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Skip Navigation LinksHome » Health Benefit Retiree Info » Major Medical  
 

Medical Benefits
Depending on the Plan you are enrolled in (see below), it may offer you and your eligible dependents comprehensive medical benefits including coverage for many hospital and physician services, in network surgi-centers, chiropractic care, diagnostic x-ray, imaging and lab tests, durable medical equipment, emergency room physician services, skilled nursing, home health, hearing aids, infertility benefits, maternity benefits, mental health and substance abuse and organ transplants. When you use a PPO in-network provider, you will receive a higher level of benefits.

Non Medicare Plans: 

- BCBS Plan # 50445 - Comprehensive Major Medical Coverage
 
Medicare Eligible Plans: (See the Medicare Supplement tab for Information on these Plans)
 
- BCBS Plan # 50498 - Secondary “Hospital Only” Coverage   or
 
- BCBS Plan # 50446 - Secondary Comprehensive Medical Benefits
 
Preferred Provider Organization
PPO vs. Non-PPO: Knowing the Difference Saves You Money
The Plan offers you access to a Preferred Provider Organization (PPO) through BlueCross BlueShield of Illinois (BCBS).  When you or other eligible members of your family use a PPO provider physician and/or hospital, you save money both for your family and the Plan.  BCBS has agreements with providers that participate in their network (PPO providers) to charge a negotiated dollar amount. Doing so saves you money in two ways: 1) The overall cost of the service is lower as a result of negotiated discounts and 2) the Plan typically pays a higher percentage of the covered expenses.
 
If your in-network PPO physician refers you to a hospital or facility, be sure to ask if it is “in-network.” As the chart below shows using healthcare providers in the PPO network, you can maximize your medical benefits and save money for yourself and the Fund. 
 
Example of Network Savings: John Smith has a knee replacement surgery on January 5, 2011.
  BCBS PPO In-Network Provider Non PPO Out-of-Network Provider
Cost of single knee replacement $70,000 $70,000
Network Discount ($30,000) n/a
Total charges for consideration $40,000     $54,000***
Participant Pays *
(Deductible, coinsurance)**
$2,000     $22,600***
Plan Pays $38,000 $47,400
  
*     In this example, all covered in-network benefits for the remainder of the 2011 calendar year will be paid at 100% as John's deductible and his Annual Co-Insurance Maximum have been met.
 
**   In-network and out-of-network deductible and coinsurance limits are separate.
 
*** The amounts charged for out-of-network medical expenses are subject to the  Reasonable and Customary Allowances as adopted by the Fund. Amounts over the Reasonable and Customary Allowance ($16,000), plus deductible ($600) and Co-Insurance ($6,000) are the Covered Individual's responsibility.
 
Health Benefits for Non-Medicare Eligible Retirees
If you are not yet eligible for Medicare, you may have coverage under the Comprehensive Major Medical.
 
Please note: Deductibles and Coinsurance Maximums for the Active Plan of Benefits do not carry over to the Retiree Plan of Benefits.
 
BCBS Plan # 50445 - Comprehensive Major Medical Coverage
The Plan’s Comprehensive Medical Benefits are provided through BlueCross BlueShield of Illinois (BCBS), the Fund’s preferred network provider (PPO).
 

 
BCBS In-Network
PPO Provider
Out-of-Network
Non-PPO Provider
Calendar Year Deductible*
$300/Individual
$600/Family
$600/Individual
Coinsurance
Plan pays 80%
Participant pays 20%
Plan pays 60%**
Participant pays 40%
Annual Coinsurance Maximum* (per calendar year)
$2,000/Individual
$4,000/Family (Includes Deductible)
$6,000/Individual
Emergency Room (ER) Copayment
$250, waived if admitted to the hospital as an inpatient within 72 hours or held in the observation unit for more than 24 hours.
 (ER co-payment no longer applicable after Individual meets the applicable calendar year Out-of-Pocket Maximum)

 
*    There are separate Calendar Year Deductibles and Annual Coinsurance Maximums for in-network and out-of-network expenses.
 
** Out-of-network expenses are subject to Reasonable and Customary Allowances (R&C), as adopted by the Fund Office. Amounts over R&C are the Covered Individual’s responsibility.
 
