| CLAIMS
FOR BENEFITS |
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| X Claim Denial |
| If your claim is denied, the Administrator's notice will state
the following: |
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• The specific reason(s) for the denial,
•
The Plan provisions that support the denial,
• Any
additional information needed to complete your application and
an explanation of why it is needed,
• Information
on how to have your claim reviewed. |
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| Review of Administrator's Decision |
| If you disagree with a decision made by the Administrator
regarding a claim under the Plan, you have the right to ask
the Administrator for a review of its decision. You should contact
the Administrator at its business address or at its business
phone number within 60 days of the date on which you receive
notice of denial of the claim. A request for review must contain
the following information: |
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• The date you received notice of denial of your claim
and the date your request for review is filed,
•
The specific part of the claim you want reviewed,
•
A statement setting forth the basis upon which you think the
decision should be reversed,
• Any written material
that you think is pertinent to your claim and that you want
the Administrator to examine. |
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| Unless additional time is required, the Administrator (or
other fiduciary responsible for reviewing claims) will review
the denial of your claim and notify you in writing of its final
decision, within 60 days of the filing of your request. If additional
review time is needed, you will be notified. In no event will
the review period exceed 120 days. |
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| If your claim is denied on review, the notice
will state the following: |
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• The specific reason(s) for the denial,
•
The Plan provisions that support the denial,
• That
you are entitled to receive reasonable access to and copies
of all documents, records, and other information relevant to
your claim for benefits,
• Information on any voluntary
appeal procedures,
• A statement of your right to
bring a civil action under ERISA. |
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| Special Rules Applicable to Disability Claims |
| If you are claiming a benefit under the Plan that is contingent
on the Administrator determining that you are disabled, you
will receive a written response within 45 days, rather than
90 days. If special circumstances require an extension, the
Administrator will notify you within the 45-day processing period
that additional time is needed. The notice will specify the
circumstances requiring the extension and the date a decision
can be expected. The extension notice will also: |
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• explain the standards for approving a disability claim,
• state the unresolved issue(s) that prevent the
Administrator from reaching a decision,
• describe
any additional information needed to resolve the issue(s). |
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| If the Administrator requests you to provide additional information
so it can process your claim, you will have at least 45 days
in which to provide the information. Otherwise, the initial
extension cannot exceed 30 days. |
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| If circumstances require further extension, the Administrator
will again notify you, this time before the end of the initial
30-day extension. The notice will state the date a decision
can be expected. In no event will a decision be postponed beyond
an additional 30 days after the end of the first 30-day extension.
|
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| If your disability claim is denied, the Administrator's notice
will state the following in addition to the information in Claim
Denial above: |
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| • If the claim denial is based on an internal rule,
guideline, protocol, or other similar provision, that a copy
of the provision is available upon request, free of charge, |
| • If the claim denial is based on an exclusion or limit
(such as a medical necessity requirement or an experimental
treatment exclusion) that an explanation of the scientific or
clinical judgment applying the exclusion or limit is available
upon request, free of charge. |
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| You may request a review of the Administrator's decision regarding
your disability claim within 180 days, rather than 60 days.
The review must be conducted by a Plan fiduciary different from
the fiduciary who originally denied your claim. This fiduciary
also cannot be subordinate to the fiduciary who originally denied
your claim. |
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| If the original denial of your claim was based on a medical
judgment, the reviewing fiduciary must consult with an appropriate
health care professional who was not consulted on the original
claim and who is not subordinate to someone who was. |
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| The review must identify the medical or vocational experts
consulted on the original claim. You may request, in writing,
a list of those medical or vocational experts. |
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| You will receive notice of the reviewing fiduciary's final
decision regarding your disability claim within 45 days, rather
than 60 days, of your request. If your disability claim is denied,
the notice will state the following in addition to the information
in Claim Denial above: |
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• If the claim denial is based on an internal rule,
guideline, protocol, or other similar provision, that a copy
of the provision is available upon request, free of charge,
• If the claim denial is based on an exclusion or limit
(such as a medical necessity requirement or an experimental
treatment exclusion) that an explanation of the scientific or
clinical judgment applying the exclusion or limit is available
upon request, free of charge,
• The following "You
and your Plan may have other voluntary alternative dispute resolution
options, such as mediation. One way to find out what may be
available is to contact your local U.S. Department of Labor
Office and your State insurance regulatory agency." |
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| Contact The Fund Office: 1-718-939-1489 |
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