CLAIMS REVIEW PROCEDURES
What Are the Claims Review Procedures Under the Plan?
If you (or your beneficiary) file a written claim for benefits under the Plan and the Trustees (or their representative) determine that the claim should be denied in whole or in part, you will be notified in writing, within 90 days of receipt of the claim, that the claim has been denied. The Trustees (or their representative) can extend this time by up to an additional 90 days if special circumstances require this. In that case, the Trustees (or their representative) will send you a notice of extension before the end of the initial 90-day period indicating what the special circumstances are and setting forth the date by which a final decision is expected to be made.
If a claim is denied, in whole or in part, the Trustees (or their representative) must tell you:
- the specific reasons for the denial;
- the exact Plan provision(s) on which the decision was based;
- what additional material or information is relevant to your case, and
- what procedure you should follow to get your claim reviewed again.
If a claim is denied by the Trustees (or their representative), you have the right to apply for a review. You must do this, in writing, within 180 days after you receive the claim denial notice. Your review application may include any written comments, documents, records, or other information relating to your claim. In addition, upon your request to the Board of Trustees, you will be provided reasonable access to, and copies of documents, records, and other information held by or on behalf of the Board of Trustees relevant to your claim.
After receiving this application, the Trustees will review your claim again. The Trustees must make a final decision on your claim within 60 days after receiving your review request. However, if special circumstances arise and you are notified in writing in advance, the Trustees may take up to 120 days to reach a final decision. The final decision must be in writing, clearly stating the reasons for the decision and the provisions of the Plan upon which the decision was based.
You may have an authorized representative act on your behalf in pursuing a benefit claim or appeal of an adverse benefit determination. The Trustees may, however, require written and/or notarized confirmation from you of your representative's authorization.
The claims and review procedures described above must be exhausted before an action may be brought in federal or state court.
In carrying out their duties with respect to the general administration of the Plan, the Trustees have the power to conclusively interpret, in their discretion, any and all provisions of the Plan.