If you have a claim that involves eligibility for coverage (such as a late self-payment), you may file an appeal pursuant to Section 3.

If you have a claim for benefits that involves the Retired Trust 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 Retired Trust Plan. If your claim for a benefit under the Retired Trust 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 Retired Trust Plan, interpret the Retied Trust Plan and resolve all questions arising in the administration, interpretation and application of the Retired Trust 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 Retired Trust 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.