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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.
.