If your claim is denied, you are entitled to a full and fair review of your claim. In addition to covered medical treatment from a covered Provider, claims include wellness, hearing, optical services, and prescription drug claims.
For the Medical or Weekly Accident and Sickness Disability Benefit claims, you or your authorized representative must submit your written appeal within 180 days of the denial of your claim (within 60 days for Death Benefit claims and Accidental Death and Dismemberment claims). If your claim involves an urgent care medical claim, you may make your request for review orally.
In making your appeal, you or your authorized representative will be entitled to submit additional proof that you are entitled to benefits and examine any document related to your claim that is in the possession of the Fund Office. You will also be entitled to review all relevant information (free of charge) upon reasonable request to the Trustees. A document, record or other information is relevant if:
- It was relied upon by the Plan in making the decision,
- It was submitted, considered or generated in the course of making the decision, regardless of whether it was relied upon in making the decision, or
- It demonstrates compliance with the claims processing requirements.
The decision on your appeal will be made as soon as possible and no later than within:
- 60 days of your Death Benefit or Accidental Death and Dismemberment claim,
- 60 days of receiving your written appeal for post-service claims,
- 45 days of receiving your written appeal for Weekly Accident and Sickness Disability Benefit claims, (this deadline may be extended for up to 45 days if special circumstances require a delay in making the decision; you will be notified of the extension in advance.)
- 30 days of receiving your written appeal for pre-service claims, and
- 72 hours for urgent care claims.
The Trustees have designated a Benefits Appeal Committee comprised of two Employer Trustees and two Union Trustees to review and decide on all claim appeals on a monthly basis. If the members of the Benefits Appeal Committee agree on the decision, then their decision is a final and binding decision. If the Benefits Appeal Committee deadlocks on a claim appeal, then the appeal is not approved and the prior decision by the Fund Office is a final and binding decision.
The written notice of the decision on review will include:
- The specific reason or reasons your claim was denied,
- A reference to the specific Plan provisions on which the denial was based,
- A statement that you are entitled to receive reasonable access to and copies of all documents relevant to your claim upon request and free of charge,
- A statement of your right to bring a civil action under ERISA following an adverse benefit determination on review, and
- A statement about alternative ways to appeal the decision and referral to the Department of Labor or your state’s regulatory agency.
The Trustees have discretionary authority to determine all benefit claim appeals and to interpret the documents governing the Plan. The determination rendered by the Trustees will be binding on all parties. The Trustees’ decision in your appeal will be given judicial deference in any later court action or administrative proceeding to the extent that it does not constitute an abuse of discretion, and is not arbitrary or capricious. You must follow the Plan’s appeal procedures before you are permitted to bring any court action against the Plan.