Plan benefits are subject to the following limitations and exceptions:
 
·        Chiropractic Care/Acupuncture/Naprapathic Care: Maximum visit limit per retired employee: 45 combined visits per calendar year. Maximum visit limit per spouse: 15 combined visits per calendar year. No coverage for dependent children
·        Convalescent Facility: Up to 120 days per convalescent period
·        Home Health Care: Up to 120 days per calendar year
·        Hospice Care: Up to 180 days per lifetime
·        Preventive Colorectal Screening: Plan pays 100%, once every five years, for covered Retirees and Spouses over the age of 50, when performed by a BCBS In-Network PPO Provider. Screenings performed by out-of-network providers are subject to Calendar Year Deductibles and Coinsurance
·        Hearing Benefits: The Plan pays a maximum of $1,500 per covered Individual for prescribed hearing aid instruments, or their repair, once every five consecutive years. Coverage is only for the device itself and is not subject to Calendar Year Deductibles.  A hearing exam is not covered. Discounts on hearing aids are available through EPIC Hearing Services. If you do not go through EPIC, claims must be submitted through BCBS.
 

CLAIMS AND APPEALS 

This section describes the procedures for filing claims for benefits from the Plan. It also describes the procedures for you to follow if your claim is denied in whole or in part and you wish to appeal the decision. 

How and When to File Claims 

Generally, when you use the Plan’s contracted providers, the provider will file the claim on your behalf. Claim forms for out-of-network benefits can be obtained from the contracted provider and filed with the appropriate provider. You must file a claim for benefits with the designated Claims Fiduciary within 24 months from the date of service, or other period specified by a third party Claims Fiduciary. When a claim is submitted for Plan benefits, the Fund Office on behalf of the Trustees or the designated third party Claims Fiduciary will determine if you are eligible for benefits and the contracted provider will calculate the amount of any benefits payable. Claims recognized under the Plan include requests for health care benefits that must include: 

•   Patient name and date of birth; 

•   Your name and Social Security number or other ID number assigned by the Fund; 

•   Date of service for a health care claim or date of fill or refill for prescription drug claim; 

•   Specific services performed and expenses charged for each service; 

•   Type of service defined by a recognized diagnosis/procedural code, including individual charges for each; 

•   Attending physician’s or provider’s name and federal tax ID number (not required for prescription drug claims); 

•   Place of service; 

•   Billing address; and 

•   Previous balances paid. 

Authorized Personal Representative 

You may designate an Authorized Personal Representative to act on your behalf by notifying the Retirement Benefits Department and completing and submitting an Authorized Personal Representative Form or other form or procedure required by a designated third party Claims Fiduciary. Only the Authorized Personal Representative Form issued by the Fund or other form or procedure required by a designated third party Claims Fiduciary will be accepted. If an authorized personal representative is designated, correspondence relating to the claim or subsequent appeal may be shared with the designated authorized personal representative, unless otherwise specified. An individual who holds a health care power of attorney is deemed an authorized representative. 

You may obtain an Authorized Personal Representative Form from the Fund’s website at www.crccbenefits.org or by calling the Retirement Benefits Department at 312-787-9455, menu option 4. To inquire regarding necessary forms or procedures for designating an Authorized Personal Representative for benefits administered on behalf of the Plan through a third party, please contact the appropriate service provider listed on page 2 of this Summary Plan Description. 

Only the Authorized Personal Representative Form issued by the Fund or other form or procedure required by a designated third party Claims Fiduciary will be accepted.

General Rules Governing Claims 

Covered individuals may submit claims in paper form specified by the designated Claims Fiduciary or their providers may submit claims in paper form or through Electronic Data Interchange (EDI). Claims must be submitted to the Plan’s contracted provider of service within 24 months of the date of service or other period specified by a third party Claims Fiduciary. 

If a covered individual’s provider and service(s) were obtained outside the contracted provider’s network area, the provider must file the claim with the contracted provider or the local affiliate of the contracted provider, if applicable. 

Each claim must indicate the name of the patient, name of the participant, and the participant’s Social Security number or ID number that may be assigned by the Fund Office, the date for each service for which the claim is made, the provider’s name and tax identification number, the appropriate ICD code (diagnosis) and specific services provided, as defined by the appropriate CPT, HCPCS, CDT, or other nationally recognized codes, and the amount charged for each service. 

