CLAIM AND APPEAL PROCEDURES

Claim Processing Procedures

When used in the following explanation, the term “Plan office” means the office or organization designated by the Trustees for handling claims.

When you file a claim for benefits, be sure to follow the proper claim filing procedures. The Fund Office receives claims during regular business hours Monday through Friday. If you or your medical provider is requesting precertification of a claim that requires you to get approval from one of the Plan’s review organizations, you must follow the rules and time frames for precertifying the proposed treatment. The Plan’s claim filing procedures are described on page 13. Claims must be submitted within two years after the date the claim is incurred.

Claim Processing Time Limits - The amount of time the Plan office can take to process a claim depends on the type of claim. A claim can fall into one of the following categories:

If all the information needed to process your claim is provided to the applicable Plan office, your claim will be processed as soon as possible. However, the processing time needed will not exceed the time frames allowed by law, which are as follows:

You may have an authorized representative act on your behalf, although the Plan office may verify that the person has been so authorized. However, in connection with an urgent care claim, the Plan will recognize a health care professional with knowledge of your medical condition as your representative.

When Additional Information Is Needed - If additional information is needed from you, your doctor or the medical provider, the necessary information or material will be requested in writing. The request for additional information will be sent within the normal time limits shown above. When the additional information needed to decide an urgent care claim is requested orally, it will be requested within 24 hours.

It is your responsibility to see that the missing information is provided to the Plan office that requested it. The normal processing period will be extended by the time it takes you to provide the information, and the limit will start to run once the Plan office that requested the information has received a response to its request. If you do not provide the missing information within 48 hours for an urgent care claim or 45 days for any other claim, the Plan office will make a decision on your claim without it, and your claim could be denied as a result.

Plan Extension -The time periods above may be extended if the Plan office determines that an extension is necessary due to matters beyond its control (but not including situations where it needs to request additional information from you or the provider). You will be notified prior to the expiration of the normal approval/denial time period if an extension is needed. If an extension is needed, it will not last more than:

Claim Denials

If all or a part of your claim is denied, you will be sent a written notice giving you the reasons for the denial. The notice will include reference to the Plan provisions on which the denial was based and a description of the claim appeal procedure. If applicable, it will give a description of any additional material or information necessary for you to perfect the claim, and the reason such information is necessary. The notice will provide the applicable time limits for following the procedures, including a statement of your right to bring a civil action under section 502(a) of ERISA following the denial of an appeal. If the Plan relied upon an internal rule, guideline, protocol or similar criterion to make its decision, the denial notice will state that the Plan will provide you with the specific internal rule, guideline, protocol or criterion used upon request free of charge. If the decision was based on medical necessity or if the treatment was deemed experimental, the notification will include either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request. For urgent claims, a description of the Plan’s expedited review process will be provided.

Claim Appeal Procedures

Requesting a Review - If you have an urgent care claim you may orally request that the Claim Review Committee review the decision by calling the Lineco Fund Office at 1 (800) 323-7268. You may also submit your request in writing to the Claim Review Committee at the address shown below.

If you have a concurrent care claim and the Plan office terminates or reduces a previously approved period of treatment, you will have the right to appeal that termination or reduction. You will be given advance notice of the termination or reduction and allowed to appeal the determination before the termination or reduction. The rule allowing the treatment to continue pending an appeal does not apply if your benefits terminate because you have lost eligibility under the Plan or if the termination or reduction is the result of a Plan amendment.

For all other claims, if you want the Claim Review Committee of the Board of Trustees to review your claim after a denial of benefits, request a claim review form from the Fund Office. When you receive the form, fill it in completely. Attach any additional information that you think will help a favorable decision to be made on your claim. Return the completed form within 180 days after the date the denial was mailed to you to:

Claim Review Committee
Line Construction Benefit Fund
2000 Springer Drive
Lombard, IL 60148

You can authorize someone else to file your request for review and otherwise act for you. You and/or your representative can review materials in the Plan’s files that are related to your claim. You and/or your representative can submit written issues and comments to support your request for review. You can also make a written request for a personal appearance (by you and/or your representative) before the Claim Review Committee. If you and/or your representative do so, it must be done at your own expense.

Full and Fair Review - The Claim Review Committee will conduct a full and fair review of all the material submitted with your claim, the action taken by the Plan office, the additional information you have provided, and the reasons you believe the claim should be paid. The review will be conducted by an appropriate named fiduciary who is neither the party who made the initial adverse determination, nor the subordinate of such party. It will not afford deference to the initial adverse benefit determination, and will take into account all comments, documents, records and other information submitted by you, without regard to whether such information was previously submitted or relied upon in the initial determination.

You have the right, upon request and free of charge, to have copies of all documents, records and other information relevant to your claim for benefits.

With respect to a review of any determination based on a medical judgement, the Claim Review Committee will consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgement. Such health care provider will be “independent,” which means the person consulted will be an individual different from, and not subordinate to, any individual who was consulted in connection with the initial decision.

Notification Following Review - If your appeal is for an urgent care claim, you will be notified of the Claim Review Committee’s decision about your appeal as soon as possible, taking into account the medical circumstances, but not later than 72 hours after receipt of your request for review. In the case of pre-service claims, you will be notified no later than 30 days after receipt of your request for review.

A review and determination for disability and post-service claims will be made no later than the date of the meeting of the Claim Review Committee that immediately follows the Plan’s receipt of a request for review. The Committee generally meets on a quarterly basis in the months of March, June, September and December. If your request for review has been received by the Committee at least 30 days before its next scheduled meeting, a decision on your request for review will normally be made at the next quarterly meeting. If your request for review is not received by the Committee at least 30 days before the next scheduled meeting date, the decision may be delayed one additional quarter. In addition, in unusual circumstances, the decision may be delayed until the third meeting of the Committee after it has received your request for review. If such circumstances require such a delay, you will be informed.

If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, a determination will be rendered not later than the third meeting of the Claim Review Committee. Before the start of the extension, you will be notified in writing of the extension, and that notice will include a description of the special circumstances and the date as of which the determination will be made.

After a decision has been made on a disability or post-service claim, you will be informed in writing of the Claim Review Committee’s decision, normally within 5 calendar days of the review. When you receive the decision on your appeal, it will contain the reasons for the decision and specific references to the particular Plan provisions upon which the decision was based. It will also contain a statement explaining that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to you claim; a statement describing any voluntary appeal procedures offered by the Plan and your right to obtain the information about such procedures; and a statement of your right to bring an action under section 502(a) of ERISA. If one was used, you will also be informed of the specific internal rule, guideline, protocol or similar criterion relied on to make the decision free of charge upon request. If the decision was based on a medical judgment, you will receive an explanation of that determination or a statement that such explanation will be provided free of charge upon request.

If the Plan fails to make timely decisions or otherwise fail to comply with the applicable federal regulations, you may go to court to enforce your rights.