14.3 In Case Your Claim for Benefits is Denied

A claim for benefits under the Plan arises only if you have filed a written request for a benefit determination with the Plan Administrator. The following sets forth the Plan’s timelines for deciding your claim, and your appeal rights if your claim for benefits is denied. Please note that there are special rules that apply to a claim that requires a determination of disability (“disability claim”).

14.3.1 Timing of Written Notice of Benefit Denial – Benefits Other Than Disability Benefits

If your claim is for benefits other than disability benefits, a written denial notice will generally be provided to you within 90 days after the date your claim is received by the Plan Administrator. However, if special circumstances require an extension of time for processing the claim beyond the initial 90-day period, written notice of the extension will be furnished to you before the end of the initial 90-day period. An extension of time will not exceed a period of 90 days from the end of the initial 90-day period. An extension notice will explain the reasons for the extension and the expected date of a decision.

14.3.2 Timing of Written Notice of Benefit Denial – Disability Benefits

If your claim is a disability claim, a written denial notice will be provided to you within a reasonable period of time, but not later than 45 days after receipt of your claim by the Plan Administrator. If matters beyond the control of the Plan Administrator require an extension of the time for processing your disability claim, the initial period may be extended for up to 30 days. Written notice of an extension will be sent before the end of the initial 45-day period. In addition, another 30-day extension of time for processing your claim due to matters beyond the control of the Plan Administrator may be taken. Written notice of such second extension will be sent before the end of the first 30-day extension period. The extensions shall not exceed a period of 60 days from the end of the initial 45-day period.

An extension notice will explain the reasons for the extension, the expected date of a decision, the standards for a benefit entitlement, any unresolved issues that prevent a decision on your claim, and any additional information needed to resolve those issues. If an extension is required because you have not provided the information necessary to decide your claim, the time period for processing your claim will not run from the date of notice of an extension until the earlier of 1) the date the plan receives your response or 2) the date set by the plan for your requested response (at least 45 days).

14.3.3 Contents of Written Notice of Benefit Denial

If your claim for a benefit is denied, you will be notified in writing by the Plan Administrator. The written notice will include the following:

• the specific reason or reasons for the denial;
  
• references to the specific Plan provisions on which the denial is based;
  
• a description of any additional material or information necessary in order for you to perfect the claim, and an explanation of why such material or information is needed;
  
• an explanation of the Plan’s review procedure for denied claims, including the applicable time limits for submitting your claim for review; and
  
• a statement of your right to bring a civil action under Section 502(a) of ERISA, if your claim is denied on appeal.
  

In addition, if your claim is a disability claim, the written notice will also include:

• any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits, or a statement that such was relied upon and a copy will be provided free of charge upon request; and
  
• if the decision was based on a medical necessity or experimental treatment or other similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying Plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request.

14.3.4 Procedure for Appeal of Denied Claim – Benefits Other than Disability Benefits

If you wish to appeal a denial of a claim for benefits other than disability benefits, you or your authorized representative must file a written appeal with the Plan Administrator within 60 days after receipt of written notice of the denial. You or your authorized representative may submit a written statement, documents, records, and other information. You may also, free of charge upon request, have reasonable access to and copies of Relevant Documents. The review will consider all statements, documents, and other information submitted by you or your authorized representative, whether or not such information was submitted or considered under the initial denial decision. Claim determinations are made in accordance with Plan documents and, where appropriate, Plan provisions are applied consistently to similarly situated claimants.

The Administrative Committee of the Board of Trustees reviews appeals of denied claims and makes final determinations. The Administrative Committee has full discretionary authority, including power to administer, construe and interpret the terms and provisions of the Plan, SPD and Trust Agreement and to determine eligibility for benefits under the Plan.

