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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.
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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.
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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.
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This folder outlines the steps you may take
to file a claim and what to do if you are denied benefits.
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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.
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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.
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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."
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But be sure to contact your plan administrator or other plan
official for complete information on filing a claim for your
benefits.
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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.
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Your claim may have been denied because you are not eligible
for benefits under the plan. Perhaps you haven't been a
participant long enough, or you are not the required age.
Perhaps you needed to file additional information about your
claim.
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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.
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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.
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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.
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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.
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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.
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-- Or --
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File claim for benefits with person designated by plan to
receive claims. Check your benefits with your plan
administrator.
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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.
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Request review of your claim. Explanation is required for
a denied claim.
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You may file claim for full and fair review. Be sure and
include all related information, especially new evidence or
information.
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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.
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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 EBSA office
concerning your rights under ERISA.
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