Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

HOW TO CLAIM BENEFITS UNDER THIS PLAN

A. HOW TO CLAIM HOSPITAL AND MAJOR MEDICAL BENEFITS

If you use a Network provider, you will not have to submit any paperwork to file your claims. You should just present your GHICard at the time of service. You must present your Identification Card at each visit to assure that your claims are filed properly. You should contact the Fund Office if you have not received or cannot locate your GHI Card.

The Fund has retained Group Health Insurance (GHI) to serve as a claims processor for all medical and hospital bills. All claims should be submitted to GHI, and will be considered submitted upon presenting your GHI Card at the time of service.

If you use an out-of-network Physician, Hospital or other health care provider, you must file a claim form with the GHI along with your original statements or bills from the provider (your provider may send these documents on your behalf). The name of the insured and patient must be clearly indicated on both the claim form and any attached statements. Claim forms may be obtained from Aetna or you may submit a universal (HCFA) claim form prepared by the provider if it is signed by you. Statements from Physician, surgeons, anesthesiologist, or Hospitals can be attached to the claim form. Complete itemization of services, including CPT codes, ICD codes and a detailed diagnosis is required for each claim. Return the claim form and all bills to the Fund Office with the name of the insured and patient clearly indicated on each. While all the charges may not be considered as Covered Expenses, you should submit all your bills so that they can be properly reviewed.

You can be assured of quicker payment of benefits if bills are complete and correct before you submit them. It is important that you retain a copy of all receipts for all submitted claims. Original bills are the "evidence" needed to pay a claim.

The Fund will pay approved claims directly to you or, if specified, to your service provider. In most cases, Hospital bills are sent by the Hospital directly to GHI, and payment of approved claims are submitted directly to the Hospital with an explanation of denied claims. You will also receive an explanation of benefits for all claims that are paid or denied.

The Fund reserves the right to determine what proof is necessary to determine whether the medical expenses for which claim is made were actually incurred and on the dates specified. The Fund further reserves the right to require a medical examination, by a Physician of its choosing, of a participant or beneficiary whose injury or sickness is the basis for a claim, when and as often as it may be reasonably required.