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- HOW TO FILE A CLAIM FOR YOUR BENEFITS
- WHAT THE LAW DOES
- The Employee Retirement Income Security Act of 1974 (ERISA)
- protects the interests of participants and their
beneficiaries who depend
- on benefits from private employee benefit plans. ERISA
sets standards
- for administering these plans, including a requirement
that financial and
- other information be disclosed to plan participants and
beneficiaries and
- requirements for the processing of claims for benefits
under the plans.
- Although some employee benefit plans are not covered by
the Act (such
- as church or government plans, etc.), if you are one of
the millions of
- participants and beneficiaries in employee benefit plans
that fall under
- the Act's protection, you have certain rights if your
claim for benefits is
- denied. Your plan must give you the reason for denial in
writing and in
- a manner you can understand. It also must give you a
reasonable
- opportunity for a fair and full review of the decision.
This folder
- outlines the steps you may take to file a claim and what
to do if you are
- denied benefits.
-
- OBTAIN A COPY OF YOUR SUMMARY PLAN DESCRIPTION
- The first step you should take is to carefully read your
plan's
- summary plan description. This is a document which your
plan
- administrator must furnish you. It gives you a detailed
summary of your
- plan--how it works, what benefits it provides, how they
may be obtained
- and how they may be lost. The summary plan description
also is
- required to spell out your rights and protections under
ERISA.
- FILING YOUR CLAIM
- You or your beneficiary may be required to first file a
claim to
- receive the benefits you are entitled to under an employee
welfare
- benefit plan or a pension plan. An employee welfare
benefit plan is a
- plan, fund, or program which provides medical, surgical,
hospital,
- sickness, accident, disability, death, severance,
unemployment, vacation,
- apprenticeship, day care center, scholarship funds,
pre-paid legal
- benefits, etc. A pension plan is a fund or program which
provides
- retirement income to employees, or results in a deferral
of income by em-
- ployees for periods extending to the termination of
covered employment
- or beyond. Each plan covered by ERISA must have procedures
for filing
- a claim and must tell you what those procedures are. This
information
- must be included in the summary plan description. If for
any reason
- information concerning the filing of a claim has not been
provided, you
- may give notification that you have a claim by writing to
an officer of
- your employer, or the unit where claims are normally
filed, or the plan
- administrator.
- WHAT YOUR PLAN REQUIRES
- All plans have standards you must meet to qualify for
benefits. Your
- pension plan will probably say that you must have worked a
certain
- number of years and/or be a certain age before you can
start receiving
- benefits. Some employee welfare benefit plans may require
you to file a
- claim or notify the plan administrator immediately when
you enter a
- hospital or see a doctor. Some plans may require that you
pay a medical
- bill and the plan will repay you when it is presented with
a copy of the
- bill marked "paid."
- But be sure to contact your plan administrator or other
plan official
- for complete information on filing a claim for your
benefits.
- WAITING PERIOD
-
- Within 90 days after you have filed a claim for benefits,
your plan
- must tell you whether or not you will receive the
benefits. Also, if
- because of special circumstances your plan needs more time
to examine
- your request, it must tell you within the 90 days that
additional time is
- needed, why it is needed and the date by which the plan
expects to
- render a final decision. If your claim is denied, the plan
administrator
- must notify you in writing and explain in detail why it
was denied. If
- you receive no answer at all in 90 days -- or 180 days
when an extension
- of time was needed -- the claim is considered a denial and
you can use
- the plan's rules for appealing the denial.
- WHAT TO DO IF YOUR CLAIM IS DENIED
- Your claim may have been denied because you are not
eligible for
- benefits under the plan. Perhaps you haven't been a
partici-pant long
- enough, or you are not the required age. Perhaps you
needed to file
- additional information about your claim. When you have
been notified
- that your claim has been denied, your plan administrator
also must tell
- you how to submit your denied claim for a full and fair
review. You
- have at least 60 days (the plan may provide you with more
time) in
- which to do this. Be sure to include all related
information, particularly
- any additional information or evidence, and get it to the
specified person
- and address.
- REVIEWING YOUR APPEAL
- If review of your appeal is going to take longer than 60
days, you
- must be notified in writing of the delay. Except where the
review is
- made by a committee or board of trustees which meets at
least quarterly,
- a decision on your appeal must be made within 120 days of
your appeal.
- Once the final decision has been made, you must be told
the reason
- and the plan rules upon which the decision was based. This
explanation
- must be written in a manner that you can understand. If
you do not
- receive a notice within the waiting time, you can assume
that your claim
- has been denied after it was reviewed.
- WHAT TO DO IF YOUR APPEAL IS DENIED
- If you disagree with the final decision upon appeal, you
may seek
- legal assistance. You also may wish to get in touch with
the Department
- of Labor concerning your rights under ERISA.
- KNOW YOUR PLAN
- By carefully reading your summary plan description and
- understanding your relationship to your plan, you can be
an informed
- participant. So know your plan, what it requires of you,
how to become
- eligible for its benefits, and what steps you can take to
assure that you
- will receive your earned benefits.
- U.S. Department of Labor
- Pension and Welfare Benefits Administration
- Washington, D.C. 20210
- SUMMARY OF STEPS
- 1. File claim for benefits
- with person designated
- by plan to receive claims.
- Check your benefits with
- your plan administrator.
- 2. Benefits approved
- payment will be made.
- or
- 2. Wait for reasonable time,
- usually 90 days for outcome
- of claim If no decision and
- the plan did not extend the
- period based on special
- circumstances you may
- consider claim denied.
- 3. Request review of your
- claim. Explanation is
- required for a denied
- claim.
- 4. You may file claim for full
- and fair review Be sure and
- include all related
- information, especially new
- evidence or information.
- 5. If appeal review will take
- longer than 60 days you must
- be notified. Generally, a
- decision must be made within
- 120 days of your appeal.
- 6. If you have not received
- notice within time set, you
- can assume appeal denied You
- may seek legal assistance or
- you may wish to get in touch
- with the nearest PWBA office
- concerning your rights under
- ERISA.
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