- In general, the Fund Office will process your application for benefits within 90 days (for regular claims) or 45 days (for disability claims).
- If you apply for an Individual Account Plan benefit and your application for benefits is denied, you have the right to appeal the denial.
Every effort will be made to complete the processing of all applications within 90 days after receipt by the Fund Office. This 90-day period will begin upon receipt of your signed application form by the Fund Office without regard to whether all of the information necessary to decide the application has been submitted.
In the event a decision on your benefit application cannot be made within 90 days of receipt of such application, a letter will be sent to you prior to the expiration of the 90-day period explaining the special circumstances requiring an extension of time to take action on your application. The letter will also include the date by which a decision is expected to be reached (not to exceed an additional 90-day period).
Special Rule for Disability Benefits
In the event you are applying for a disability benefit, the Fund will make every effort to process your benefit application within a 45-day period (in lieu of the 90-day period).
If the Fund Office determines an extension is appropriate due to matters beyond the control of the Plan, the initial 45-day period may be extended by an additional 30 days, provided that the Fund Office notifies you of the extension prior to the expiration of the initial 45-day period. This notice will:
- indicate the special circumstances requiring an extension of time;
- set forth the date by which the Fund Office expects to decide your claim;
- explain the standards on which entitlement to a disability benefit is based;
- describe the unresolved issues that prevent the claim from being decided;
- specify the additional information that may be needed to decide your claim; and
- if necessary, provide you with at least 45 days within which to provide the specified information.
If the Fund Office finds that it is unable to decide your claim during the first 30-day extension due to matters beyond its control, a second 30-day extension is possible. In the event that a second 30-day extension is required, the Fund Office will notify you of the extension prior to the expiration of the initial 30-day extension period and the notice will contain the same information required to be included in the first notice.
Appealing a Denied Claim or Disagreeing with an Action
If your application for benefits is denied in whole or in part, the Fund Office will provide you with a written or electronic notice that sets forth:
- the reasons for the denial;
- references to any pertinent Plan provisions, internal rules, guidelines, protocols or other criteria relied on in making the adverse determination;
- a description of any additional materials or information which might help your claim (including an explanation of why that information may be helpful); and
- a description of the appeals procedures and applicable filing deadlines including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review.
If you receive such a notice, or if you disagree with a policy, determination or action of the Fund, you may submit a written appeal to the Trustees requesting that the Board of Trustees review your benefit denial or the Fund policy, determination or action with which you disagree. The time you have to appeal to the Trustees will depend on the type of claim denied:
- Benefit Claims in General. Your written appeal must be submitted within 120 days of receiving the notice of denial of benefits (other than disability benefits).
- Disability Claims. Your written appeal must be submitted within 180 days of receiving the notice of denial of disability benefits.
- Disagreement Regarding a Fund Policy, Determination or Action other than a Benefit Claim. Your written appeal must be submitted within 60 days after you learn of a Fund policy, determination or action with which you disagree and which is not a denial of benefits.
Your written appeal should state the reason for your appeal. This does not mean that you are required to cite all applicable Plan provisions or make “legal” arguments; however, you should state clearly why you believe you are entitled to the benefit you claim, or why you disagree with a Fund policy, determination or action.
You are permitted to submit written comments, documents, records and other information relating to your claim even if such information was not submitted in connection with your initial claim for benefits. The Trustees can best consider your position if they clearly understand your claims, reasons and/or objections.
The Trustees or a designated committee of Trustees will review your appeal and render their decision within a reasonable period of time but no later than 60 days (45 days for disability benefit claims) after their receipt of your written appeal. If special circumstances require additional time, the Trustees or a designated committee of Trustees may render their decision within 120 days (90 days for disability benefit claims) after receipt of the appeal. If an extension is needed for the Fund to process your appeal, the Fund Office will provide written notice of the delay and state the reason(s) why the extension is necessary.
Special Procedures for Disability Claims
For disability benefit claims, the Trustees or the designated committee of Trustees will not defer to the initial adverse benefit determination of the Fund Office and will review the entire record of the Fund Office in addition to all other information submitted on appeal.
When the Trustees or designated committee of Trustees decide a disability benefit claim that involves a medical judgment, they will consult with a health care professional who has appropriate training and expertise in the field of medicine upon which the Fund Office’s determination was based. This medical professional will not be the person who was consulted in connection with the adverse determination that is the subject of the appeal nor his or her subordinate. In their decision, the Trustees or committee will identify all medical expert(s) whose advice was obtained by the Fund in connection with your claim without regard to whether the advice was relied upon in makin the benefit determination or decision on appeal.
Once your claim has been reviewed and a benefit determination has been made, you will receive written or electronic notice of the decision. The notice will explain the reasons for the decision, include specific references to Plan provisions, internal rules, guidelines, protocols or other criteria on which the decision is based and may state whether additional information may help your claim. Additionally, the notice will indicate that you are entitled to request access to documents, records, and other information relevant to your claim for benefits.
You may renew your appeal if you have any additional information or arguments to present. A renewed appeal must be submitted in writing, and the rules and limits stated above apply. In connection with an appeal or a renewed appeal, you may review relevant documents in the Fund Office after making appropriate arrangements, or you may request that documents be provided to you. This information will be provided free of charge.