A covered individual must pay any amounts not paid by the Fund, with the exception of PPO network discounts or discounts that may be negotiated between the Plan and the provider on out-of-network claims. PPO or other negotiated discounts do not apply to expenses that are not covered by the Plan. 

A covered individual is prohibited from assigning his rights under the medical portion of the Plan to a third party or in any way alienating the covered individual’s claims for benefits. Any attempt to assign rights or in any way alienate a claim for benefits will be void and will not be recognized by the Fund as an assignment. The Fund will treat any document attempting to assign a participant’s rights, or to alienate a claim for benefits to a provider, as an authorization for direct payment by the Fund to the provider. In the event that the Fund receives a document claiming to be an assignment of benefits, the Fund may send payments for the claims to the provider, but will send all claim documentation, such as an explanation of benefits, and any procedures for appealing a claim denial directly to the covered individual. If the Fund denies the claim, only the participant, the participant’s spouse, the patient or his authorized representative will have the right to appeal. 

The Fund will pay claims only when covered under the terms of the Plan provisions under which a covered individual is eligible. If the Fund pays claims that it is not required to pay, it may recover and collect payments from a covered individual or any other entity or organization to whom the Fund was not required to make the payment or that received an erroneous payment. The Fund may recover such erroneous payments through, but not limited to, an offset or reduction of any future benefits a covered individual, or other eligible dependents, may be entitled to receive from the Fund. The Fund shall be permitted to pursue legal and equitable remedies to recover overpayments. 

For the purposes of this section, the Claims Fiduciary means the entity that has full discretionary authority to interpret the terms of the Plan and to decide benefit claims under the Plan and the appeal of such decision, and to maintain any applicable external review process. The Plan’s Claims Fiduciary is the Board of Trustees unless the Trustees take action to delegate such authority to a third party Claims Fiduciary, such as to an insurance carrier or to a third party service provider responsible for maintaining a benefit program under the Plan. 

Please note that the Trustees have designated Claims Fiduciaries for the Retiree Plan who have the authority to decide and review all benefit claims and all denied claims upon appeal under the Plan as follows: 

•   Fund Office for eligibility and premiums. 

•   Blue Cross Blue Shield of Illinois for medical, mental health and substance use disorder claims. 

•   Express Scripts, Inc. for prescription drug claims. 

•   Diplomat Specialty Pharmacy for specialty drug claims. 

Please see Important Contact Information for telephone numbers and website addresses. 

The above Claims Fiduciaries are named fiduciaries under the Retiree Plan and have the authority to make final decisions regarding claims for benefit considerations under the Plan. The Trustees shall decide claims appeals relating to eligibility, premiums, and adding or dropping dependents. 

Types of Claims 

There are several types of health care claims under the Plan, including medical, mental health and substance use disorder, prescription drug, and hearing aid claims. Health care claims include the following: 

•   Urgent Health Care Claim: Any claim for medical care or treatment with respect to which the application of the periods for making pre-service claim determinations would, in the opinion of a physician with knowledge of the covered individual’s condition, seriously jeopardize the covered individual’s life or health or ability to regain maximum function if normal pre-service standards were applied or would subject the covered individual to severe pain that cannot be adequately managed without the care or treatment for which approval is sought; 

•   Pre-Service Health Care Claim: Any claim for a benefit for which the Plan requires approval of the benefit (in whole or in part) before the covered individual obtains medical care; 

•   Post-Service Health Care Claim: Any claim for health care benefits for which the covered individual has already received the services in the claim; and 

•   Concurrent Care Claim: Any claim that is reconsidered after it is initially approved and the reconsideration results in reduced benefits, an extension of benefits or a termination of benefits. 

The deadlines for processing the initial determination and the extension period are shown in the chart on the next page. The Plan may request an extension of the initial determination period due to matters beyond the Fund’s or Claims Fiduciary’s control.  

Type of Claim

Response Time Upon Receipt of Your Claim

Extension

Urgent claims

72 hours

Extension not applicable. However, if additional information is required from you, you will be notified within 24 hours of receipt of the claim the specific information needed, and you have at least 48 hours to provide the information.

Pre-service claims/ Predetermination of benefits

15 days

You will be notified within the 15-day initial determination period that one 15-day extension is necessary. If an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice. If the Claims Fiduciary receives the requested information in the 45-day period, the claim will be processed within 15 days following the receipt of the additional information.

