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Defined Contribution Plan Document
Section 13: Claims Review and Appeals Procedure.
- No Participant, Annuitant, Beneficiary or other person shall have any
right or claim to benefits under this Plan, other than as specified in this
Plan. If any person shall have a dispute with the Trustees as to eligibility,
type, amount, or duration of such benefits, the dispute shall be resolved
solely by the Trustees under and pursuant to this Plan, and its decision of the dispute shall be final and binding upon all parties thereto, subject to
applicable federal law.
- Any person whose application for benefits under the Plan has been denied
in whole or in part, or whose claim to benefits or against the Fund is
otherwise denied, shall be notified in writing of such denial within 90
days after receipt of such application or claim. An extension of time not
exceeding 90 days may be required by special circumstances; if so, notice
of such extension, indicating what special circumstances exist therefor
and the date by which a final decision is expected to be rendered, shall be
furnished the claimant prior to the expiration of the initial 90 day period.
The notice of denial shall set forth in a manner calculated to be
understood by the claimant,
- The specific reason or reasons for the denial;
- Specific reference to pertinent Plan provisions on which the denial
- A description of any additional material or information necessary
for the claimant to perfect the claim and an explanation of why
such material or information is necessary;
- Appropriate information as to the steps to be taken if the claimant
wishes to submit his or her claim for review; and
- A description of the Plan's review procedures and time limits
applicable to such procedures, including a statement of the
participant's right to bring a civil action under ERISA Section
502(a) following exhaustion of the Plan's appeal procedures.
- Any such person may petition the Trustees for a review of the denial. A
petition for review shall be in writing, shall state in clear and concise
terms the reason or reasons for disputing the denial, shall be accompanied
by any pertinent documentary material not already furnished to the
Trustees, and shall be filed by the petitioner or his duly authorized
representative with the Trustees within 60 days after the petitioner
received notice of the denial. The petitioner or his duly authorized representative shall be permitted to review pertinent documents and
submit issues and comments in writing.
- Upon good cause shown, the Trustees shall permit the petition to be
amended or supplemented and shall grant a hearing on the petition before
a hearing panel to receive and hear any evidence or argument which
cannot be presented satisfactorily by correspondence. The failure to file a
petition for review within such 60 day period or the failure to appear and
participate in any such hearing, shall constitute a waiver of the claimant's
right to review of the denial, provided that the Trustees may relieve a
claimant of any such waiver for good cause if application for such relief
is made within one year after the date shown on the notice of denial.
- A decision by the Trustees shall be made promptly and not less than 60
days after the Trustees' receipt of the petition for review, unless special
circumstances require an extension of such time for processing, in which
case notice of such extension shall be furnished to the claimant prior to
the expiration of the 60 day period. A decision shall be rendered as soon
as possible, but no later than 120 days after receipt of the petition for
review. The petitioner shall be advised of the Trustees' decision in
writing. The decision shall include specific reasons for the decision,
written in a manner calculated to be understood by the petitioner and
specific references to the pertinent Plan provisions on which the decision
is based. The decision shall also include a statement that the claimant is
entitled to receive, upon request and free of charge, reasonable access to,
and copies of, all documents, records and other information relative to the
claimant's claim for benefits and a statement of the claimant's right to
bring a civil action under ERISA Section 502(a).
- The decision of the Trustees with respect to a claim or petition for
reconsideration shall be final and binding upon all parties, including the
petitioner and any person claiming under the petitioner. The provisions of
this section shall apply to and include any and every claim to benefits
from the Fund, and any claim or right asserted under this Plan or against
the Fund, regardless of when the act or omission upon which the claim is
- Entitlement to a Disability Benefit under the Plan, which is not based on a
Social Security Award but is based on competent medical evidence, is a "disability benefit" under Department of Labor Regulation Section
2560.503-1, and thus is subject to special claims and appeals procedures.
The Board of Trustees adopts the following changes to the claims and
appeals procedures for such disability benefits only:
- The Board of Trustees will notify the claimant of the Board's
adverse benefit determination within a reasonable period of time,
but not later than 45 days after receipt of the claim by the Board.
This period may be extended for up to 30 days, provided the Board
determines such extension is necessary due to matters beyond the
control of the Board and notifies the claimant (prior to the
expiration of the initial 45-day period) of the circumstances
requiring the extension and the date the Board expects to render a
decision. An additional 30-day extension is allowed, provided the
Board again determines it is necessary and notifies the claimant
(prior to the end of the first 30-day extension period). Any notice
of extension will specifically explain the standards on which
entitlement to a benefit is based, the unresolved issues that prevent
a decision on the claim, and additional information needed to
resolve those issues. The claimant will be afforded at least 45 days
to provide such information.
- A claimant for disability benefits will be allowed 180 days
following receipt of notice of an adverse benefit determination to
appeal the decision.
- Review of a claim for disability benefits will not afford deference
to the initial benefit determination. Review of a claim for
disability benefits upon appeal will continue to be made at regular
meetings of the Board of Trustees.