This section of your Answerbook provides information
about how your TeamstersCare benefits are administered.
If you have questions about this material or need further
information, call TeamstersCare directly. This Answerbook describes TeamstersCare benefits for active members
and their eligible dependents who are enrolled in Teamsters
Union 25 Health Services & Insurance Plan Active Medical
Program. TeamstersCare has separate benefit booklets for
other member groups, such as retired and NCH members. For
more information, call Charlestown Member Services.
Coordination of Benefits
If you or a family member has—or
acquires—healthcare coverage under some other group
benefits plan (for example, Medicare or your spouse’s
employer medical plan), then any benefits you receive
from that other plan will be “coordinated” with
your TeamstersCare coverage. This includes medical, prescription
drug, dental, or mental health
& substance abuse benefits.
It’s extremely important to
understand this concept called “Coordination of
Benefits”
or “COB.” COB provisions are routinely included
in group health plans. They’re designed to provide
Plan participants the fullest allowable coverage, while
avoiding benefit over-payment.
FImportant
Note: Under COB, TeamstersCare will make certain your expenses
are properly paid, but we also need to ensure that the total
payments you’re eligible to receive, from all your
coverages combined, do not exceed 100% of the charges you’re
billed. By “coordinating”
our own Plan with other health coverages, we create efficiencies
that will often result in full coverage for you—with
lower out-of-pocket costs.
Basically, COB provisions
help determine the order in which multiple parties are
responsible for reimbursement in the event of a claim.
To prevent a covered person from being caught in the middle
of a dispute between two plans, and to provide a consistent
method of deciding which plan pays first, TeamstersCare
uses the National Association of Insurance Commissioners’
(NAIC) guidelines to help determine the general order
of benefit payment.
General COB Guidelines
In general terms, the Plan follows
certain guidelines in determining whether TeamstersCare
is “primary”
or “secondary” payer. In the following description,
if a plan is described as “primary,” it means
that plan pays first. “Secondary” means that
plan pays second.
Generally, benefits are determined
so that if you are covered by:
• two plans from
two different jobs, the plan that has covered you the longer
is primary
• a plan that
covers you as an active employee, it is primary to a plan
that covers you as a retired employee
• a TeamstersCare
Plan, but also by a spouse’s employer plan, the spouse’s
plan is primary for your spouse’s coverage, secondary
for your coverage
• two plans and
only one plan has (and abides by) COB provisions, then the
plan
that does not have (or does
not abide by) COB provisions
is primary, and the plan with the COB provision is secondary
• Medicare while
still an active employee, Medicare is secondary
In cases where you are covered
by COBRA as a former TeamstersCare participant, but you
also have coverage under some other health benefits plan
(for example, another employer’s plan or your spouse’s
employer plan), that other plan—and not the COBRA
continuation—always pays first when benefits are “coordinated.”
Example
Suppose John Doe’s spouse
has primary coverage through her employer and secondary
coverage through TeamstersCare. In order for TeamstersCare
to pay benefits as the secondary payer, all of the TeamstersCare
Plan requirements must be satisfied. In the case of an
HMO, for example, John’s spouse must obtain a referral
from her Primary Care Physician in order to qualify for
TeamstersCare secondary coverage.
FImportant
Note: TeamstersCare will communicate with Network Blue New
England, Tufts Health Plan, RESTAT, and Delta Dental, as
appropriate, on coordination of benefit issues.
Exceptions to General
COB Guidelines
In cases where there are exceptions
to these general guidelines, TeamstersCare will determine
its COB obligations on the basis of the particular facts
and circumstances.
COB for TeamsterShare Payments/Copays
Coordination of benefits does
not apply to TeamsterShare Payments for pharmacy and other
TeamstersCare clinical services. HMO and Out of Area copays
are not coordinated, except in the case where the primary
plan has a higher copay than the TeamstersCare Plan, and
you have met the requirements of both plans.
COB for TeamstersCare Pharmacies/RESTAT
TeamstersCare Pharmacies are
available only to members and eligible dependents who have
TeamstersCare as primary coverage. The same is true for
the RESTAT network. This means in cases where other coverage
is primary, a person is not eligible to use TeamstersCare
Pharmacies or their RESTAT card to fill prescriptions.
Since the TeamstersCare Pharmacy benefit
is secondary in these cases, benefits are coordinated with
the primary plan. You must submit appropriate documentation
and a Claim Form to
Charlestown Member Services for coordination and reimbursement.
COB in cases of Double TeamstersCare
Coverage
When both a member and a spouse
have primary coverage through TeamstersCare, there is
no coordination of benefits for HMO or Out of Area copays
or for TeamsterShare Payments.
