Department of Labor (DOL) Claims & Appeals

In accordance with federal law, the Electrical Welfare Trust Fund maintains  “Claims & Appeals Procedures” designed to simplify for participants the handling of claims. In addition, if the participant’s claim has been denied, these procedures help to explain the participant’s right to appeal the denial of the claim.

Claims Generally

EWTF requires that a written claim for benefits be made either by you or a representative authorized by you. Often, a claim will be filed by your doctor’s office staff, particularly if your doctor is a member of OneNet Preferred Provider Network.

Under the Plan of Benefits adopted by the Board of Trustees, only certain medical and related benefits are payable.  Some medical treatment falls outside the scope of the Plan of Benefits approved by the Board of Trustees and will, therefore, not be paid by the Fund.

Furthermore, in order to qualify for coverage under the Plan of Benefits, a participant or beneficiary must be “eligible”. If a participant or beneficiary loses eligibility, then later claims or benefits will not be allowed under the terms of the Fund.  The definition of Beneficiary, for the purposes of this section, is a spouse or dependent.

Furthermore, claims presented to the Fund are only payable if the participant or beneficiary follows the Fund rules for submission of claims.  These rules are set forth in your Summary Plan Description.

Finally, certain benefits are payable under the terms of the Fund only if they are medically appropriate, which may depend upon the medical opinions and judgment of doctors. The Board of Trustees may consult with doctors from time to time to determine whether certain medical treatment is covered as medically necessary or otherwise appropriate medical treatment under the terms of the Fund.

Questions

What is a “claims denial” or an “adverse benefit determination”?

Some claims may be paid in full when presented, because they are covered by the terms of EWTF and because they meet all of the foregoing conditions. Other claims may be denied in whole or in part either because the claim involves medical treatment not covered by the Fund or for one of the reasons set forth in the previous paragraph. Also a claim may be paid only in part because the Plan of Benefits only covers a portion of the claim, such as 80% of major medical benefits, or because your deductible must be used to pay part of the claim. If a claim is denied in whole or in part, that is known as a “claim denial” or an “adverse benefit determination.” If you receive a claim denial or an adverse benefit determination you are entitled to begin the appeal process provided by the Fund that is described above, and you are also entitled to be advised of the Fund’s appeal procedures and other information which may be necessary or helpful to you presenting your appeal.

Can the Fund charge me a fee to make a claim determination?  Am I required to submit to arbitration or mediation?

There are certain things EWTF cannot and does not require of its participants and beneficiaries (spouses and dependent children). Some of these are as follows:

  • The Fund cannot and does not charge a fee to a participant or beneficiary to submit a claim or an appeal.
  • The Fund cannot use the claims or appeal procedure, in any way, to prohibit you from or make it difficult for you to present your claim for benefits or your appeal of a denial of benefits.
  • The Fund will not restrict your ability to authorize someone else to act on your behalf to present your claim or appeal.
  • The Fund will not withhold important information that was used to address your claim or appeal from you.
  • The Fund cannot require you to undertake arbitration or mediation in order to seek your entitlement to benefits.
  • The Fund will not require you to undertake more than 2 levels of appeal before you can present your claim to a court, if you should seek to do so.
  • The Fund will not restrict your ability to go to court to seek to obtain benefits following a denial of your claim and your appeals.

What information will I be provided if my claim is denied?

If the claim of a participant or beneficiary is denied in whole or in part, the EWTF, will provide to the participant or beneficiary a written notice that the claim has been denied.  This notice will include information making clear to you:

  • which claim is being denied;
  • a specific reason or reasons for the full or partial denial of your claim;
  • an explanation of the EWTF provision upon which the full or partial denial was based;
  • a description of any additional material or information needed in order for the participant or beneficiary to perfect the claim, with an explanation of why that material is necessary.
  • a description of the appeal and review procedure for the participant or beneficiary to follow in bringing an appeal, along with an identification of the time limits applicable to those procedures;
  • an explanation of the participant’s or beneficiary’s right to bring a lawsuit under the statute following the denial of benefits in part or in full following the appeal period;
  • if an internal rule or guideline was relied upon, information about that guideline; and
  • if the full or partial denial was based upon issues, such as medical necessity, experimental treatment or similar medical issues, an explanation of why the claim was denied, included an explanation of the Fund’s rationale in making that determination.

Can the Fund make a determination to stop covering benefits after a course of treatment has begun?

It would be unusual for the Fund to make a decision to stop coverage of benefits once a course of treatment has begun.  But if the Fund has approved an ongoing course of treatment to be provided over a period of time or a number of treatments, any reduction or termination by the Fund for this ongoing treatment must be communicated to you in a way to give you time to appeal the decision before the time the treatment is to be terminated or reduced.  Under these circumstances, the Fund will decide your appeal as soon as possible.  If the issue involves urgent care, the decision will be made within 24 hours, provided the request has been made at least 24 hours before the treatment was to be terminated or reduced.

How will the EWTF handle my appeal?

The Fund will consider any additional information you have provided with your appeal.  Your appeal will be reviewed by someone other than the person who made your initial benefit determination and will not be made by an individual under the authority or control of the person who made your initial determination.  If the issues of your appeal involve medical issues, the Fund will consult with a healthcare professional that has appropriate training in the relevant field of medicine involving medical judgment. Any healthcare professional engaged for this purpose will be a different person than the person who made the initial benefit determination and will not be a subordinate of that person.  If the Fund decides to use medical or vocational experts in considering your appeal, you will be notified of the name and address of those individuals, even if the Fund does not rely upon their advice in making a determination.

Can I provide additional information for my appeal?

Yes, you may submit additional medical information or additional factual statements of your own or from other individuals that you believe may help the Fund decide the issues involving your appeal.

If my appeal is denied, what will the Fund tell me?

If your appeal is denied in whole or in part, you will be provided with sufficient information in order to understand how your appeal is being resolved.  This will include at least the following information:

  1. You will be given the specific reason or reasons your appeal is being denied in whole or in part.
  2. You will receive a reference to the specific provisions of the Fund upon which the determination has been made.
  3. You will receive a statement that you are entitled to receive upon request, and free of charge, access to and copies of all documents, records and other information relevant to your claim.
  4. You will be advised as to any voluntary appeal procedures that may be available to you.
  5. You will be provided with information regarding any internal rules, guidelines or protocols used in evaluating your claim.
  6. If your appeal was denied based upon medical issues, you will be provided an explanation as to why that determination was made.
  7. A statement that you will have the right to bring an action under the Employment Retirement Income Security Act of 1974, as amended, pursuant to §502(a) of that statute.

Can I make an appeal directly to the Board of Trustees?

It is the policy of the Board of Trustees that it will always entertain an appeal from a participant of the full or partial denial of benefits.  Although the initial appeals are generally handled by the Fund, either alone or in consultation with medical experts or third-party advisors in the appropriate medical field and familiar with the Plan of Benefits, a participant may always appeal a denial of benefits directly to the Board of Trustees. The full Board of Trustees will act upon any appeal in a manner consistent with these claims and appeal procedures.

Where else can I obtain additional information?

It is the policy of the Board of Trustees that participants should fully understand their rights to benefits under the EWTF and should be given every reasonable and fair opportunity to make appeals and present their position regarding entitlement to benefits.  If you have questions, please review your Summary Plan Description.  If you do not have a Summary Plan Description, please contact the Fund Office and you will be provided with a copy free of charge.  If you still have questions, please email or call Fund Office at (301) 731-1050 and your questions will be answered as promptly as reasonably possible.  If you have additional questions, you may submit them in writing to the Fund and you will receive a written response.

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