(from: U.S. Dept of Labor - Pension & Welfare Benefits Admin. 5/24/94
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.
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.
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
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
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
Written and produced by PWBA's Division of Public Affairs - 1991
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