UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Appealing a Denied Claim

If a claim for medical benefits under the Keystone Point of Service Program is denied, in whole or in part, you may file a written appeal with Keystone (referred care) or QCC (self-referred care), subsidiaries of Independence Blue Cross. If you are not satisfied with the final decision with respect to your claim, you may file a written appeal to the Fund Administrator as provided below. Please note, however, that any claim directly relating solely to eligibility to participate in the Fund or one of its programs should be appealed to the Fund Administrator as provided below. If your claim for any other benefit is denied, in whole or in part, or if you dispute whether or not you are eligible to participate in any program under the Fund, you may file a written appeal to the Fund Administrator within 90 days of the date of the notice of denial. The Fund Administrator will respond with a written notice within 60 days of receipt of your appeal, stating whether the appeal is approved or denied. This notification will include the specific reasons for the decision, the Plan provisions on which the decision is based, the information needed to complete the claim, and the reasons why this information is needed. The notice will also explain the Plan's claim review procedures. If you are not satisfied with the Fund Administrator's decision regarding your claim appeal, you may request a review of the Fund Administrator's denial. The review will take place at the next regularly scheduled Board of Trustees' meeting, if possible. However, the review must take place within 120 days after the Board receives your written request for a review. You or your representative has the right to review pertinent Plan documents and submit a written statement in support of your claim. However, the Board of Trustees has discretionary power and authority to make benefit eligibility determinations, to construe the terms of the Plan, and to determine your rights under the Plan. Its decisions are entitled to the maximum deference permitted by law. The Board's decision on your appeal will be made in writing and is final and binding.