FImportant
Note: To ensure benefits are
properly coordinated, you (or someone acting
on your behalf) must contact TeamstersCare anytime you or a dependent acquires
additional medical, dental, prescription drug, or mental
health
& substance abuse coverage. You’ll need to provide
us with the name of the insurance company, the type of
coverage, the effective date, and the names of any family
members who are enrolled in the other benefit plans.
Coordinating Coverage
for Children
If your children are covered by both
TeamstersCare and your spouse’s employer plan, the
plans use a guideline called “the birthday rule” to
determine which plan pays first for healthcare benefits provided to your children. The birthday rule says that benefits
will be paid first by the plan of the parent whose birthday
comes earlier in the calendar year.
Coordinating Coverage
with Medicare
If you’re an active TeamstersCare
member when you or your spouse becomes entitled to Medicare
at age 65, TeamstersCare will be your “primary payer.”
This means TeamstersCare will pay benefits before Medicare,
then Medicare will consider assuming any remaining expenses.
TeamstersCare is also primary payer, for up to 30 months,
for members and dependents who have permanent kidney failure.
This also applies if you have any
dependents who are entitled to Medicare because they’re
disabled.
Remember that Medicare Part A coverage
is automatic when:
• you or your
spouse reaches age 65 and have enough quarters of covered
employment,
or
• you have a
disabled spouse or dependent who has been receiving Social
Security disability payments for at least two years
Enrollment for Medicare Part B is
not the same as for Part A. The two plans differ in a
number of important ways. Part A covers hospital expenses, while Part B covers
other medical expenses. In addition, you generally pay
no premiums for Part A coverage, whereas you are required
to pay a monthly premium for Part B coverage. If
you need more information, call the Social Security Administration
directly.
Third Party Liability
In certain instances, a “third
party”
may be responsible for the cost of treating an illness or
injury incurred by you or an eligible dependent. A “third
party”
means someone other than you or the TeamstersCare Plan. It
can be a person, a legal entity, or some other insurance
plan (e.g., Workers’ Compensation, uninsured motorists’ pool).
Before TeamstersCare can cover you
for healthcare expenses that might have been caused by
a third-party, you’re required to sign a reimbursement
agreement approved by the Board of Trustees. The agreement
obligates you to reimburse the Plan for any payments it
has made on your behalf, should you subsequently receive
proceeds from a third party or under your own insurance
policy. If you fail to sign the reimbursement agreement,
no benefits will be paid to you. You may not release any
third party that might be obligated to pay you without
the Plan’s written approval.
If you act on your own behalf to
collect monies due from a third-party, you must inform
anyone involved in that transaction (e.g., your attorneys,
the third-party, etc.) of your obligation to reimburse
the Plan, and you must include the Plan’s subrogation
claim in your action. TeamstersCare has priority claim
to any monies you are subsequently paid by a third party—up
to the full amount of the reimbursement due. In no event
will fees and costs associated with this action be paid
by the Plan. You must hold all recovered proceeds in
trust for the Plan’s benefit.
If you are legally obligated to reimburse
the Plan, and you secure a recovery but you do not make
the reimbursement, TeamstersCare can suspend your benefits
and/or withhold future benefits equal to the amount due.
If TeamstersCare needs to take legal action to collect
any balance due the Plan, you are legally prohibited from
taking any action that would interfere with the Plan’s
right to recover. Also, you will be liable for collection
costs and reasonable legal fees.
Under certain circumstances, TeamstersCare
may need to seek reimbursement directly from the third-party
under your name, a process called “subrogation.” When
this happens, the Plan is collecting on your behalf, with
your authorization and cooperation. Again, in this regard,
the reimbursement agreement prohibits you from interfering
with the Plan’s right—or any actions the Plan
may take—to recover the reimbursement due. Further,
the agreement requires you to provide any assistance the
Plan may request.
If the original illness or injury
that led to the subrogation involves a minor child, then
the child’s guardian or parents are responsible for
cooperating with the subrogation process. Similarly, if
the illness or injury ends in the wrongful death of the
member or a dependent, then the responsibility passes on
to that person’s personal representative.
The most common situations involving
subrogation are auto accidents where someone causes injury
to a member. However, this is not the only basis for recovering
benefits from a third party. Recoveries can be made from
a second medical policy (e.g., for medical malpractice);
from a homeowner’s policy (e.g., for accidents in
another’s home or property); or from general liability
coverage (e.g., for a defective product, where the member
incurred medical expenses for which the third party was
liable).
