Summary Plan Description
If a claim is denied by the plan administrator or the administrator’s representative, you have the right to request the Board of Trustees to review the decision of the administrator. This review is known as an appeal. However, you must make this request, in writing, to the Trustees at the Trust Office within 60 days after notification of the denial of the claim.
Your request must set out the reasons for the appeal and your dissatisfaction or disagreement. Any evidence or documentation to support this position should be submitted with the written appeal.
The appeal will be conducted by the Appeals Committee of the Board of Trustees, which has been given the authority for making a final decision in connection with the appeal.
The Trustees will review a properly filed appeal at the next regularly scheduled quarterly meeting of the Appeals Committee, unless the request for review is received by the Trustees within 30 days preceding the date of such meeting. In such case, the appeal will be reviewed no later than the date of the second quarterly meeting following the Trustees’ receipt of the notice of appeal, unless there are special circumstances requiring a further extension of time, in which case the appeal will be reviewed not later than the third quarterly meeting of the Appeals Committee following the Trustees’ receipt of the notice of appeal. If such an extension of time for review is required because of special circumstances, such as a request for a hearing on the appeal, then prior to the commencement of the extension, the plan will notify you, in writing, of the extension, describe the special circumstances and the date as of which the benefit determination will be made.
You will be provided upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your appeal. You are entitled to submit evidence to the Trustees on behalf of your appeal. In most instances, you will have the right to a hearing before an Appeals Committee of the Board of Trustees. You have the right to be represented by counsel at your own expense.
After consideration of the appeal, the Appeals Committee will issue a written statement granting or denying the appeal. The statement will include:
- The specific reasons for the decision.
- Specific references to pertinent plan provisions on which the denial is 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 appeal.
If you are dissatisfied with the determination by the Trustees, you may ask for arbitration, in accordance with the Employee Benefit Plan Claims Arbitration Rules of the American Arbitration Association. This request must be made, in writing, within 60 days after you are notified of the formal decision of the Appeals Committee of the Board of Trustees. If requested, the plan administrator will help you prepare the request for arbitration.
The arbitrator’s review is an appellate-type review, which will be limited to the evidence in the record. The scope of the arbitrator’s review is limited to these issues:
- Whether the decision of the Trustees is supported by substantial evidence.
- Is erroneous as a matter of law.
- Is arbitrary and capricious.
The expense of arbitration will be borne equally by each party, unless otherwise ordered by the arbitrator. However, each party shall bear their own attorney fees. The decision of the arbitrator is final and binding on all parties. The Appeals Procedures are the sole and exclusive procedures available if you are dissatisfied with a claim determination made by the plan administrator, or if you are otherwise adversely affected by any action of the plan administrator or Trustees.
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