Section XI: Claim Procedures

Initial Claim for Benefits Other Than Disability Benefits:
The initial determination of benefits will be made within a reasonable period of time but not longer than 90 calendar days after the Administrative Office receives your application for benefits and all required information. (If all required information is not received with your application, and you are notified of this by the Administrative Office, the 90-day period for making the initial determination will be suspended during the time you are obtaining the additional information).

If the Administrative Office determines that special circumstances require an extension of time for processing your claim, the Administrative Office will notify you, in writing, prior to the expiration of the 90 days of the circumstances requiring the extension of time and the date by which the Plan expects to make a determination. The extension cannot be more than 90 calendar days from the end of the initial 90-day period.

Initial Claim for Disability Benefits:
The initial determination of benefits will be made within a reasonable period of time but not longer than 45 calendar days after the Administrative Office receives your application for benefits and all required information. (If all required information is not received with your application, and you are notified of this by the Administrative Office, the 45-day period for making the initial determination will be suspended during the time you are obtaining the additional information).

The initial 45-day period may be extended for up to 30 calendar days, to a total of 75 calendar days, if an extension is necessary due to matters beyond the Plan's control. The Administrative Office will notify you, in writing, prior to the expiration of the initial 45-day period of the circumstances requiring the extension of time and the date by which the Plan expects to make a determination.

If the Plan needs a second extension of time to make a determination due to circumstances beyond its control, you will be notified of an extension of up to 30 calendar days, or a maximum of 105 calendar days after the initial receipt of your application. Before the end of the first 30-day extension period, the Administrative Office will notify you, in writing, of the circumstances requiring the extension and will give you a new date by which a determination will be made.

Notice of Claim Denial
If the Plan denies your application for benefits, in whole or in part, you will be notified in writing of the determination and be given the opportunity for a full and fair review of the benefit decision. The written notice of denial shall include:

1. The specific reason(s) for the denial;
   
   
2. The specific reference to pertinent Plan provision(s) on which the denial is based;
   
   
3. A description of any additional material or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
   
   
4. A description of the Plan's review procedures and the time limits applicable to such procedures, including a statement of the your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review; and
   
   
5. For a claim for disability benefits only, the internal rule, guideline, protocol or other similar criterion, if any, relied upon in making the adverse determination and an explanation of the scientific or clinical judgment for the determination if based on medical necessity or other similar exclusion or limitation.

Right to Appeal
If you apply for benefits and your claim is denied, or if you believe that you did not receive the full amount of benefits to which you are entitled, you have the right to petition the Board of Trustees for reconsideration of its decision. Your petition for reconsideration:

1. Must be in writing; and
   
   
2. Must state in clear and concise terms the reason(s) for your disagreement with the decision of the Board of Trustees; and
   
   
3. May include documents, records, and other information related to your claim for benefits; and
   
   
4. Must be filed by you or your duly authorized representative with the Administrative Office within 60 calendar days after you received notice of denial. In the case of a claim for disability benefits, your petition for reconsideration must be filed with the Administrative Office within 180 calendar days after you received notice of denial. Failure to file an appeal within these time limits will constitute a waiver of your right to a review of the denial of your claim. A late application may be considered if the Board of Trustees finds that the delay in filing was for reasonable causes.

Upon request, you or your duly authorized representative will be provided, free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits, including identification of medical or vocational experts whose advice was obtained by the Plan in connection with your adverse benefit determination without regard to whether such advice was relied upon in making the determination. In the case of a claim for disability benefits, any statement of policy or guidance with respect to the Plan concerning the denial of disability benefits, without regard to whether such advice or statement was relied upon in making the benefit determination.

Review of Appeal
The Trustees are required to review your appeal and notify you in writing of their decision no later than 60 calendar days after your appeal is submitted (45 for disability benefits). The written notice of an adverse determination must include the reasons for the decision, the specific Plan provision on which the decision is based, a statement that you are entitled to receive upon request and free of charge access to copies of all documents and other relevant information regarding your claim, any additional appeal procedures available, and a statement of your right to bring a civil action under ERISA. The written notification of an adverse determination of a claim for disability benefits will also include the specific rule, guideline, protocol or other similar criterion, if any, relied upon in making the determination and an explanation of the scientific or clinical judgment for the determination if based on medical necessity or other similar exclusion or limitation.

In special circumstances additional time may be needed to handle your appeal. In such cases you will be notified of a delay in the decision and the reason for it. If an extension of time is necessary to review an appeal, the appeal will be decided within 120 calendar days after it is submitted. If an extension of time is necessary to review an appeal of a disability benefit claim, the appeal will be decided within 90 calendar days after it is submitted.

The Board of Trustees will review all submitted comments, documents, records and other information related to your claim, regardless of whether the information was submitted or considered in the initial benefit determination. The Board of Trustees will not give deference to the initial adverse benefit determination.

In deciding an appeal that is based in whole or in part on a medical judgment, the Board of Trustees will consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment. Such health care professional shall not be an individual who was consulted in connection with the initial adverse benefit determination, nor a subordinate of such an individual.

The Trustees have discretion to interpret Plan documents and to make any factual determinations relevant to your appeal. Their decisions are subject to review only for abuse of discretion. No legal action may be brought or maintained against the Plan more than 2 years after a claim has been denied.

If you are dissatisfied with the Trustees' decision on your appeal, you may request review by an arbitrator. You must submit your request for arbitration in writing within sixty (60) calendar days after you receive the Trustees' decision on your appeal. The arbitrator's decision is final and binding, except as otherwise required by law.

If you have questions concerning the appeal procedure, please write to the Administrative Office.