If you have a claim concerning the denial of a time loss benefit, refer
to the next section of the Benefit Booklet entitled Claims Appeal Procedure
for Time Loss Claims.
If you have a claim concerning Providence, Kaiser Permanente, Vision
Service Plan or Standard Insurance Company, the claim should be filed
with that organization in accordance with its claims appeal procedures.
If you have a claim that involves eligibility for coverage (such as
insufficient money in your reserve account or a late self-payment), you
may file an appeal pursuant to Section 3.
If you have a claim for benefits that involves the Active Employee Plan
(such as a medical, prescription drug or dental benefit), the procedures
outlined below apply.
1. Denial of a Claim by the Plan Administrator.
a. The Plan Administrator, A&I Benefit Plan
Administrators, Inc. is responsible for reviewing claims concerning
eligibility and the Active
Employee Plan. If your claim for a benefit under the Active Employee
Plan is denied, in whole or in part, you or your dependent will receive
a written explanation from the Plan Administrator or the Trust's
designee. The time in which a denial letter must be provided is based
on the type
of claim you have submitted.
i. Concurrent Claim. A concurrent claim is a claim that is reconsidered
after initial approval of an ongoing course of treatment and results
in a reduction or termination of benefits before the end of the approved
course of treatment. An example would be an in-patient hospital stay
originally approved for five days that is subsequently shortened to three
days. In the event of reconsideration, you must be notified so that you
can appeal the decision and obtain a decision on appeal before the benefit
is reduced or terminated. An appeal to extend a course of treatment for
a claim involving urgent care must be acted upon with 24 hours after
receipt of the appeal but only if the appeal is received at least 24
hours prior to the expiration of the approved course of treatment.
ii. Post-Service Claim. A post-service claim is a claim for payment
after the care or treatment has already been provided, i.e. the extent
to which a provider's bill will be paid. The Plan Administrator will
provide notice of the benefit determination (whether approved or adverse)
within a reasonable period of time but not later than 30 days after receipt
of the claim. The time period may be extended up to an additional 15
days for matters beyond the Plan Administrator's control, but you will
be notified of the extension before the end of the initial 30 day period.
The notice will identify circumstances requiring the extension and the
date by which the Plan Administrator expects to issue a decision. If
the extension is necessary because you did not submit necessary information,
the notice will describe the information required and give you an additional
period of at least 45 days to furnish the information. In the event of
an adverse benefit determination, you may appeal to the Board of Trustees,
who will act on the appeal within the time limits set forth in section
4, below.
2. Content of Initial Adverse Benefit Determination Notice.
a. If your claim is denied, the adverse benefit determination will
be in writing and will provide:
i. The specific reason for the adverse benefit determination;
ii. Reference to the specific Plan provision on which the adverse
benefit determination is based;
iii. A description of any additional material or information necessary
to perfect the claim and an explanation why such material or information
is necessary;
iv. A description of the Plan's review procedure, the time limits applicable
to such procedures, and your right to bring a civil lawsuit for the benefit
after an adverse determination by the Board of Trustees;
v. If the adverse benefit determination is based upon an internal rule,
guideline, protocol or similar criterion, you will be notified of your
right to receive the document free of charge upon request; and
vi If the adverse benefit determination is based upon a decision involving
medical necessity or because the service was experimental or investigational,
you will be notified of your right to receive a statement of the scientific
or clinical judgment for the decision free of charge upon request.
3. Appeal of an Adverse Benefit Determination and Eligibility Determination.
a. If you disagree with the initial adverse benefit or eligibility
determination, you or your authorized representative may file a written
appeal within 180 days after receiving the adverse benefit or eligibility
determination. The written appeal must be filed as follows:
Harrison Electrical Workers Trust Fund
Attn: Appeals
Board
c/o A&I Benefit Plan Administrators, Inc.
1220 SW Morrison Street,
Suite 300
Portland, OR 97205
b. Upon written request, you will be provided free of charge reasonable
access to and copies of all documents, records and other information
relevant to your appeal. Whether a document, record or other information
is relevant is determined in accordance with 29 CFR §2560.503-1(m)(8).
c. In conjunction with your appeal, you or your authorized representative
may submit written comments, documents, records or other information
relating to your claim to the Board of Trustees.
d. If you or your authorized representative request to appear at a hearing
before the Board of Trustees at the time your appeal is filed, you will
be notified of the time, date and place of a hearing by regular mail
at the return address shown on your appeal.
e. You may be represented at the hearing before the Board of Trustees
by an attorney or other authorized representative of your choosing at
your own cost and expense.
