Effective January 1, 2002
the following claim processing and appeal procedures will apply to the Weekly
Loss of Time benefits:
1.
Claim processing time limits -
The Fund Office receives claims, Monday through Friday, during regular
business hours. If all information
is provided to the Fund Office, your claim will usually be processed within 45
days. If you send a claim to the
Fund Office which can’t be processed because of missing information, you will
receive a notice stating why the claim can’t be completed and what additional
information is needed. The notice
about incomplete claim information will be sent to you within 45 days.
It is your responsibility to send the missing information to the Fund
Office.
When all
necessary information has been received, approval or denial of a claim will
usually be made within 30 days. An
extension may be necessary due to matters beyond the control of the Plan.
You will be notified prior to the expiration of the normal
approval/denial time period if an extension is needed.
If an extension is needed, it will not last more than 30 days.
A second 30 day extension may be needed in special circumstances beyond
the Plan’s control.
2.
Claim denials - If all or a
part of your claim for Weekly Loss of Time benefits is denied after the Fund
Office has received a completed claim form and all other necessary information
from you, you will be sent a written notice giving you the reasons for the
denial. The notification will
state: (1) the specific reason for
the determination with reference to the specific Plan provision(s) on which the
determination was based; (2) a
description of any additional material or information necessary to perfect the
claim, and the reason such information is necessary;
(3) a description of the review procedures and the applicable time limits
for following the procedures, including a statement of your right to bring a
civil action under section 502(a) of ERISA; (4) the specific internal rule, guideline, protocol or
similar criterion the administrator relied on to make the decision (if
applicable); and (5) if the decision was based on medical necessity, either an
explanation of the scientific or clinical judgment for the determination or a
statement that such explanation will be provided free of charge upon request.
3.
How to file a claim -
If you want the Trustees to review your claim after a denial of Weekly
Loss of Time benefits, request a claim appeal form from the Fund Office.
When you receive the form, fill it out completely, and attach any
information that you think will help a favorable decision to be made on your
claim. Return the completed form
within 180 days after the date the denial was mailed to you to:
Board of Trustees, IBEW Local 701 General Welfare Fund, 28600 Bella Vista
Parkway, Suite 1110
Warrenville, IL 60555-1600
4.
Full and Fair Review – The Trustees will conduct a full and fair review
of all the material submitted with your Loss of Time benefits claim, the action
taken by the Fund Office, the additional information you have provided, and the
reasons you believe the claim should be paid.
The review will: (1) be
conducted by an appropriate named fiduciary who is neither the party who made
the initial adverse determination, nor the subordinate of such party;
(2) not afford deference to the initial adverse benefit determination;
and (3) take into account all comments, documents, records and other information
submitted by you, without regard to whether such information was previously
submitted or relied upon in the initial determination.
You have the right, upon request and free of charge, to have copies of
all documents, records and other information submitted by you, without regard to
whether such information relevant to your claim for benefits.
With respect to a review of any determination based on a medical
judgment, the Board of Trustees must consult with a health care professional
with appropriate training and experience in the field of medicine involved in
the medical judgment. Such health care provider must be “independent,” which
means the medical individual consulted must be an individual different from, and
not subordinate to, any individual who was consulted in connection with the
initial decision. The Plan will not
preclude an authorized representative (including a health care provider) from
acting on your behalf, although the Trustees will verify that an individual has
been so authorized.
5.
Notification Following Review -
A review and determination of your Weekly Loss of Time benefit claim will
be made no later than the date of the Trustees meeting that immediately follows
the Plan’s receipt of a request for review, unless the request for review is
filed within 30 days preceding the date of such meeting. In such cases, a determination may be made no later than the
date of the second meeting. If
special circumstances (such as the need to hold a hearing) require a further
extension of time for processing, a determination will be rendered not later
than the third Trustees meeting. Before
the start of the extension, you will be notified in writing of the extension,
including a description of the special circumstances and the date as of which
the determination will be made. After
a decision has been made, you will be informed in writing of the Trustee’s
decision, normally within 5 calendar days of the review.
When you receive the decision on your appeal, it will contain the reasons
for the decision and specific references to the particular Plan provisions upon
which the decision was based. It
will also contain a statement explaining 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; a statement describing
any voluntary appeal procedures offered by the Plan and your right to obtain the
information about such procedures; and a statement of your right to bring an
action under section 502(a) of ERISA. If
applicable, you will also be informed of the specific internal rule, protocol or
similar criterion relied upon to make the decision.
If the decision was based on a medical judgment, you will receive an
explanation of the determination or a statement that such explanation will be
provided free of charge upon request. If
the Plan fails to make timely decisions or otherwise fails to comply with the
applicable federal regulations, you may go to court to enforce your rights.
