C. NOTICE OF CLAIM DENIAL

If a claim is wholly or partially denied, the claimant shall receive a written notice of denial as follows:

1. Contents of Notice.

The notice of denial shall contain the following, written in a manner calculated to be understood by the claimant:

1. the specific reason or reasons for the denial;


2. specific reference to pertinent Plan provisions on which the denial is based;


3. a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and


4. appropriate information as to the steps to be taken if the claimant wishes to submit the claim for review.

2. Time of Notice.

To assure that you are eligible for medical or Hospital benefits, you should call or have your Physician /Hospital call the Plan Office at (415) 263-3670 to pre-certify your eligibility for benefits. In the event that you do not obtain pre-certification and the Plan Office determines that a Claim is not covered for any reason, you will be notified of a Claim denial:

1. Urgent Care Claims. In the event the claim involves “Urgent Care”, which is defined above in B.2(a)(i), you will be notified within twenty-four (24) hours of the submission of the Claim, if the information necessary to process the claim is incomplete, and/or within seventy-two (72) hours of receipt of the Claim by the Plan Office in the event coverage is denied.


2. Pre-Service Claims. A Pre-Service Claim is a Claim for a benefit for which the Plan requires pre-certification or prior authorization before medical care is obtained as a condition of receiving maximum benefits allowed under the Plan. Under the terms of this Plan, claimants are not required to obtain pre-certification for any services.


3. Concurrent Claims. Any request by a Participant to extend an approved Urgent Claim will be acted upon by the Plan within 24 hours of receipt of the Claim, provided the Claim is received at least 24 hours prior to the expiration of the approved Urgent Claim. A request to continue a plan of treatment that is in progress that does not involve an Urgent Claim will be decided in enough time to request an appeal and to have the appeal decided before the benefit is reduced or terminated. (See C.3, below for a description of Appeal Procedures.)


4. Post-Service Claims. A Post-Service Claim must be submitted to the Plan Office in writing, using an appropriate claim form (which may be obtained by contacting the Plan Office), as soon as possible after expenses are incurred. Failure to file a Post-Service Claim within the time required will not invalidate or reduce any Claim if it was not reasonably possible to file the Claim within such time. In that case, however, the Claim must be submitted electronically and/or as soon as reasonably possible, but in no event later than one year from the date the charges were incurred.
   
   The Claim form must be completed in full and an itemized bill(s) must be attached to the claim form in order for the request for benefits to be considered a Claim. The Claim form and/or itemized bill(s) must include all information required by the Plan Office as indicated on the form.
   
   A Post-Service Claim is considered to have been filed upon receipt of the Claim by the Plan Office. Ordinarily, claimants will be notified of decisions on Post-Service Claims within 30 days from the receipt of the Claim by the Plan Office. The Plan may extend this period one time for up to 15 days if the extension is necessary due to matters beyond the control of the Plan. If an extension is necessary, the claimant will be notified, before the end of the initial 30-day period, of the circumstances requiring the extension and the date by which the Plan expects to render a decision.
   
   If an extension is required because the Plan needs additional information from the claimant, the Plan will issue a Request for Additional Information that specifies the information needed. The claimant will have 45 days from receipt of this form. During the 45-day period in which the claimant is allowed to supply additional information, the normal deadline for making a decision on the Claim will be suspended. The deadline is suspended from the date of the Request for Additional Information form is issued until either 45 days or until the date the claimant responds to the request for information, whichever is earlier. The Plan then has 15 days to make a decision on the Claim and notify the claimant of the determination.
   
   If the Plan determines that additional information is required from the claimant, and the claimant fails to provide any requested information within 45 days, the Claim will be denied and the Plan will issue a Notice of Adverse Benefit Determination.


5. Disability Claims. A Disability Claim must be submitted to the Plan Office within 90 days after the date of the onset of the disability. The Plan will make a decision on the Disability Claim and notify the claimant of the decision within 45 days after receipt of the Claim by the Plan Office. If the Plan requires an extension of time due to matters beyond the control of the Plan, the Plan Office will notify the claimant of the reason for the delay and the date by which the Plan expects to render a decision. This notification will occur before the expiration of the initial 45-day period. The notice of extension will explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the Claim, and the additional information needed to resolve those issues.
   
