If a claim for any insured benefit (for example, a claim for medical benefits
under Keystone Point of Service) is denied, in whole or in part, you may file a written
appeal with the applicable insurance company. Any claim relating to eligibility for coverage
under an insured benefit, however, may be appealed to the Fund Administrator as provided below.
If you claim for any non-insured benefit is denied, in whole or in part, of if you dispute whether or
not you are eligible to participate in an insured program, you may file a written appeal to
the Fund Administrator within 90 days of the date of the notice of denial. Furthermore,
any claim relating to
eligibility for coverage under the Fund ( with respect to insured or self-insured benefits) may also be
appealed in writing to the Fund Administrator within 90 days of the date of notice of denial of coverage.
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
decision, the Plan provisions on which the decision 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 maximum deference permitted by law. The Board's decision on
your appeal will be made in writing and is final and binding
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