If your claim is denied, in whole or in part, the Fund Office will provide you with an explanation of benefits which sets forth the reasons for the denial.
If benefits are denied, in whole or in part; if you disagree with a Fund policy, determination or action in whole or in part; if you have a question concerning your claim; or if you have been adversely affected by an action or decision of the Board of Trustees, here is what you (or your representative) should do:
- Before using the toll free number to call the Fund Office, review your claim worksheets and medical bills carefully.Make certain that the Fund Office has received all medical bills for your claim. If you still have a question concerning your claim, use the toll free number (800) 638-2603 and discuss your claim problem with a Claims Representative. The Claims Representative can also refer you to any pertinent Plan provisions or a description of any additional material or information which might help your claim, and explain why that information is necessary.
- If you are still not satisfied or if you have further questions, talk to the Claims Manager or the Fund Administrator either on the toll free number or write a letter explaining your problem. You will be advised in writing of the results of their investigation.
- If you are still not satisfied with the Claim Manager’s or the
Administrator’s report to you, you may request the Board of
Trustees to review your benefit denial or the Fund policy,
determination or action with which you disagree, by submitting
a written appeal to the Trustees. Your written appeal must
be submitted within 60 days of receiving the report of the
Claims Manager or Administrator, or within 60 days after you
learn of a Fund policy determination or action with which you
disagree and which is not a benefits denial.
Your appeal should be sent to:
Appeals Committee of the Board of Trustees
National Automatic Sprinkler Metal Trades Welfare Fund
8000 Corporate Drive
Landover, MD 20785
Your written appeal should state the reason for your appeal. This does not mean that you are required to quote all applicable Plan provisions or to make “legal” arguments; however, you should state clearly why you believe you are entitled to the benefit you claim or why you disagree with a Fund policy, determination or action. The Trustees can best consider your position if they clearly understand your claims, reasons and/or objections.
The Trustees or a designated committee of the Trustees will review your appeal at their quarterly meeting immediately following the receipt of your appeal unless your appeal was received by the Fund Office within 30 days of the date of the meeting. In this case, your appeal will be reviewed at the second quarterly meeting following receipt of the appeal. You may wish to contact the Fund Office concerning the date of the next meeting so that you may submit your appeal in time to be heard at that meeting. If special circumstances require an extension of the time for review by the Trustees or the committee, you will be notified in writing.
You will receive written notice of the decision of the Trustees or committee promptly following their review. The notice will explain the reasons for the decision, will include specific references to Plan provisions on which the decision is based, and may indicate if additional information might help your claim.
You may renew your appeal if you have any additional information or arguments to present. A renewed appeal must be submitted in writing, and the rules and time limits stated above apply.
In connection with an appeal or renewed appeal, you may review pertinent documents in the Fund Office after making appropriate arrangements or you may request that documents be provided to you. The Fund may charge $.25 per page to provide documents to you and this amount must be paid in advance.
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