14.3.5 Procedure for Appeal of Denied Claim – Disability Benefits

If your claim is a disability claim, the requirements of the preceding Section 14.3.4 apply except where modified as follows. Any appeal from a disability claim denial must be filed with the Plan Administrator within 180 days after receipt of written notification of the denial. In addition, the following procedures supplement the appeal procedures discussed in the preceding Section:

• the appeal decision will not defer to the initial decision denying your disability claim and will be made by Plan trustees who are not persons who made the initial decision, nor subordinates of such person;
  
• if the initial denial decision was based in whole or in part on a medical judgment, the Administrative Committee will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;
  
• any health care professional engaged for such consultation will not be a person consulted in the initial decision, nor a subordinate of any such person; and
  
• any medical or vocational expert whose advice was obtained in connection with the decision to deny your disability claim will be identified upon request, whether or not the advice was relied upon.

14.3.6 Timing of Written Notice of Appeal Decision – Benefits Other Than Disability Benefits

If the Administrative Committee holds regularly scheduled quarterly meetings, the decision on your appeal generally will be made at the next regularly scheduled quarterly meeting after an appeal is received. If, however, your appeal is received within 30 days prior to such a meeting, it will be considered at the second regularly scheduled quarterly meeting after it is received. In addition, if special circumstances require an extension of time for processing your appeal, a decision will be rendered no later than the third regularly scheduled quarterly meeting after your appeal is received. Written notice of any extension of time will be sent before it commences explaining the reason for the extension and the expected date of the appeal determination. Notice of the appeal decision will be provided not later than five days after the decision is made.

If the Administrative Committee does not hold regularly scheduled quarterly meetings, a decision on your appeal will be made not later than 60 days after an appeal is received, unless special circumstances require an extension of time for processing, in which case a decision will be rendered not later than 120 days after an appeal is received. Written notice of any extension of time will be sent before the end of the initial 60-day period explaining the reason for the extension and the expected date of the appeal determination.

If an extension is required because you have not provided the information necessary to decide your claim, the time period for processing your claim will not run from the date of notice of an extension until the earlier of 1) the date the plan receives your response or 2) the date set by the plan for your requested response (at least 45 days).

14.3.7 Timing of Written Notice of Appeal Decision – Disability Benefits

If your claim is a disability claim, the preceding Section 14.3.6 will apply except that 45 days will be substituted for 60 days and 90 days will be substituted for 120 days.

14.3.8 Contents of Written Notice of Appeal Decision

If you appeal a denied claim, the decision on review will be in writing and will include the following information:

• the specific reason or reasons for the decision;
  
• reference to the specific Plan provisions on which the decision is based;
  
• a statement of your right to receive, upon request free of charge, reasonable access to and copies of Relevant Documents; and
  
• a statement of your right to bring a civil action under Section 502(a) of ERISA.

In addition to the above information, in the case of a claim for disability benefits, the written decision on review will also include:

• any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits on review, or a statement that such was relied upon and a copy will be provided free of charge upon request;
  
• if the decision on review was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying Plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request; and
  
• 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.”

14.3.9 Hearing on Appeal

Within a reasonable time after receipt of the request for review, you will be notified of the date, time and place of the appeal hearing by regular mail addressed to your address as shown on the request for review. You may request to be present at the hearing before the Administrative Committee. You may be represented at the hearing by an attorney or any other representative of your choosing. The proceedings at the hearing may be recorded by a method determined by the Committee. In conducting the hearing, the Committee shall not be bound by the usual common law or statutory rules of evidence. Copies will be made of all statements, documents, and records that you or your authorized representative introduces at the hearing and all other Relevant Documents. This information will be attached to the record of the hearing, and made a part thereof.

14.3.10 Relevant Documents

Relevant Document means any document, record or other information that:

• was relied upon in making a decision to deny benefits;
  
• was submitted, considered, or generated in the course of making the decision to deny benefits, whether or not it was relied upon in making the decision to deny benefits;
  
• demonstrates compliance with any administrative processes and safeguards designed to confirm that the benefit determination was in accord with the Plan and that Plan provisions, where appropriate, have been applied consistently regarding similarly situated individuals; or
  
• in the case of a disability claim, constitutes a statement of policy or guidance to the Plan concerning a denied treatment option or benefit for your diagnosis, whether or not it was relied upon in making the decision to deny benefits.