HOW TO FILE A CLAIM FOR YOUR BENEFITS

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 employees 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.