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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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| How to File a Claim |
To file a claim for Weekly Accident and Sickness Benefits, contact the Fund office
for a green claim form. You and your
doctor must complete the form and return it to the Fund office within the later
of 40 days from the date you last worked
or 40 days from the date you were released from the hospital.
It is your responsibility to notify your
employer of your accident or sickness immediately so that your employer can
complete the Health and Accident Report form (blue form) and return it to the
Fund office within four days of your absence due to the disability.
If the forms are not submitted within these
time frames, the Plan may deny your claim. Workers’ Compensation Supplementary Benefits If you are unable to work because of an occupational or job-related sickness, accident or injury, you are eligible for Workers’ Compensation Supplementary Benefits for up to a maximum of 26 weeks. This program supplements Workers’ Compensation - your employer provides your actual Workers’ Compensation coverage. You receive Workers’ Compensation claim forms and file your claim through your employer, not through the Fund office. Workers’ Compensation Supplementary Benefits are calculated the same as Weekly Accident and Sickness Benefits. However, the amount you receive from Workers’ Compensation is subtracted from your payment. No compensation is paid during the first seven days after the disability begins. If the disability lasts fourteen days or more, compensation will be paid retroactively for the first seven days of the disability. The waiting period is based on calendar days, not work days, so weekends are included. Let's go back to the example in the previous section and assume you were eligible for a benefit of $320 each week, based on your regular pay rate. Let's also assume that Workers' Compensation pays you $250 per week. You would receive a payment of $320 minus $250, or $70 per week from the Workers' Compensation Supplementary Benefit Program. In addition, if your claim for Workers’ Compensation benefits is denied, the Supplementary Benefit plan will pay benefits up to the maximum of 66 and 2/3 percent of your regular weekly salary. You must file an appeal with Workers’ Compensation if your claim is denied, and you must keep the Fund office notified of the status of that appeal. To qualify for benefits, you must submit the Workers’ Compensation denial and sign a reimbursement and subrogation agreement. This agreement states that you agree to reimburse the Plan for benefit payments if you receive payments from another source. If you do not sign a reimbursement and subrogation agreement, you will not be eligible for any payments under the Plan. |