Initial Claim Determinations

The Claims Administrator has full discretion to deny or grant a claim in whole or in part. Such decisions will be made in accordance with the governing Fund documents, and where appropriate, Fund provisions will be applied consistently with respect to similarly situated claimants in similar circumstances. The Claims Administrator will have the discretion to determine which claimants are similarly situated in similar circumstances.

How and when claims are processed depends on the type of claim it is. Most claims under the Fund that are required to be submitted to the Administrative Office are post-service health care claims. Most other claims under the Fund will also be post-service health care claims.

Post-Service Health Care Claims

• A post-service claim is a claim for benefits after services or treatment have been provided.
• The Claims Administrator will notify the claimant of a denial within a reasonable period of time but not later than 30 days after receipt of the claim, unless an extension of 15 days is necessary due to circumstances beyond the Fund's control. If the reason for the extension is because the Claims Administrator doesn't have enough information to decide the claim, the notice will describe the required information, and the claimant will have 45 days from the date he/she receives the notice to provide the necessary information.