   A decision will be made within 30 days of the date the Plan notifies the claimant of the delay. The period for making a decision may be delayed an additional 30 days, provided the Plan notifies the claimant prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to render a decision.
   
   If an extension is needed because the Plan needs additional information from the Participant, the extension notice will specify the information needed. If the information is not provided within the 45-day period, the Claim will be denied. During the 45-day period in which the Participant is allowed to supply additional information, the normal period for making a decision on the Claim will be suspended. The period for making the determination is suspended from the date of the extension notice until the earlier of: (1) 45 days from the date of the notification; or (2) the date the claimant responds to the request. Once the claimant responds to the Plan's request for the information, the claimant will be notified of the Plan’s decision on the Claim within 30 days from the date of receipt of the information by the Plan Office.
   
   For Disability Claims, the Plan reserves the right to have a Physician examine the claimant (at the Plan’s expense) as often as is reasonable while a Claim for benefits is pending.
   


6. Authorized Representatives. An authorized representative, such as a spouse, Domestic Partner or an adult child, may submit a Claim or appeal on behalf of a claimant if the claimant has previously designated the individual to act on his or her behalf. An Appointment of Authorized Representative form, which may be obtained from the Plan Office, must be used to designate an authorized representative. The Plan Office may request additional information to verify that the designated person is authorized to act on the claimant's behalf.
   
   A health care professional with knowledge of the claimant’s medical condition may act as an authorized representative in connection with an Urgent Claim without the claimant’s having to complete the Appointment of Authorized Representative form.


7. Notice of Initial Benefit Determination. The claimant will be provided with written notice of the initial benefit determination. If the determination is an Adverse Benefit Determination, the notice will include:
   1. the specific reason(s) for the determination;
      
   2. reference to the specific Plan provision(s) on which the determination is based;
      
   3. a description of any additional material or information necessary to perfect the Claim, and an explanation of why the material or information is necessary;
      
   4. a description of the Plan’s appeal procedures and applicable time limits;
      
   5. a statement of the Participant’s right to bring a civil action under ERISA Section 502(a) following the appeal of an Adverse Benefit Determination;
      
   6. if an internal rule, guideline or protocol was relied upon in deciding the Claim, a statement that a copy of such rule, guideline or protocol is available upon request at no charge;
      
   7. if the determination was based on the absence of Medical Necessity, or because the treatment was Experimental or Investigational, or other similar exclusion, a statement that an explanation of the scientific or clinical judgment for the determination is available upon request at no charge; and
      
   8. for Urgent Claims, a description of the expedited review process applicable to Urgent Claims (for Urgent Claims, the notice may be provided orally and followed with written notification).

3. Appeal Procedures.

1. Appealing an Adverse Benefit Determination. If a Claim is denied in whole or in part, or if the Participant disagrees with the decision made on a Claim, the claimant may appeal the decision. Appeals must be made in writing and must be submitted to the Plan Office within 180 days after the claimant receives the Notice of Adverse Benefit Determination.
   1. Urgent Claims. Appeals of Adverse Benefit Determinations regarding Urgent Claims must be made within 180 days after receipt of the Notice of Adverse Benefit Determination by either:
      1. Calling the Plan Office and asking to speak to the Utilization Review Representative. All oral requests must be followed by a faxed written request within 24 hours.
      2. axing the request to the attention of the Utilization Review Representative.
      NOTE: Appeals of Urgent Claims may not be submitted via the US Postal Service.
   
   
   2. Concurrent Claims. Appeals of Adverse Benefit Determinations regarding Concurrent Claims must be made in the same manner described for Urgent Claims.
   
   
   3. Post-Service Claims and Disability Claims. The appeal of a Post-Service Claim or Disability Claim must be submitted in writing to the Plan Office within 180 days after receipt of the Notice of Adverse Benefit Determination and must include:
      1. the patient's name and address
      2. the claimant's name and address, if different;
      3. a statement that this is an appeal of an Adverse Benefit Determination to the Board of Trustees;
      4. the date of the Adverse Benefit Determination; and
      5. the basis of the appeal, i.e., the reason(s) why the Claim should not be denied.


