Circumstances Which May Result in the Denial or Loss of Benefits

The Trustees or their representatives are authorized to deny payment of a claim, and the reasons for denial may include one or more of the following:

  1. The person on whose behalf the claim was filed was not eligible for benefits on the date the expenses were incurred.
  2. The claim wasn't filed within the Plan time limits.
  3. The expenses that were denied are not covered under the Plan or were not actually incurred.
  4. The person for whom the claim was filed had already received the maximum benefit allowed for that type of expense during a stated period of time.
  5. No payment, or a reduced payment, was made because some or all of the expenses for which the claim was filed were applied against a deductible.
  6. A third party (such as the driver of a car that caused an accident for which medical expenses were incurred) was responsible for paying the incurred medical expenses and you or your dependent did not comply with the rules governing third party liability claims (see Subrogation and Repayment Agreement and Payment of Benefits for Compensated Injuries starting on page 83).
  7. Another plan was primarily responsible for paying benefits for the expenses (see Coordination of Benefits).
  8. The Trustees amended the Plan eligibility rules or decreased Plan benefits.
  9. The Trustees reduced or temporarily suspended future benefit payments to a family member in order to recover an overpayment of benefits previously made on that person's behalf.
  10. Your employer terminated contributions to Lineco, either because he did not enter into a successor collective bargaining agreement requiring contributions to the Fund, or because his participation agreement providing for contributions to the Fund was terminated.
  11. The Plan of Benefits was terminated.

The preceding list is not an all-inclusive listing of the circumstances which may result in denial or loss of benefits. It is only representative of the types of circumstances, in addition to failure to meet the regular eligibility requirements, that might cause denial of a claim for benefits. If you have any questions about a claim denial, contact the Fund Office.