If you or a covered dependent receives
money from a third party—regardless of how such monies
are classified—for expenses TeamstersCare has paid,
then TeamstersCare has the right to receive that money
to offset expenses the Plan has paid on your behalf. This
is true whether or not these monies are sufficient to pay
for all of your other expenses associated with the action
of that third party. These reimbursements are to be made
by the member (and/or the member’s guardian or estate)
up to the total amount payable to or on behalf of the member
(and/or his/her guardian or estate). This includes reimbursements
from:
• any policy
or contract from any insurance carrier, including the member’s
insurer, and/or
• any third party,
plan, or fund whether as a result of a judgment or settlement
or otherwise
You, or anyone acting on your behalf,
must not do anything to prejudice TeamstersCare’s
rights to this reimbursement. You must provide TeamstersCare
with any instruments and papers that it requests in order
to assure the Plan’s rights to reimbursement.
If you fail to comply with such requests,
TeamstersCare is entitled to withhold benefits, services,
payments, or credits due under the Plan. TeamstersCare
will be subrogated to all claims, demands, actions, and
rights of your recovery against a third party or parties
and/or the third party or parties’
insurers (including the member’s insurer) where subrogation
is lawfully permitted.
The amount of subrogation will equal
the total amount paid under this Plan for the illness or
injury the member (and/or his or her guardian or estate)
has, may have, or for which the member (and/or his or her
guardian or estate) asserts a claim. This Plan will also
be subrogated for attorney fees related to enforcing the
Plan’s subrogation rights under this provision.
As Plan participants, you and your
covered dependents hereby agree that you will execute and
deliver any and all instruments and papers required by
TeamstersCare in order to protect the Plan’s rights
to subrogate as explained in this section. You must also
do whatever is requested or necessary in order to fully
execute and to fully protect all the Plan’s rights.
Additionally, you acknowledge and
agree that TeamstersCare will be reimbursed by the member
(and/or his/her guardian or estate) in full before any
amounts, including attorney fees incurred by the member
(and/or his/her guardian or estate), are deducted from
any policy, proceeds, judgments, or settlements.
You agree, on behalf of yourself and/or
any covered dependents (guardians and/or estates), to notify
the Plan Administrator in writing whenever benefits are
paid under this Plan for any injury or illness that provides
or may provide TeamstersCare subrogation rights. Failure
to comply with the requirements of this provision may,
at the Plan Administrator’s discretion, result in
a forfeiture of TeamstersCare benefits.
No-Fault Auto Insurance
If you have a medical or disability
claim related to a motor vehicle or motorcycle accident,
you (or someone acting on your behalf) must notify TeamstersCare
as soon as possible. TeamstersCare coverage varies with
a number of factors. In all cases, you will have to sign
a reimbursement agreement obligating you—should you
receive any third-party settlements—to reimburse
TeamstersCare for any money the Plan may have paid out
on your behalf.
States Requiring Mandatory No-Fault
Insurance
If you live in Massachusetts,
or any other state with mandatory no-fault insurance,
and you are covered by such insurance, then any medical
claim or lost wages resulting from a motor vehicle accident
are covered by the mandatory no-fault insurance. The no-fault
policy will be liable for medical, prescription drug, dental
benefits and /or lost wages up to the first $8,000 of expenses—or
the maximum amount called for by law, whichever is greater.
After this amount is paid, TeamstersCare will then cover
any remaining eligible expenses, upon receipt of a signed lien agreement.
If no-fault insurance is available
but you decline the coverage, and you have a claim resulting
from a car or motorcycle accident, you will
still be responsible for the first $8,000 of expenses—or
the maximum amount that no-fault insurance would have paid,
whichever is greater. TeamstersCare excludes from the benefits
that it provides all amounts that would have been covered
had you obtained no-fault insurance.
FImportant
Note: If you are denied benefits under your motor vehicle insurance
due to driving under
the influence, TeamstersCare
excludes from your benefits all amounts that would have
been covered by the insurance carrier.
FImportant
Note: Mandatory no-fault insurance does not cover motorcycle accidents.
Other States
If you live in a state
that does not require mandatory no-fault coverage,
the Plan will administer motor vehicle and motorcycle accident
medical or disability claims in the same way as any other
claim. However, if you receive any third-party settlements,
you will be required to reimburse TeamstersCare an amount
equal to any payments the
Plan may have made on your behalf.
Workers’ Compensation
TeamstersCare does not pay medical
or disability benefits for a work-related sickness or injury.
If you submit a Workers’ Compensation
claim, then you cannot claim TeamstersCare benefits for
the same sickness or injury. If you submit a Workers’ Compensation
claim and that claim is denied, you have the right to appeal.
