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.
14.3.1 Timing of Written Notice of Benefit Denial
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 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.
14.3.3 Procedure for Appeal of Denied Claim
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 the discretionary authority to construe and interpret the terms and provisions of the Plan, SPD and Trust Agreement and to determine eligibility for benefits under the Plan.
14.3.4 Timing of Written Notice of Appeal Decision
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).
14.3.5 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.
14.3.6 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.
14.3.7 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; or
- 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.