Members Right to Appeal and Plan Review Procedures
Members have a right to appeal a benefit decision by following the appeal procedure described below. This process is intended to provide you with a full and fair review of your claim.
You must file your appeal within 180 days of the date you receive a Notice of Benefit Denial.
You may submit written comments, documents, records and other information relating to the claim.
You are entitled to receive, upon request and free of charge, access to copies of documents, records, and other information relevant to your claim for benefits. Information that is relevant to your claim may include:
If you would like to request relevant information, please contact the Fund Administrator.
Information that the plan relied upon considered or generated in its review of your claim;
Information that was submitted to the Fund Administrator for the claims review;
Information that shows that the plan made the claims decision consistently and according to the plan documents; or
Information that may constitute a statement of plan policy or guidance regarding your benefit.
The review will take into account all comments, documents, and other information submitted that relates to the claim. This would include comments, documents, records and other information that either were not submitted previously or were not considered in the initial benefit denial. The review on appeal will be a “fresh” look at your claim without deference to the initial benefit denial. It will be conducted by the Appeal Committee that was not involved in the initial benefit denial.
If your benefit denial was based on whole or in part on a medical judgment, the plan will consult with a health care professional with training and experience in the relevant/applicable medical/dental field. This health care professional may not have been involved in the denial decision, nor be a subordinate of the health care professional who was involved. Upon your request, if the Plan has obtained medical or vocational experts in connection with your claim, and the Plan relied on their advice in making a benefit determination, you will be provided with their identity.
Timeframes for the Appeal Decisions
The International Union of Operating Engineers Local 14-14B Welfare Fund meets at least quarterly. The Board will make a benefit determination no later than the date of the meeting of the board that immediately follows the Plan’s receipt of a request for review, unless the request for review is filed within 30 calendar days preceding the date of such meeting. In such case, a benefit determination may be made no later than the date of the second meeting following the Plan’s receipt of the request for review. If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, a benefit determination shall be rendered not later than the third meeting of the Board following the Plan’s receipt of the request for review. If such an extension is necessary the Plan will provide you with a Notice of Extension describing the special circumstances and the date the benefit determination will be made. The Fund Administrator will notify you of the benefit determination no later than 5 days after the benefit determination is made.
You have a right to bring civil action under ERISA 502(a) if you file an appeal and your request for coverage or benefits is denied following review.
Reliance on Internal Rule, Guideline, Protocol or Similar Criterion
If the Plan relied upon an internal rule, guideline or protocol in making its decision to deny your claim for benefits you may receive a copy of this information by contacting the Fund Office at (718) 939-1489. The Fund Administrator will provide this information to you free of charge.
Denial Based on Medical Necessity Provision or Experimental Treatment or Similar Exclusion or Limit that Involves Scientific or Clinical Judgment
If the denial decision on your claim is based on the Plan’s medical necessity or experimental treatment provision limiting certain benefits, you may obtain a written explanation of the scientific or clinical judgment for the plan’s determination applying the terms of the plan’s medical necessity or experimental treatment limits to your medical circumstances by contacting the Fund Office at (718) 939-1489. This explanation will be provided free of charge.
If you decide to appeal the denial by requesting a review, your appeal should be sent in writing within 180 days to the Fund Office.
International Union of Operating Engineers
Local 14-14B Fringe Benefit Funds
141-57 Northern Boulevard
Flushing, N.Y. 11354
If you have any questions, please call the Fund Office between the hours of 8:00 am and 3:00 pm at (718) 939-1489.