Claiming Your Supplemental Health Benefits
When Benefits May Be Withheld Or Denied
Request For Review Of Denial Of Claim
Claiming your Supplemental Health Benefits
The procedure for claiming your General Medical Reimbursement, Dental, Vision, Prescription Drug, Hearing Aid, Mental Health and Podiatry Benefits are described by type of Benefit under the heading “Getting Your Benefit.”.
Please pay special attention to the time limits for filing your claims.
IN GENERAL, ALL SUPPLEMENTAL HEALTH BENEFITS MUST BE CLAIMED NO LATER THAN 90 DAYS AFTER THE SERVICE IS RECEIVED. CLAIMS FILED AFTER THAT DATE WILL BE DENIED.
If you require claim forms, visit or call the Fund Office at:
CWA Local 1180 Security Benefits Fund
6 Harrison Street, 3rd Floor
New York, NY 10013-2898
You can also download Claim Forms at the Fund’s website: www.cwa1180.org
When Benefits May Be Withheld or Denied
Recovery of Overpayments or Mistaken Payments
If you received benefits from the Fund to which you are not entitled, on your behalf or on behalf of your spouse or children, you are required to make restitution of the overpayment or mistaken payment promptly. If you fail to do so, the Fund will offset any future benefit payments by the amount of the mistaken payment until full restitution of the amount of the mistaken payment or overpayment is made.
Right To Audit and Verify Claims Request for Review of Denial of Claim
Before or after paying any benefits, the Fund reserves the right to audit and verify any claims that are submitted to the Fund.
If your claim for supplemental health benefits is denied and you disagree with the decision, you may request a review of your claim:
- All initial claims for benefits by a Member or Beneficiary (hereinafter for purposes of the Section the “Claimant”) under the Plan must be in writing and sent to the Fund Office, to the attention of the Trustees. A decision regarding the claim will be made by the Trustees, or their duly authorized designee, within 90 days from the date the claim is received by the Fund Office, unless it is determined that special circumstances require an extension of time for processing the claim, not to exceed an additional 90 days. If such an extension is required, written notice of the extension will be furnished to the Claimant prior to expiration of the initial 90-day period. The notice of extension will indicate the special circumstances requiring the extension of time and the date by which the Trustees, or their duly authorized designee, expect to make a determination with respect to the claim. If the extension is required due to the Claimant’s failure to submit information necessary to decide the claim, the period for making the determination will be tolled from the date on which the extension notice is sent to the Claimant until the date on which the Claimant responds to the Fund Office’s request for information.
- A Claimant whose application for benefits under the Plan has been denied, in whole or in part, will be provided with written notice of the determination, setting forth: (i) the specific reason(s) for the adverse benefit determination, with references to the specific Plan provisions on which the determination is based; (ii) a description of any additional material or information necessary for the claimant to perfect the claim (including and explanation as to why such material or information is necessary); and (iii) a description of the Fund’s review procedures and applicable time limits, as well as a statement of the claimant’s right to bring a civil action following and adverse benefit determination on review.
- If an adverse benefit determination is made by the Trustees, or their duly authorized designee, the Claimant (or his/her authorized representative) may request a review of the determination. All requests for review must be sent in writing to the Trustees within sixty (60) days after receipt of the notice of denial or other adverse benefit determination. In connection with the request for review, the Claimant (or his/her duly authorized representative) may submit written comments, documents, records, and other information relating to the claim. In addition, the Claimant will be provided, upon written request and free of charge, with reasonable access to (and copies of) all documents, records, and other information relevant to the claim. The review by the Trustees will take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim.
- A decision on review will be made by the Trustees (or a committee designated by the Board of Trustees) at their next regularly scheduled meeting following receipt of the request for review, unless the request is filled less than thirty (30) days prior to the next regularly scheduled meeting, in which case a decision will be made by no later than the date of the second regularly scheduled meeting following receipt of such request for review. If special circumstances require an extension of time for processing a request for review, the decision may be made at the third meeting following receipt of such request. The Claimant will be notified in advance of any such extension. The notice will describe the special circumstances requiring the extension, and will inform the Claimant of the date as of which the determination will be made. If the extension is required due to the Claimant’s failure to submit information necessary to decide the claim, the period for making the determination will be tolled from the date on which the extension notice is sent to the Claimant until the date on which the Claimant responds to the Fund Office’s request for information.
- The Claimant will be notified in writing of the determination on review within 5 days after the determination is made. If an adverse benefit determination is made on review, the notice will include: (i) the specific reason(s) for the adverse benefit determination, with references to the specific Plan provisions on which the determination is based; (ii) a statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to (and copies of) all documents, records and other information relevant to the claim; and (iii) a statement of the Claimant’s right to bring a civil action. The decision of the Trustees (or their designated committee) on review shall be final and binding on all parties.
In the event the Trustees, or their duly authorized designee, fail to respond to an initial claim for benefits or an appeal thereof within the time frames applicable thereto, the claim or appeal shall be deemed denied for all purposes of this Section as of the date on which the Trustees, or their duly authorized designee, would otherwise be required to respond to the claim or appeal.