APPEALS

Right to an Appeal

If an application for benefits is denied, in whole or in part, by the Fund Office (acting for the Board of Trustees), the applicant will be notified of the denial, in writing, within a reasonable period, but not later than 90 days after receiving the application, unless the Fund Office determines that special circumstances require an extension of time for processing the application. In that case, a written notice of the extension will be furnished to the applicant prior to the end of the 90-day period. Under no circumstances, will the extension exceed 90 days from the end of the initial 90-day period. The notice of extension will indicate the special circumstances requiring an extension and the date by which the Plan expects to make a decision. 

The written notification of the denial of benefits will be set forth, in a manner calculated to be understood by the applicant, and include:

• The specific reason(s) for the adverse determination; 
• Reference to the specific Plan provision(s) on which the denial is based;
• A description of any additional material or information necessary for the applicant to complete the claim and an explanation of why the material or information is necessary;
• A description of the Plan’s review procedures and the time limits that apply to those procedures, including a statement of the applicant’s right to bring a civil action under §502(a) of ERISA following an adverse benefit determination on review.

Any person whose application for benefits under this Plan has been denied, in whole or in part, by the Board of Trustees, or whose claim to benefits is denied by the Board of Trustees, may petition the Board of Trustees to reconsider its decision. A petition for reconsideration:

1. must be in writing; and
2. must state in clear and concise terms the reason(s) for disagreement with the decision of the Board of Trustees; and,
3. may include documents, records, and other information related to the claim for benefits; and,
4. must be filed by the petitioner or the petitioner’s duly authorized representative with or received by the Fund Office within 60 days after the date the notice of denial was received by the petitioner.

Upon good cause shown, the Board of Trustees may permit the petition to be amended or supplemented. Failure to file a petition for reconsideration within the 60-day period will constitute a waiver of the petitioner’s right to reconsideration of the decision. Failure to file a petition, however, will not prevent the petitioner from establishing his entitlement at a later date based on additional information and evidence that was not available to him at the time of the decision by the Board of Trustees.

Upon request, the petitioner or the petitioner’s duly authorized representative will be provided, free of charge, reasonable access to and copies of all documents, records and other information relevant to the petitioner’s claim for benefits. A document, record, or other information is considered relevant to a petitioner’s claim if it was:

• relied upon in making the benefit determination,
• submitted, considered or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the benefit determination,
• demonstrates that the benefit determination was made in accordance with Plan provisions and that Plan provisions have been applied consistently with respect to similarly situated claims.

Determination of Disputes

The review of the determination will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim without regard to whether the information was submitted or considered in the initial benefit determination.

A benefit determination on review will be made by the Trustees or by a committee designated by the Trustees no later than the date of the quarterly meeting of the Board of Trustees that immediately follows receipt of the request for review, unless the request for review is filed within 30 days preceding the date of the meeting. In that case, a benefit determination will be made no later than the date of the second meeting following receipt of the request for review. If special circumstances require a further extension of time for processing, a benefit determination will be made no later than the third meeting following receipt of the request for review. The Board of Trustees will provide the petitioner with a written notice of the extension, describing the special circumstances and the date by which the benefit determination will be made, prior to the commencement of the extension. The Board of Trustees will notify the petitioner of the benefit determination as soon as possible, but not later than 5 days after the benefit determination is made.

The notification of a benefit determination on review will be made in writing and will include the reason(s) for the determination, including references to specific Plan provisions on which the determination is based. It will include a statement that the petitioner is entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the claim for benefits.

The denial of a claim to which the right to review has been waived, or the decision of the Board of Trustees or its designated committee with respect to a petition for review, is final and binding upon all parties, subject only to any civil action the applicant may bring under §502(a) of ERISA. Following issuance of a written decision of the Board of Trustees on an appeal, there is no further right of appeal to the Board of Trustees or right to arbitration.

However, a petitioner may reestablish his entitlement to benefits at a later date based on additional information and evidence not available to him at the time of the decision of the Board of Trustees.