Post-service claims

30 days

You will be notified within the 30-day initial determination period that one 15-day extension is necessary. If the extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice. If the Claims Fiduciary receives the requested information within the 45-day period, the claim will be processed within 15 days following the receipt of the additional information.

Concurrent

As soon as possible, in time to receive a decision before reduction or termination of the benefit.

Not applicable.

Claim Denial 

If for any reason your claim is denied, in whole or in part, you will receive a written notice comprising the information detailed below. 

When the Plan or Claims Fiduciary notifies you of its initial denial of your claim, it will provide (if relevant): 

•   Identification of the claim involved, including date of service, provider, claim amount, and a statement with denial codes and their respective meanings; 

•   The specific reason or reasons for the decision, and any Plan standards used in denying the claim; 

•   Upon request and free of charge, the diagnosis code and its corresponding meaning, as well as the treatment code and its corresponding meaning; 

•   Reference to the Plan provisions on which the decision was based; 

•   A description of any additional information or material needed to properly process your claim and an explanation of the reason it is needed; 

•   A copy of the Plan’s internal review procedures and time periods and information needed to appeal your claim, and external review processes for health care claims; 

•   A statement of your right to bring a civil action under ERISA following an adverse benefit determination of your claim on review; 

•   Disclosure of the availability of, and contact information for, any applicable ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes for health care claims; 

•   A copy of any internal rule, guideline, protocol or similar criteria that was relied on in making the decision to deny your claim, or a statement that a copy is available to you, free of charge, upon request; and 

•   A copy of the scientific or clinical judgment, or statement that it is available to you, free of charge, upon request, if your claim is denied due to medical necessity, experimental or investigational treatment, or similar exclusion or limit. 

NOTE: The applicable Claims Fiduciary decides and processes all levels of appeal for a benefit claim. 

Adverse Benefit Determination Appeal Process 

You may appeal any denied post-service or urgent care health claims. The Explanation of Benefits (EOB) that you receive serves as the notice of an adverse benefit determination when payment of a claim for benefits has been denied by a Claims Fiduciary, in whole or in part, for the reasons stated on the EOB. An adverse benefit determination also includes a rescission of coverage, whether or not there is an adverse effect on any particular benefit at that time. A rescission of coverage, as described more fully on page 66, is a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or other events (such as fraud). 

You may appeal a denied post-service health care claim within 180 days after receiving notice of the denied claim. All appeals must be in writing on the forms required by the applicable Claims Fiduciary and addressed to the applicable Claims Fiduciary, and must include your or your authorized personal representative’s signature. Your appeal should include evidence or specific facts and Plan provisions that support your claim. Submit a completed appeal form and any additional information to substantiate the appeal to the applicable Claims Fiduciary. Contact the applicable Claims Fiduciary for forms for appealing a denied claim. 

You have certain rights when you appeal a claim: 

•   To receive, upon written request, copies of all documents relevant to the claim; 

•   To designate an authorized personal representative (who may be an attorney) subject to executing any forms required by the Plan; 

•   To request, free of charge, a copy of relevant information if your claim is denied based on internal rules, guidelines, protocol or other similar criteria; 

•   To request, free of charge, a copy of an explanation of the scientific or clinical judgment that is the basis of the adverse benefit determination, if your claim is denied based on medical necessity, experimental treatment or similar exclusion or limit; and 

•   To be advised of the identity of any medical expert relied upon for the determination of the claim. 

For health care claims, the Claims Fiduciary will also provide you, free of charge, with any new or additional evidence considered or rationale, relied upon, or generated by the Claims Fiduciary (or at the direction of the Claims Fiduciary) in connection with the claim. 

Appeal Review 

Appeal of a Claim Related to Eligibility, Premiums or Adding or Dropping Dependents 

For claims related to eligibility, premiums and adding or dropping dependents, for which the Board of Trustees is the Claims Fiduciary, the Fund Office will process and provide a decision on your claim generally within 30 days. If you disagree with the decision, you may appeal the decision to the Board of Trustees within 180 days of receiving the Fund Office’s decision using the appeal procedures described on page 45. You should address your appeal to the Fund Office, Attn: Appeals Committee. The Fund Office will review your appeal within five business days of receiving it to determine if it is in order. Appeals will be reviewed at the next regularly scheduled appeals meeting of the Trustees or their delegate (e.g., an Appeals Committee), who meet at least quarterly. 

