, Assignment of Rights and Reimbursement Agreement is received.

Further, the Plan excludes coverage for any charges for any medical or other treatment, service or supply to the extent that the cost of the professional care or hospitalization maybe recoverable by, or on behalf of, you or your dependent in any action at law, any judgment, compromise or settlement of any claims

against any party, or any other payment you, your dependent, or your attorney may receive as a result of the accident or injury, no matter how these amounts are characterized or who pays these amounts, as provided in this section.

Under this provision, you and/or your dependent are obligated to take all necessary action and cooperate fully with the Fund in its exercise of its rights of reimbursement and subrogation, including notifying the Fund of the status of any claim or legal action asserted against any party or insurance carrier and of your or your dependent’s receipt of any recovery. You or your dependent also must do nothing to impair or prejudice the Fund’s rights. For example, if you or your dependent choose not to pursue the liability of a third party, you or your dependent may not waive any rights covering any conditions under which any recovery could be received. If you are asked to do so, you must contact the Fund office immediately. Where you or your eligible dependent choose not to pursue the liability of a third party, the acceptance of benefits from the Fund authorizes the Fund to litigate or settle your claims against the third party. If the Fund takes legal action to recover what it has paid, the acceptance of benefits obligates you and your dependent (and your attorney if you have one) to cooperate with the Fund in seeking its recovery, and in providing relevant information with respect to the accident.

You or your dependent must also notify the Fund before accepting any payment prior to the initiation of a lawsuit. If you do not, and you accept payment that is less than the full amount of the benefits that the Fund has advanced you, you will still be required to repay the Fund, in full, for any benefits it has paid. The Fund may withhold benefits if you or your dependent waive any of the Fund’s rights to recovery or fail to cooperate with the Fund in any respect regarding the Fund’s subrogation rights.

If you or your dependent refuse to reimburse the Fund from any recovery or refuse to cooperate with the Fund regarding its subrogation or reimbursement right, the Fund has the right to recover the full amount of all benefits paid by methods which include, but are not necessarily limited to, offsetting the amounts paid against your future benefit payments under the Plan. “Non-cooperation” includes the failure of any party to execute a Subrogation, Assignment of Rights, and Reimbursement Agreement and/or the failure of any party to respond to the Fund’s inquiries concerning the status of any claim or any other inquiry relating to the Fund’s rights of reimbursement and subrogation. This reimbursement and subrogation program is a service to you and your dependents.  It provides for the early payment of benefits and also saves the Fund money (which saves you money too) by making sure that the responsible party pays for your injuries.

Enforcement and Remedies

In addition to any legal or equitable remedy that may be available under the law, the Trustees may exercise the following remedies if a participant fails to comply with them.

  • Refuse to pay any benefits related to the participant’s injuries or illness;
  • Recover from the participant benefits already paid through deducting any overpayments from claims otherwise payable. If the covered person is the participant, the Trustees may also offset claims payable to any eligible dependent of the participant. If the covered person is an eligible dependent, the Trustees may also offset claims payable to any other eligible dependent or the participant;
  • Access interest on the outstanding benefits or the amount of claims paid at a rate of 12-percent per annum, compounded annually, until paid, or
  • In the event the Trustees institute litigation to enforce these provisions, the participant, and any other responsible person, shall be required to pay the Plan’s costs and attorneys’ fees, as well as any investigation fees.

The Trustees may promulgate rules and regulations to govern procedures hereunder.

PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan will not be construed as a contract for or of employment.

NONASSIGNABILITY OF RIGHTS
Your right to receive any benefit or reimbursement under the Plan shall not be alienable by you by assignment or any other method and is not be subject to being taken by your creditors by any process whatsoever, and any attempt to cause such right to be so subjected will not be recognized, except to such extent as may be required by law.

NO GUARANTEE OF TAX CONSEQUENCES
The Plan Sponsor does not make any commitment or guarantee that any amounts paid to a Plan participant or for the benefit of a participant will be excludable from the Participant’s gross income for federal or state income employment tax purposes, or that any other federal or state tax treatment will apply to, or be available to, any participant. It is your obligation to determine whether each payment under the Plan is excludable from your gross income for federal and state income and employment tax purposes, and to notify the Plan Sponsor if you have reason to believe that any such payment is not so excludable.

SEVERABILITY
If any provision of this Plan is held invalid, unenforceable or inconsistent with any law, regulation or requirement, its invalidity, unenforceability or inconsistency will not affect any other provision of the Plan, and the Plan shall be construed and enforced as if such provision were not a part of the Plan.

CONSTRUCTION OF TERMS
Words of gender shall include persons and entities of any gender; the plural shall include the singular and the singular shall include the plural. Section headings exist for reference purposes only and shall not be construed as part of the Plan.

APPLICABLE LAW
The Plan shall be construed and enforced according to the laws of the Commonwealth of Massachusetts to the extent not preempted by any federal law.

NO VESTED INTEREST
Except for the right to receive any benefit payable under the Plan in regard to a previously incurred claim, no person shall have any right, title, or interest in or to the assets of the Plan.

LEGAL ACTION
No action at law or in equity may be brought to recover benefits allegedly due under the Plan before the claimant has exhausted the applicable claims procedures.

CHANGES IN LAW
Unless the context clearly indicates to the contrary, a reference to a Plan provision, statute, regulation or document shall be construed as referring to any subsequently enacted, adopted or executed counterpart; provided, however, that any other provision of this Plan to the contrary notwithstanding, this Plan may be operated in accordance with legal requirements before it is amended to reflect them.

PLAN AMENDMENT, MODIFICATION, OR TERMINATION

The Board of Trustees reserves the right to amend this Plan at any time or from time-to-time without the consent of or, to the extent permitted by law, prior notice to any participant.  Although the Board of Trustees expects to continue the Plan indefinitely, it is not legally bound to do so, and it reserves the right to terminate the Plan or any Plan benefit option or feature at any time without liability. A plan amendment or termination requires the affirmative vote of two (2) Union Trustees and two (2) Employer Trustees.