4. Decision by the Board of Trustees.
a. Upon receipt of a timely appeal, the Board of Trustees will review
the claim de novo (meaning without deference to the initial decision).
The Board of Trustees will review all relevant information regardless
of whether the information was previously submitted. If the appeal involves
issues of medical judgment such as whether a particular treatment, drug
or other item is experimental, investigational or medically necessary,
the Board of Trustees shall consult a health care professional who has
appropriate training and experience in the field of medicine. If the
Board of Trustees consult a health care professional, he will be identified
regardless of whether the Board of Trustees rely on his opinion. If the
Board of Trustees consult a health care professional, he will be different
than the health care professional previously consulted and will not be
a subordinate of the health care professional previously consulted.
b. A decision will be made by the Board of Trustees at their next regularly
scheduled meeting following receipt of the appeal unless the appeal is
filed less than 30 days prior to the meeting. If this is the case, the
Board of Trustees will review the appeal not later than the date of the
subsequent Board of Trustees' meeting. If, due to special circumstances,
the Board of Trustees requires an extension of time to review the appeal,
you will be notified in writing of the special circumstances necessitating
the extension and when the decision will be made.
c. The decision of the Board of Trustees will be in writing and sent
within five days after the decision is reached.
d. If the Board of Trustees denies your benefit appeal, the adverse
benefit determination will include the following:
i. The specific reason for the adverse benefit determination;
ii. Reference to the specific Plan provision on which the decision
is based;
iii. A statement that, upon written request, you will be provided
free of charge reasonable access to and copies of all documents,
records and
other information relevant to your claim. Whether a document, record
or information is relevant is determined in accordance with 29
CFR §2560.503-1(m)(8);
iv. A statement of your right to bring a civil lawsuit for the benefit
under ERISA;
v. A statement that any internal rule, guideline, protocol or similar
criterion used as a basis for the adverse benefit determination will
be available free of charge upon written request; and
vi. A statement that if the adverse benefit determination was based
on medical necessity, experimental treatment or other similar exclusions
or limitations, the scientific or clinical judgment used in the decision
will be provided free of charge upon request.
e. If the Board of Trustees denies your eligibility appeal, the decision
will include the following:
i. The specific reason for the decision;
ii. Reference to the specific Plan provision on which the decision
is based; and
iii. A statement of your right to bring a civil lawsuit under ERISA.
f. You are required to use the procedures set forth above before bringing
a civil lawsuit for the benefit under ERISA.
g. The Board of Trustees has the full and exclusive authority to administer
the Active Employee Plan, interpret the Active Employee Plan and resolve
all questions arising in the administration, interpretation and application
of the Active Employee Plan. The Board of Trustees' authority includes,
but is not limited to:
i. The right to resolve all matters when review has been requested;
ii. The right to establish and enforce rules and procedures for the
administration of claims so long as the rules and procedures are consistent
with ERISA;
iii. The right to construe and interpret the Active Employee Plan;
and
iv. The exercise of the aforementioned powers and authorities by the
Board of Trustees will be given the fullest deference allowed by law.
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1. The Plan Administrator, A&I Benefit
Plan Administrator, Inc., is responsible for reviewing an application
for time loss benefits subject to the following time frames:
If a claim for time loss benefits is to be denied by the Plan Administrator,
you will be notified in writing. The written notice of denial will normally
be provided to you within 45 days after receipt of a completed application
for time loss benefits. If the Plan Administrator determines an extension
of time is necessary to complete review of the time loss claim because
of matters beyond its control, the 45 day period may be extended for
up to 30 days provided the Plan Administrator notifies you of the extension
of time for processing the time loss claim during the initial 45 day
period. If prior to the end of the first 30 day extension, the Plan Administrator
determines that a further extension of time is necessary to complete
review of the time loss claim because of matters beyond its control,
the 30 day extension period may be extended for up to an additional 30
days provided that the Plan Administrator notifies you of the extension
of time for processing the time loss claim before the end of the first
30 day extension period. If an extension of time is required by the Plan
Administrator, you will be notified in writing and the notice shall specify
the reason(s) for the extension, the unresolved issue(s), if any, preventing
a decision, additional information, if any, needed to resolve the issue(s)
and the date a decision is expected.