If your appeal is denied, you must provide TeamstersCare
with a copy of the final determination notice before we
can process claims.
TeamstersCare reserves the right in
all cases to make its own independent determination on
whether an injury is work-related. TeamstersCare may refuse
to process claims where, in the good-faith judgment of
the Plan Administrator, a member unreasonably chose not
to pursue a claim or appeal.
If you submit a claim for work-related
sickness or injury and your employer disputes the claim,
TeamstersCare may pay you weekly disability benefits during
the period your claim is under dispute.
You need to sign an agreement to reimburse
TeamstersCare in full for any Workers’ Compensation
benefits you may subsequently receive. Your employer is
responsible for paying up to 12 months of contributions
to TeamstersCare, on your behalf, while you are out of
work due to a work-related injury.
The maximum weekly disability benefit
you may collect is 26 weeks from the date of injury. Any
payments you receive from Workers’ Compensation count
toward this 26-week maximum.
While a Workers’ Compensation
claim is pending, and during any period of disability that
follows, TeamstersCare will continue to cover any eligible
medical expenses you have that are unrelated to the disability.
Coverage also continues for your dependents, so long as
you remain eligible.
Your Rights as a Plan
Member Under ERISA
At a number of places in this Answerbook, you’ll find
references to “the Plan” or to “TeamstersCare.” These
terms refer to the benefit plan whose official name is “Teamsters
Union 25 Health Services & Insurance Plan.”
The Plan is administered by a Board
of Trustees, according to the terms of:
• the Agreement
and Declaration of Trust of the Teamsters Union 25 Health
Services &
Insurance Plan, and
• this Summary
Plan Description (SPD)—i.e., the Answerbook and accompanying medical Option descriptions, and
• certain Life
and AD&D insurance policies
These documents, taken together,
make up the official “Plan Documents” as specified
by the Employee Retirement Income Security Act of 1974
(ERISA).
The Board of Trustees has delegated
certain day-to-day administrative duties to the Executive
Director of the Fund.
As a participant in the Teamsters
Union 25 Health Services & Insurance Plan, you are
entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA).
Under ERISA, you’re entitled
to receive information about your plan and benefits. You
may examine, free of charge, all the official documents
related to the Plan. This includes insurance contracts,
collective bargaining agreements, and copies of all documents
filed by the Plan with the U.S. Department of Labor (such
as detailed annual reports and Plan descriptions). These
documents are available for review in the TeamstersCare
Charlestown office during regular business hours.
You may obtain copies of all Plan
documents—including insurance contracts, collective
bargaining agreements, copies of the latest annual report
(Form 5500 Series), a summary of any material Plan changes
and updated Summary Plan Descriptions—by writing
to the Plan Administrator. You may have to pay a reasonable
charge to cover the cost of photocopying.
A copy of the Plan’s most recent
annual report (Form 5500 Series) is available at the Public
Disclosure Room of the Employee Benefits Security Administration.
By law, the Plan Administrator must
furnish each participant with a copy of the Plan’s
Summary Annual Report (SAR).
Under ERISA, you may be entitled
to continue group health plan coverage if you lose eligibility
for certain reasons. You can continue healthcare coverage for yourself, your
spouse, or your dependents if you lose coverage under the
Plan as a result of a qualifying event. You or your dependents
may have to pay for this coverage. Review this Answerbook and the documents governing the Plan for the rules
that apply to your COBRA continuation coverage rights.
For more information, see Continuing
Your Health Care Coverage Under COBRA, click
here
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) provides that, in cases
where you have become ineligible for TeamstersCare benefits,
you are entitled to receive a “certificate” verifying
your previous coverage under the TeamstersCare Plan. This
verification can then be used to reduce whatever pre-existing
condition exclusions might be imposed by any new coverage
you obtain.
For members who lose their TeamstersCare
eligibility, the Plan will automatically issue a certificate—free
of charge—reflecting the single most recent period
of continuous coverage, under the following circumstances:
• when you lose
coverage under the Plan
• when you become
entitled to continue coverage under COBRA
• when your COBRA
continuation coverage ceases, if you request the certificate
before you lose coverage, or if you request it up to 24 months
after losing coverage
Without such evidence of
creditable coverage, you may be subject to a preexisting
condition exclusion for 12 months (18 months for late enrollees)
after your enrollment date in your new coverage. See Your Rights Under HIPAA, click
here.
