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Health Fund

Decisions On Appeal

The Claims Administrator's review will take into account all comments, documents, records and other information submitted, regardless of whether the information was previously considered on initial review. The Claims Administrator will have discretion to deny or grant the appeal in whole or part. Such decisions will be made in accordance with the governing Fund documents and, where appropriate, Fund provisions will be applied consistently with respect to similarly situated claimants in similar circumstances. The Claims Administrator will have discretion to determine which claimants are similarly situated in similar circumstances.

Reviews of denials by the Administrative Office will be heard by the Benefits Committee at its next regularly scheduled quarterly meeting. However, if an appeal is received within 30 days before the meeting, the review will be delayed until the next meeting. In addition, if special circumstances require further extension of time, the review may be delayed to the following meeting. Once the benefit determination is made, the claimant will be notified as soon as possible, but not later than five days after the determination.

For appeals of claims denied by a party other than the Administrative Office, the claimant will be notified of the determination within a reasonable period of time, but not later than 60 days after receipt of the request for review. The Fund will notify you of its decision for urgent care claims as soon as possible but no later than 72 hours after the receipt of such claim, provided that you provide the Fund with sufficient information for it to determine whether and to what extent benefits are covered under the Fund under such circumstances. If the Fund requires additional information from you in order to make a determination for an urgent care claim, you will have not less than 48 hours to provide the Fund with the requested information.

Following an adverse determination on appeal by a party other than the Benefits Committee (i.e., a third party claims administrator), the claimant may submit a voluntary appeal to the Benefits Committee. While this voluntary appeal is being processed, the limitations period for filing a lawsuit described below is tolled. While the claimant may not bring a lawsuit regarding a claim without first exhausting the Fund's claims and appeal procedures, the claimant is not required to first submit a voluntary appeal.

If the decision to deny the claim was based in whole or in part on a medical judgment, the Claims Administrator will consult with a health care professional who has experience and training in the relevant field and who was not involved in the initial determination. Identification of any such health care professional will be provided to the claimant upon request and free of charge.