However, if the request for review is received within 30 days of the next regular meeting, the request for review will be considered at the second regularly scheduled meeting following receipt of the request. If special circumstances require a further extension for processing, a determination will be made at the third regularly scheduled meeting following receipt of the request for review. Before the extension begins, you will be advised in writing in advance if this extension will be necessary, and will be notified of the special circumstances and the date by which a determination will be made. 

Once a decision has been made, the Trustees will mail their decision to you within five business days after making a determination. If your appeal is denied, you have the right to initiate a lawsuit under ERISA Section 502(a). Any lawsuit must be initiated within 12 months of the denial on review. 

Appeal of Post-Service Health Care Claims 

For post-service health care claims, the Claims Fiduciary will review your appeal and provide you with notice of its decision within 60 days of receiving your appeal. You will receive notice of the decision within 30 days after your appeal was received if the Claims Fiduciary allows two levels of appeal. 

If your appeal is denied, you have the right to initiate a lawsuit under ERISA Section 502(a). In some circumstances you may have the right to request an external review from an Independent Review Organization (IRO). Any lawsuit must be initiated within 12 months of the denial on review. 

When the Claims Fiduciary notifies you of its determination on your appeal, it will provide: 

•   Identification of the claim involved, including date of service, provider, claim amount and a statement with denial codes and their respective meanings; 

•   The specific reason or reasons for the decision, and any Plan standards used in denying the claim; 

•   Reference to the Plan provisions on which the decision was based; 

•   A statement that you may request, without charge, the diagnosis code and its corresponding meaning, as well as the treatment code and its corresponding meaning; 

•   A statement notifying you that you have the right to request a free copy of all documents, records and other information relevant to your claim; 

•   Information relating to external review processes for health care claims, and any voluntary appeal procedures offered by the Plan; 

•   A statement of your right to bring a civil action under ERISA; 

•   Disclosure of the availability of, and contact information for, any applicable ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes for health care claims; 

•   A copy of any internal rule, guideline, protocol or similar criteria that was relied on in making the decision to deny your claim, or a statement that a copy is available to you, free of charge, upon request; and 

•   A copy of the scientific or clinical judgment, or statement that it is available to you, free of charge, upon request, if your claim is denied due to medical necessity, experimental or investigational treatment, or similar exclusion or limit. 

For post-service health care claims for which a third party is the Claims Fiduciary, the designated Claims Fiduciary will review the claims appeal and provide its written decision to the covered individual within 60 days of receiving the appeal. The covered individual will receive written notice of the decision within 30 days after the appeal was received when the Claims Fiduciary has two levels of appeal. 

External Review of Claims 

If an appealed health care claim is denied by the applicable Claims Fiduciary, you may request further review by an Independent Review Organization (IRO), as described below. Only denied health care claims that involve medical judgment and rescission claims are eligible for external review. Claims that do not involve medical judgment (e.g., eligibility claims, premium payments) are not eligible for external review. Generally, you may only request an external review after you or your authorized personal representative have exhausted the internal review and appeals process described above. The external review of claims is intended to comply with applicable law and regulations and guidance as issued by the Department of Labor, Department of Health and Human Services and the Internal Revenue Service. 

External Review of Standard Claims: External review of a claim will only apply to an adverse benefit determination or final internal adverse benefit determination involving a medical judgment. You must request external review of a non-urgent claim in writing, within four months of the date the EOB indicates an adverse benefit determination or the date of the letter advising of an adverse appeal claim benefit determination, whichever is later. 

Expedited External Review of Claims: You may request an expedited external review if you receive an initial adverse benefit determination that involves a medical condition for which the timeframe for completion of an internal appeal or standard external review would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an urgent care internal appeal or you receive an adverse appeal benefit determination that concerns an admission, availability of care, continued stay or health care item or service for which you received emergency services, but have not yet been discharged from a facility. 

Preliminary Review: The Claims Fiduciary will complete a preliminary review of the request immediately upon receipt of your request for an expedited external review or within five business days of the Claims Fiduciary’s receipt of your request for an external review to ensure the claim is in order. The Claims Fiduciary will notify you in writing within one business day of completing its preliminary review if your request meets the requirements for external review. If applicable, the notification will inform you if the request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility and the contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA [3272]). 

