Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

DENIAL OF CLAIMS AND PROCEDURES FOR APPEAL

The following procedures will apply to all claims for benefits and appeals of adverse determinations on claims for benefits filed under the Plan (including hospital and major medical benefits, dental benefits and optical benefits). Please be aware that references to GHI in this section refer to the claims and appeals procedures for hospital and major medical benefits, as all initial appeals of a claim for hospital and major medical benefits will be handled by GHI. However, your should be aware that all initial appeals of a claim for dental benefits are handled by Dentplex and all initial appeals of optical benefits and death benefits will be handled by the Fund Office. If you have any questions about these procedures, please contact the Plan at 44-61 11th Street, 3rd Floor, Long Island City NY 11101 (718)-609-6401.

Please keep in mind that a claim for benefits is a request for Plan benefits made in accordance with these claims procedures and requires submission of a written claim form. Simple inquiries about the Plan’s provisions or eligibility that are unrelated to any specific benefit claim will not be treated as claims for benefits for purposes of these procedures. In addition, a request for prior approval of a benefits claim that does; not require prior approval by the Plan is not a claim for benefits for purposes of these procedures.

In the event that a Participant (claimant) is denied a benefit or claim, in whole or in part, the following notice and appeal procedure will be followed:

General Information

You may file claims for benefits under the Fund, and appeal adverse benefit decisions, either yourself or through an authorized representative. An “authorized representative” means a person you authorize, in writing, to act on your behalf. The Fund and GHI will also recognize a court order giving a person authority to submit claims on your behalf. In addition, in the case of a claim involving urgent care, a health care professional with knowledge of your condition may always act as your authorized representative. If your claim is denied in whole or part, you will receive a written notice of the denial from ,GHI which notice will explain the reason for denial and the review procedures described in detail below.

Timing of Initial Claim Determinations

Pre-Service Claims

A “pre-service claim” is any claim for a health benefit under the Fund that must be approved (in whole or in part) before you can receive the medical service, supply or procedure.

If you file a pre-service claim, GHI will notify you of the benefit determination no later than 15 days after receipt of your claim. If GHI determines that an extension of time is necessary due to matters beyond the control of the Fund, this period may be extended for up to an additional 15 days. You will be notified of the extension before the initial 15-day period expires, and the notice will describe the circumstances requiring the extension and inform you of the date by which GHI expects to make a decision on your claim. If the extension is necessary because you failed to submit information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will have an additional period of at least 45 days from your receipt of the notice to provide the requested information. You will be notified of GHI’s claim decision no later than 15 days after the end of that additional period (or after receipt of the information, if earlier).

If you (or your authorized representative) fail to follow the Fund’s procedures for filing a pre-service claim, you (or your representative) will be notified of the failure and the proper procedures to follow. You (or your authorized representative) will be provided with this notification within 5 days following the procedural failure. This notification may be oral, unless you (or your representative) request written notification. You will only receive notification of a procedural failure if your claim is received by Aetna and it includes: (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested.

Post-Service Claims

A “post-service claim” is any claim for a health benefit that is not deemed a “pre-service claim” (as defined above). These are claims for which you do not need advance approval before receiving medical care.

If you file a post-service claim, GHI will notify you of an adverse benefit determination no later than 30 days after receipt of your claim. If GHI determines that an extension of time is necessary due to matters beyond the control of the Fund, this period may be extended for up to an additional 15 days. You will be notified of the extension before the initial 30-day period expires, and the notice will describe the circumstances requiring the extension and inform you of the date by which GHI expects to make a decision on your claim. If the extension is necessary because you failed to submit information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will have an additional period of at least 45 days from your receipt of the notice to provide the requested information. You will be notified of GHI’s claim decision no later than 15 days after the end of that additional period (or after receipt of the information, if earlier).

Urgent Care Claims

An “urgent care claim” is a claim for medical services with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or, in the opinion of a physician with knowledge of the claimant’s medical conditional would subject the claimant to severe pain that cannot be adequately managed without the prompt care or treatment that is the subject of the situation.

If you file an urgent care claim, GHI will notify you of the benefit determination as soon as possible, taking into account medical exigencies, but no later than 72 hours after receipt of your claim. However, if you fail to provide sufficient information in order for GHI to decide the claim, you will be notified within 24 hours after receipt of your claim of the specific information necessary to complete the claim. You will then have a period of no less than 48 hours, taking into account the circumstances, to provide the specified information to GHI. GHI will then notify you of the benefit determination no later than 48 hours after the earlier of (i) GHI’s receipt of the specified information, or (ii) the end of the period afforded to you to provide the specified additional information.

If you (or your authorized representative) fail to follow the Fund’s procedures for filing an urgent care claim, you (or your authorized representative) will be notified of the failure and the proper procedures to follow. You (or your authorized representative) will be provided with this notification within 24 hours following the procedural failure. This notification may be oral, unless you (or your representative) request written notification. You will only receive notification of a procedural failure if your claim is received by GHI and it includes: (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested.