2. The Appeal Process. The claimant will be given the opportunity to submit written comments, documents, and other information for consideration during the appeal, even if such information was not submitted or considered as part of the initial benefit determination. The claimant will be provided, upon request and free of charge, reasonable access to and copies of all Relevant Documents pertaining to his or her Claim.
   
   A different person will review the appeal than the person who originally made the initial Adverse Benefit Determination on the Claim. The reviewer will not give deference to the initial Adverse Benefit Determination. The decision will be made on the basis of the record, including such additional documents and comments that may be submitted by the claimant.
   
   If the Claim was denied on the basis of a medical judgment (such as a determination that the treatment or service was not Medically Necessary, or was Investigational or Experimental), a health care professional who has appropriate training and experience in a relevant field of medicine will be consulted. Upon request, the claimant will be provided with the identification of medical or vocational experts, if any, that gave advice on the Claim, without regard to whether the advice was relied upon in deciding the Claim.
   


3. Time Frames for Sending Notices of Appeal Determinations.
   1. Urgent Claims. Notice of the appeal determination for Urgent Claims will be sent within 72 hours of receipt of the appeal by the Plan Office.
   2. Concurrent Claims. Notice of the appeal determination for a Concurrent Claim that involves an extension of an Urgent Care Claim will be sent by the Plan within 72 hours of receipt of an appeal by the Plan Office.
   3. Post-Service Claims and Disability Claims. Ordinarily, decisions on appeals involving Post Service Claims and Disability Claims will be made at the next regularly scheduled meeting of the Board of Trustees following receipt of claimant’s request for review. However, if the request for review is received at the Plan Office within 30 days before the next regularly scheduled meeting, the request for review may be considered at the second regularly scheduled meeting following receipt of the claimant’s request. In special circumstances, a delay until the third regularly scheduled meeting following receipt of the claimant’s request for review may be necessary. The Participant will be advised in writing in advance if this extension will be necessary. Once a decision on review of claimant’s Claim has been reached, the claimant will be notified of the decision as soon as possible, but no later than 5 days after the decision has been reached.
   4. If the decision on review is not furnished to the claimant within the time specified in this subparagraph (c), the Claim shall be deemed denied upon review. The claimant shall be free to bring an action upon his or her Claim in accordance with subparagraph (e), below.


4. Content of Appeal Determination Notices. The determination of an appeal will be provided to the claimant in writing. The notice of a denial of an appeal will include:
   1. the specific reason(s) for the determination;
   2. reference to the specific Plan provision(s) on which the determination is based;
   3. a statement that the claimant is entitled to receive reasonable access to and copies of all documents relevant to the Claim, upon request and free of charge;
   4. a statement of the claimant’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on appeal;
   5. if an internal rule, guideline or protocol was relied upon, a statement that a copy of such rule, guideline or protocol is available upon request at no charge; and
   6. if the determination was based on Medical, Necessity, or because the treatment was Experimental or Investigational, or other similar exclusion, a statement that an explanation of the scientific or clinical judgment for the determination is available upon request at no charge.


5. When a Lawsuit may be Started. No Employee, Dependent, beneficiary or other person shall have any right or claim to benefits under the terms of this Plan or any right or claim to payments from the Plan, other than as specified herein. A Participant may not commence a lawsuit to obtain benefits until after either: (1) the Participant has submitted a Claim pursuant to the Plan terms, requested a review after an Adverse Benefit Determination, and a final decision has been reached on review; or (2) the appropriate time frame described above has elapsed since Participant filed a request for review and Participant has not received a final decision or notice that an extension will be necessary to reach a final decision.
   
   No lawsuit may be commenced more than 2 years after the end of the year in which medical or dental services were provided or a benefit was denied or other action, omission or rule affected your situation or, if the Claim is for Long Term Disability Benefits, more than 2 years after the onset of the disability.
   
   The provisions of this subparagraph shall apply to and include any and every claim to benefits from the Plan, and any Claim or right asserted under the Plan or against the Plan, regardless of the basis asserted for the Claim, and regardless of when the act or omission upon which the Claim is based occurred, and regardless of whether or not the claimant is a “Participant” or “beneficiary” of the Plan with the meaning of those terms as defined in ERISA. Such Claim shall be limited to benefits due to him or her under the terms of the Plan, or to clarify his or her rights to future benefits under the terms of the Plan, and shall not include any claim or right to damages, either compensatory or punitive.