Benefits and Coverage

Claim Denial – Appeal Procedures/Claim
Claim Denial Procedures

Some or all charges sent in for a particular claim may be denied. For example, charges for telephone calls on a hospital bill are not covered and would be deducted from the bill. Some expenses may not be covered at all, others may be higher than the covered expenses for a particular procedure and the extra charges will be denied.

Appealing a Denied Claim. A claim is a request for a benefit by you, your covered dependents or a beneficiary. If a claim is denied in whole or in part, you or your beneficiary will receive a written explanation from the Plan Administrator.

Notice of Denial. The notice of denial will contain the specific reasons for the denial and will refer to applicable Plan provisions on which the denial is based. If any additional information or materials are necessary for you to complete the claims, the notice will contain a description of such information or materials, and an explanation of why such information is necessary. It will also explain the steps to take if you wish to submit the claim for review.

The Plan Administrator must give written notice of denial within 90 days after the appeal is filed, unless special circumstances require an extension of time. If such an extension is required, the Plan Administrator must notify you of this extension before the end of the initial 90-day period. The Plan Administrator's explanation will state the special circumstances requiring an extension of time and the date by which a decision on the claim can be expected. The date will not be more than 180 days from the date when the appeal was filed. If this notice of denial is not given within the time required, you may request a review under the following procedures.

Review Procedures

Application for Review. You or your authorized representative may request a review of the claim denial by filing a written application for review within 60 days after you receive the written notice of the denial. This application must be in writing, addressed to the TBT Board of Trustees. The Board of Trustees may consider a late application if it concludes the delay in filing was for reasonable cause.

Trustee Review. When the Board receives a written request for review, it will give the claim and its denial a full and fair review. This review will be made within 60 days, or within 120 days if there are circumstances requiring delay.

The decision of the Board of Trustees is final and binding on all persons, except in one circumstance. If the benefits involved are provided by an insurance company, insurance service, HMO or other similar organization, the Board of Trustees may permit this organization to conduct their review and make the decision.

Employees, dependent beneficiaries or other persons will not have any right or claim to benefits under the Plan other than as specified in policies or contracts approved by the Board of Trustees or in the rules and regulations of the Board, or in the written plan materials. Any concern regarding eligibility, type, amount or duration of benefits or any rights or claim to payments from the Plan shall be resolved by the Board following the Plan and Trust agreement and related policies and procedures. Any decision by the Board will be final and binding upon all parties, subject only to judicial review as provided by federal law.

Legal action may not be brought for benefits provided by the Plan, or to enforce any right under the Plan, until a claims appeal has been submitted to and determined by the Board of Trustees. And after that, the only action which may be brought is one to enforce the decision of the Board or clarify the rights of the claimant under the decision.

Right of Reimbursement

The TBT Board of Trustees reserves the right to recover claim payments under any of its Plans made on behalf of an employee or covered dependent if the Trust overpays a claim. In such cases, the covered person is obligated, as a condition of coverage under the Plan, to reimburse the Trust for the amount overpaid. If you or a dependent have been overpaid by the Trust and do not repay this amount to the Trust, the Trust may recover the overpayment by deducting it from any future benefit payments payable to you or assigned by you.