If your claim is denied in whole or in part, you will receive notice of the denial of your claim within the appropriate time frame that provides the following information:

  • The specific reason or reasons your claim was denied,
  • A reference to the specific Plan provisions on which the denial was based,
  • A copy of  an internal rule, protocol or guideline which was relied on in making the denial,
  • If the determination was based on Medical Necessity, Experimental/Investigational exclusion, or similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination, applying the terms to the claim or a statement that the explanation is available upon request at no charge,
  • A description of any additional information you need to submit to support your claim,
  • An explanation of why the additional information is needed,
  • An explanation of the Plan’s claim appeal procedures and applicable time limits, and
  • A statement of your right to bring a civil action under ERISA following an adverse benefit determination.

If you do not receive the notice within such time period and there has been no settlement on your claim, you should write to the Fund Office for information.