Pension - Appeals

Applying for Benefits

The initial application process is described in the Applications section.  Once your claim has been filed, the Administrative Office will make the initial determination of benefits within the time periods described below.

Determining Initial Claim

Benefits Other Than Disability Benefits Under Subsections 6.05.b.(3) and 6.06.f.(1)(a) of the Plan Document

The initial determination of benefits will be made within a reasonable period of time but not longer than 90 calendar days after the Administrative Office receives your application for benefits and all required information.  (If all the required information is not received with your application, the 90-day period for making the initial determination will be suspended during the time you are obtaining the additional information.)

If the Administrative Office determines that special circumstances require an extension of time for processing the claim, the Administrative Office will notify you, in writing, prior to the expiration of the 90 days of the circumstances requiring the extension of time and the date by which the Plan expects to make a determination.  The extension cannot be more than 90 calendar days from the end of the initial 90-day period.

Disability-Related Benefits under Subsections 6.05.b(3) and 6.06.f.(1)(a) of the Plan Document

The initial determination of benefits will be made within a reasonable period of time but not longer than 45 calendar days after the Administrative Office receives your application for benefits and all required information.  (If all the required information is not received with your application, the 45-day period for making the initial determination will be suspended during the time you are obtaining the additional information.)

If the Plan needs a second extension of time to make a determination due to circumstances beyond its control, you will be notified of an extension of up to 30 calendar days, or a maximum of 105 calendar days after the initial receipt of your application.  Before the end of the first 30-day extension period, the Administrative Office will notify you, in writing, of the circumstances requiring the extension and will give you the new date by which a determination will be made.

If your application for benefits is not acted on within these time periods, you may proceed to the appeal procedures as if the claim had been denied.

Notice of Claim Denial

If the Plan denies your application for benefits, in whole or in part, you will be notified in writing of the determination and be given the opportunity for a full and fair review of the benefit decision.  The written notice of denial will include:

1. The specific reason(s) for the denial;
2. The specific reference to pertinent Plan provision(s) on which the denial is based;
3. A description of any additional material or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
4. A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement of your rights to bring civil action under §502(a) of ERISA following an adverse benefit determination on review; and
5. For a claim under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) of the Plan, the basis for a discussion of the decision, including the basis for disagreeing with or not following the views of the treating physician or vocational professional who evaluated you, the views of medical experts obtained by the Plan, or, if applicable, the reason the Plan disagreed with the disability determination of the Social Security Administration. If the denial is based on medical necessity, experimental treatment or similar exclusion or limitation, a statement that an explanation of the scientific clinical judgment for the determination as applied to your medical circumstances will be provided free of charge upon request.  Also included are the internal rules, guidelines, protocols, standards or other similar criterion that was relied upon in making the adverse determination, and that a copy of all relevant documents will be provided to you free of charge upon request.  If you reside in a county in which 10% or more of the population is literate only in a language other than English, then the notice of denial will state that your notice will be provided upon request in that other language.

Right to Appeal

If you apply for benefits and your claim is denied, or if you believe that you did not receive the full amount of benefits to which you are entitled, you have the right to petition the Board of Trustees for reconsideration of its decision.  Your petition for reconsideration:

1. Must be in writing; and
2. Must state in clear and concise terms the reason(s) for your disagreement with the decision of the Administrative Office; and
3. May include documents, records, and other information related to the claim for benefits; and
4. Must be filed by you or your authorized representative with the Administrative Office within 60 days after you received notice of denial.

In the case of a claim based on disability Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) of the Plan, your petition for reconsideration must be filed with the Administrative Office within 180 days after you received notice of denial.  Failure to file an appeal within these time limits will constitute a waiver of your rights to a review of the denial of your claim.  A late application may be considered if the Board of Trustees finds that the delay in filing was for reasonable causes.

Upon request, you will be provided, free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits.  In the case of a claim for disability-related benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) of the Plan, the notification will include the basis for a discussion of the decision, including the basis for disagreeing with or not following the views of the treating physician or vocational professional who evaluated you, the views of medical experts obtained by the Plan, or, if applicable, the reason the Plan disagreed with the disability determination of the Social Security Administration.  If the denial is based on medical necessity, experimental treatment or similar exclusion or limitation, a statement that an explanation of the scientific clinical judgment for the determination as applied to your medical circumstances will be provided free of charge upon request.  If you reside in a county in which 10% or more of the population is literate only in a language other than English, then the notice of denial will state that your notice will be provided upon request in that other language.

Review of Appeal

A properly filed appeal will be reviewed by the Board of Trustees at its next regularly scheduled quarterly meeting.  However, if the appeal is received within 30 days prior to such meeting, the appeal may be reviewed at the second quarterly meeting following the receipt of your appeal.  If special circumstances require an extension of time, the Board of Trustee will render a decision at the third scheduled quarterly meeting following the receipt of your appeal. The Administrative Office will notify you, in writing, before the beginning of the extension of the special circumstances and the date that the Board of Trustees will make its decision.

The Board of Trustees will review all submitted comments, documents, records and other information related to your claim, regardless of whether the information was submitted or considered in the initial benefit determination.  The Board of Trustees will not give deference to the initial adverse benefit determination.

In deciding an appeal that is based in whole or in part on a medical judgment, the Board of Trustees will consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment.  Such health care professional shall not be an individual who was consulted in connection with the initial adverse benefit determination, nor with the subordinate of that individual.

You will receive written notification of the benefit determination on an appeal no later than five calendar days after the benefit determination is made.

In the case of an adverse benefit determination on the appeal, the written denial will include the reason(s) for the determination including references to the specific Plan provisions on which the determination is based.  The written denial will also include 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 claim for benefits.  The written notification of an adverse benefit determination concerning disability benefits will also include the specific rule, guideline, protocol or other similar criterion relied upon in making the adverse determination.

The denial of a claim to which the right to review has been waived, or a decision of the Board of Trustees or its designated committee with respect to a petition for review, is final and binding upon all parties, subject only to any civil action you may bring under ERISA.  Following issuance of the written decision of the Board of Trustees on an appeal, there is no further right of appeal to the Board of Trustees or right to arbitration.