Claims And Appeals Procedure

Appealing a Denied Claim or Disagreeing with an Action

If you receive a notice that your claim for Pension Benefits has been denied, 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 Plan 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:

  • Pension Benefit Claims in General — Your written appeal must be submitted within 60 days of receiving the notice of denial of benefits (other than disability benefits).
  • Disability Pension Claims — Your written appeal must be submitted within 180 days of receiving the notice of denial of Disability Pension benefits.

You will be entitled to a full and fair review. 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 Plan 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.

On appeal, the Board of Trustees will render a decision by the date of the next quarterly Trustees’ meeting, but if the appeal is received less than 30 days prior to the next quarterly meeting, then no later than the second quarterly Trustees’ meeting after the appeal is received. If special circumstances arise which warrant an extension of time to make a decision on appeal, such as the need for additional information, then the Trustees may provide written notice of the extension to the participant or beneficiaries, and then may wait until the following quarterly Trustees’ meeting after receipt of the notice of appeal. In the event an extension of time is required based on the need for additional information, the time for making a determination on appeal shall be tolled until the additional information is received by the Fund Office. Once a decision on appeal is rendered, the Fund Office will notify you of the Trustees’ decision as soon as administratively feasible, but, in any event, not longer than five (5) days.

When the Board of Trustees decides a disability benefit appeal that involves a medical judgment, it will consult with a health care professional who has appropriate training and expertise in the field of medicine upon which the Plan’s initial 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 Plan in connection with the claim without regard to whether the advice was relied upon in making the benefit determination or decision on appeal.

If your appeal 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 adverse benefit determination;
  • References to any plan provisions on which the determination was based;
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits;
  • A statement describing any voluntary appeal procedures offered by the Plan, if any, and your right to obtain the information about such procedures 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 an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination, then a free copy of either the specific rules, guideline, protocol or other similar criterion that was relied upon;
  • The following statement: “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.”

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. Nothing contained in this SPD shall require you to file more than (two) appeals. 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.

The Trustees shall be the sole judge of the standard of proof required in any case, subject to the limitations regarding Rights on Appeal for benefits requiring a disability determination. In the application and interpretation of the Plan, the decision of the Trustees shall be final and binding on all parties, including employees, employers, the Union, participants, claimants and beneficiaries or their representatives.

To the extent permitted by these claims procedures, you must furnish to the Trustees any information or proof requested and reasonably required to administer the Plan. Failure to comply with requests for information in prompt fashion and in good faith shall be sufficient grounds for denying or discontinuing benefits to participants and beneficiaries.

The Trustees are authorized to modify this procedure to include additional administrative processes and safeguards designed to ensure and to verify that the benefit claim determinations are made in accordance with governing plan documents, in accordance with the law and to ensure that the Plan provisions have been applied consistently with respect to similarly situated claimants.