2. Content of the Denial Notice from the Plan Administrator
a. If the Plan Administrator denies your claim for time loss benefits,
the denial notice will be in writing and will provide:
i. The specific reason or reasons for the decision. If the decision
is based on an internal rule, guideline, protocol or other similar criterion,
the internal rule, guideline, protocol or similar criterion will be described
or provided to you free of charge upon request;
ii. Reference to the specific Plan provision on which the denial is
based;
iii. A description of any additional material or information necessary
for you to perfect the claim and an explanation why such material or
information is necessary; and
iv. A description of the Plan’s review procedures, your right
to relevant documents, records and information and the time limits
applicable to such procedures.
3. Appeal Procedure to the Board of Trustees
a. Where a claim for time loss benefits has been denied or partially
denied, you may appeal the denial to the Board of Trustees.
b. Upon written request, you will be provided free of charge reasonable
access to and copies of all documents, records and other information
relevant to your claim for time loss benefits. Whether a document,
record or other information is relevant to a claim will be determined
in accordance
with ERISA regulation 29 CFR §2560.503-1(m)(8).
c. You or your representative has 180 days following receipt of the
denial notice from the Plan Administrator to file an appeal with the
Board of Trustees. The appeal must be in writing and mailed or delivered
as follows:
Harrison Electrical Workers Trust Fund
c/o A&I
Benefit Plan Administrators
1220 SW Morrison ST STE 300
Portland, OR 97205
d. In conjunction with your appeal, you or your representative may
submit written comments, documents, records and other information relating
to your claim for time loss benefits to the Board of Trustees.
e. If you request to appear at the hearing before the Board of Trustees
at the time your appeal is filed, you will be notified of the time, date
and place of the hearing by regular mail at the return address shown
on your request for review.
f. You may be represented at the hearing before the Board of Trustees
by an attorney or other representative of your choosing at your own cost
and expense.
4. Decision by the Board of Trustees
a. Upon receipt of an appeal, the Board of Trustees will review the
claim de novo (meaning without deference to the decision of the Plan
Administrator). The Board of Trustees will review all relevant information
regardless of whether the information was submitted to the Plan Administrator.
If the appeal involves issues of medical judgment, the Board of Trustees
will consult a health care professional who has appropriate training
and experience in the field of medicine involved in the medical judgment.
If the Board of Trustees consult a medical or vocational expert, he will
be identified regardless of whether the Board of Trustees rely on his
opinion.
b. A decision will be made by the Board of Trustees at their next
regularly scheduled meeting following receipt of the appeal unless
the appeal is
filed less than 30 days prior to such meeting. If this is the case,
the Board of Trustees will review the appeal not later than the date
of the
subsequent Board of Trustees’ meeting. If, due to special circumstances,
the Board of Trustees require an extension of time to review the
appeal, you will be notified in writing of the special circumstances
necessitating
the extension and when the decision will be made.
c. The decision of the Board of Trustees will be in writing and sent
within five days after the decision is reached.
d. If the Board of Trustees denies your appeal for time loss benefits,
the decision will include the following:
i. The specific reason or reasons for the decision. If the decision
is based on an internal rule, guideline, protocol or other similar criterion,
the internal rule, guideline, protocol or similar criterion will be described
or provided to you free of charge upon request;
ii. Reference to the specific Plan provision on which the denial is
based;
iii. Upon written request, you will be provided free of charge reasonable
access to and copies of all documents, records and other information
relevant to your claim for time loss benefits. Whether a document,
record or other information is relevant to a claim will be determined
in accordance
with 29 CFR §2560.503-1(m)(8);
iv. Your right to bring a lawsuit for time loss benefits under §502(a)
of ERISA; and
v. A statement of voluntary alternative dispute resolution options,
if any, which may be available to you.
e. You are required to use the procedures set forth above before bringing
a lawsuit for time loss benefits under ERISA.
f. The Board of Trustees has the full and exclusive authority to administer
time loss claims, interpret the Active Employee Plan as it relates
to time loss benefits and resolve all questions arising in the administration,
interpretation and application of the Active Employee Plan that concerns
time loss benefits. The Board of Trustees’ authority includes,
but is not limited to:
i. The right to resolve all matters when review has been requested;
ii. The right to establish and enforce rules and procedures for the
administration of time loss benefits and any claim concerning time loss
benefits so long as the rules and procedures are consistent with ERISA;
and
iii. The right to construe and interpret the Active Employee Plan as
it relates to time loss benefits.
The exercise of such power and authority by the Board of Trustees will
be given the fullest deference allowed by law.
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