Concurrent Care Claims (Ongoing Course of Treatment)

A concurrent care claim is a claim relating to an ongoing course of treatment approved by the Fund, which you have been receiving over a period of time or for a specified number of treatments. If you are receiving concurrent care benefits and a decision has been made to reduce or terminate benefits for the course of treatment before the end of the previously approved treatment period (other than by plan amendment or termination), you will be notified sufficiently in advance of the reduction or termination to allow you time to request a review of the decision and obtain a determination upon review before the benefit is reduced or terminated.

If the course of treatment involves urgent care, and you request an extension of the course of treatment at least 24 hours before its expiration, you will be notified of the decision within 24 hours after receipt of the request.

Notice of Initial Claim Determinations

If your claim is denied, in whole or in part, or any other adverse benefit determination has been made, GHI will notify you (or your authorized representative) of the benefit determination in writing within the time periods described above. This notification will include:

• the specific reason(s) for the denial or other adverse benefit determination;
• references to the specific plan provisions on which the determination was based;
• a description of any additional material or information necessary for you to complete your claim, and an explanation of why that material or information is necessary; and
• a description of the Fund’s review procedures and the applicable time limits.

If your claim involves urgent care, the notification will also include a description of the expedited review process that applies to those types of claims. In addition, for urgent care claims, the notification may be provided to you orally within the 72-hour time frame described above, but written notification will also be furnished to you within 3 days of the oral notification.

Requests for Review of Claim Denials and Other Adverse Benefit Determinations

If your claim is denied, in whole or in part, or any other adverse benefit determination has been made, you have the right to request a review of that determination. In order to do so, you (or your authorized representative) must, within 180 days after you receive the notice of denial, submit your written request for review to GHI. In connection with your request for review, you (or your authorized representative) may submit written comments, documents, records or other information relating to your claim. A copy of the specific rule, guideline, or protocol relied upon in the adverse benefit determination will be provided free of charge and upon request by you or your authorized representative. In addition, you may request (in writing) that the Fund provide you, free of charge, with reasonable access to (and copies of) all documents, records and other information relevant to your claim. The review will take into account all comments, documents, records and other information that you submit relating to your claim.

Please note that, upon receipt of a request for review,GHI will first review its initial decision to deny the claim and will determine whether there are reasons to change the denial decision. If the denial is not reversed by Aetna, the request for review will then be forwarded to the Fund’s Board of Trustees for final decision.

NOTE: If your claim involves urgent care, an expedited review process will be available to you, pursuant to which you may request an expedited review either orally by telephoning GHI ’s Member Services (at the telephone number on your Identification Card) or in writing. All necessary information, including the determination on review, will be exchanged between GHI (or the Fund Office) and you (or your authorized representative) by telephone, fax or other similar methods. You will receive a detailed description of the expedited review process in the notice of claim denial that is sent to you. You will be notified of the decision not later than 36 hours after the appeal is received.

Timing of Benefit Determinations On Review

Pre-Service Claims

If you request a review of a pre-service claim, you will be notified of the decision on review no later than 30 days after GHI receives your request for review.

Post-Service Claims

If you request a review of a post-service claim, the decision on review will be made by no later than the date of the meeting of the Board of Trustees immediately following GHI’s receipt of your request for review, unless the request is received within 30 days of the meeting, in which case the determination will be made by no later than the date of the second meeting following GHI’s receipt of the request. If it is determined that special circumstances require an extension of time for processing the request for review, then the decision on review will be made by no later than the third meeting following receipt of the request for review. You will be notified of the extension in writing before the extension period begins, and the extension notice will indicate the special circumstances requiring the extension as well as the date by which the Board of Trustees expects to make the determination on review. You will be notified of the determination on review within 5 days after the determination is made.

If an extension is required due to your failure to submit information necessary to decide the claim, the period for making the determination on review will be tolled from the date on which the extension notice is sent to you until the earlier of: (i) the date on which you respond to the request for additional information, or (ii) expiration of the 45-day period within which you must provide the requested additional information.

Urgent Care Claims

If you request a review of an urgent care claim, you will be notified of the decision on review no later than 72 hours after GHI receives your request for review. If you are dissatisfied with the appeal decision on a claim involving urgent care, you may file a second level appeal with Aetna. You will be notified of the decision not later than 36 hours after the appeal is received.

Concurrent Care Claims

If you request a review of a decision denying your request to extend a course of treatment, you will be notified of the decision in accordance with the above rules for pre-service, post-service or urgent care claims, as applicable.

If you request a review of a decision to reduce or terminate a course of treatment before the end of the previously-approved period or number of treatments, you will receive a decision on review before the benefit is reduced or terminated.

Notice of Benefit Determinations on Review

You will be notified in writing of the determination on review. If an adverse benefit determination is made on review, the notice will include the specific reason(s) for the determination, with references to the specific plan provisions on which it is based. All decisions on review are final and binding on all parties.