If the request is not complete, the notice will describe the information or materials needed to make the request complete and allow you to complete your request for external review within the four-month filing period or within a 48-hour period following receipt of the notification, whichever is later. 

Review by Independent Review Organization (IRO) 

If the request is complete and eligible, the Claims Fiduciary will assign the request to an IRO. The IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits. The Claims Fiduciary may rotate assignment among IROs with which it contracts. Once the claim is assigned to an IRO, the following procedure will apply: 

•   The assigned IRO will notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, you must submit such information within 10 business days following your receipt of notice from the IRO). 

•   If you submit additional information related to the claim, the assigned IRO will, within one business day, forward that information to the Claims Fiduciary. Upon receipt of any such information, the Claims Fiduciary may reconsider its adverse benefit determination that is the subject of the external review. Reconsideration by the Claims Fiduciary will not delay the external review. If the Claims Fiduciary reconsiders the claim and reverses its adverse benefit determination, it will provide written notice of its decision to you and the IRO within one business day after making that decision and the IRO will terminate its external review. 

•   The IRO will review all information and documents received in a timely manner, without regard to whether the information was submitted or considered in the initial benefit determination. 

•   After the IRO receives the request for the external review, the assigned IRO will provide written notice of its final external review decision to you and the Claims Fiduciary within 45 days. The assigned IRO’s decision notice will contain: 

   A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning and the reason for the previous denial); 

   The date that the IRO received the assignment to conduct the external review and the date of the IRO decision; 

   The principal reason(s) for its decision, including references to the evidence or documentation and specific coverage provisions and evidence-based standards considered in reaching its decision; 

   A statement that the determination is binding except to the extent that other remedies may be available to you or the Claims Fiduciary under applicable state or federal law; 

   A statement that judicial review may be available to you; and 

   Current contact information, including phone number, for the health insurance consumer assistance or ombudsman established under law to assist with external review processes. 

Expedited Review by Independent Review Organization 

If you have met the requirements for an expedited review in accordance with the criteria described on page 47, the IRO will provide notice of the final external review decision, in accordance with the requirements in this section, as quickly as your medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the IRO must provide written confirmation of the decision to you and the Claims Fiduciary. 

After External Review 

If the final external review reverses the Claims Fiduciary’s adverse benefit determination, upon the Claims Fiduciary’s receipt of notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim. 

If the final external review upholds the Claims Fiduciary’s adverse benefit determination, the Plan will maintain denial for the reviewed claim. If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a). Any lawsuit must be initiated within 12 months of the denial upon appeal. 

The Trustees, the Appeals Committee or their Claims Fiduciaries have sole, full and discretionary authority to make final determinations regarding any application for benefits, the interpretation of the Plan and all documents, rules, procedures and terms of the Plan, and any administrative rules adopted by the Claims Fiduciaries. It is the intention that the decisions of the Trustees or Claims Fiduciaries will be accorded judicial deference in any subsequent administrative or court proceeding, to the extent the decisions do not constitute an abuse of discretion. Benefits will be paid under the Plan only if the Claims Fiduciaries decide, in their discretion, that the Claimant is entitled to them. 

Exhaustion of Remedies 

Generally, you must follow and completely exhaust the Plan’s appeal procedures (including time limits) before you can file a lawsuit under ERISA or initiate proceedings before any administrative agency. If the Plan fails to adhere to all claims and claims appeal requirements, you are deemed to have exhausted the claims appeal process and may seek an external review or file a lawsuit, unless the Plan’s failure is minor. In the event you submit a claim for review and the claim is denied, any legal action must begin within 12 months of the date the Fund provides an adverse benefit appeal determination. 

Facility of Claims Payment 

In the event the Fund becomes aware that you have been deemed incompetent or incapable of executing a valid receipt and no guardian has been appointed, the Fund may pay any amount otherwise payable to you, to your spouse, or any other person or institution determined by the Fund to be equitably entitled to payment. Any payment in accordance with this provision discharges the Fund from any further obligation. 

Right to Information in Claims and Appeals Process 

You have the right to receive, upon written request, copies of all documents relevant to the decision made on your appeal. You may also request in writing to receive the identification of medical or other experts whose advice was obtained for reviewing your appeal. Any and all disclosures will be made in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 
 

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