Under ERISA, you’re entitled
to enforce certain rights. No
one—including your employer, your union, or any other
person—can fire you or otherwise discriminate against
you in order to prevent you from obtaining a Plan benefit
or exercising your ERISA rights.
If Plan fiduciaries misuse the Plan’s
money, or if you’re discriminated against for exercising
your rights, you can ask for help from the U.S. Department
of Labor or file suit in a Federal court. If you sue
successfully, the court can order the person you’ve
sued to pay court costs and your legal fees. If you lose
your suit, the court can order you to pay costs, plus
certain fees, if, for example, it finds your claim is
frivolous.
Under ERISA, there are steps you can
take to enforce the above rights. For instance, if you
request a copy of Plan documents or the latest annual report
from the Plan and do not receive them within 30 days, you
can file suit in a Federal court. The court may require
the Plan Administrator to provide the materials and pay
you up to $110 a day until you receive the materials, unless
the materials were not sent because of reasons beyond the
control of the Administrator.
If you believe you’ve been improperly
denied a Plan benefit, in full or in part, you have a right,
within certain time schedules, to:
• know why this
was done
• obtain copies
(without charge) of documents relating to the decision, and
• appeal any
denial
If you have a claim for benefits
that is denied or ignored, in full or in part, you can
file suit in a state or Federal court. In addition, if
you disagree with the Plan’s decision or lack thereof
concerning the qualified status of a domestic relations
order or a medical child support order, you may file suit
in Federal court.
Prudent Actions by Plan Fiduciaries
In addition to creating rights
for Plan participants, ERISA imposes duties upon the people
responsible for operating a benefit Plan. These persons
are called “fiduciaries.”
Plan fiduciaries are obligated to operate a Plan prudently
and in the interest of you and other Plan participants
and beneficiaries. Fiduciaries who violate ERISA may
be disqualified and required to make good any losses
they have caused the Plan.
If Plan fiduciaries misuse the Plan’s
money, or if you are discriminated against for asserting
your rights, you can ask for help from the U.S. Department
of Labor, or you can file suit in a Federal court. The
court will decide who should pay court costs and legal
fees. If you are successful, the court may order the person
you have sued to pay these costs and fees. If you lose,
the court may order you to pay these costs and fees—for
example, if it finds your claim is frivolous.
Help With Your Questions
If you have any questions
about your Plan, you should contact the Plan Administrator.
If you have any questions about this statement or about
your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact
the Employee Benefits Security Administration (EBSA).
EBSA Headquarters:
Division of Technical Assistance
and Inquiries
Employee Benefits Security Administration
U.S. Department of Labor
Frances Perkins Building
200 Constitution Avenue
N.W.
Washington, D.C. 20210
1-202-219-8776
toll free: 1-866-444-EBSA
(3272)
EBSA Boston Regional Office:
Employee Benefits Security Administration
Boston Regional Office
J.F.K. Building, Room 575
Boston, MA 02203
1-617-565-9600
You may also obtain certain publications
about your rights and responsibilities under ERISA by calling
the publications hotline of the Employee Benefits Security
Administration.
Information About
Teamsters Union 25
Health Services & Insurance Plan
Plan Administrator/Named
Fiduciary
The Teamsters Union 25 Health Services
& Insurance Plan is a collectively bargained plan, administered
by a Board of Trustees that includes three union representatives
and three employer representatives. The Trustees serve as the “Named
Fiduciary” under ERISA.
The address and telephone number for
the Board of Trustees is:
Board of Trustees
Teamsters Union 25 Health
Services
& Insurance Plan
16 Sever Street
Charlestown, MA 02129
Telephone: 617-241-9220
The Board of Trustees
Plan Year
The plan year for the Teamsters Union
25 Health Services & Insurance Plan is September 1
through August 31.
Employer and Plan
Identification Numbers
The Board of Trustees’ employer
identification number is 04-6374631. The Plan number for
all programs is 501.
Plan Contributions
Employers contribute to the Plan according
to the terms of their individual collective bargaining
agreements or standard participation agreements.
The collective bargaining agreements
require contributions to the Plan at fixed rates. These
rates are applied to the number of hours for which an employee
who is covered by an agreement receives or is due pay,
up to a maximum of 40 hours per week.
If you make a request in writing,
TeamstersCare will provide you with a copy of your relevant
collective bargaining agreement (CBA) and information as
to whether a particular employer is contributing on your
behalf under the bargaining agreement.
Benefit Payment
TeamstersCare medical and weekly disability
benefits payments are provided from Plan assets and are
not guaranteed under a policy of insurance. These assets
are accumulated under the provisions of the collective
bargaining and trust agreements. Tufts Health Plan and
Blue Cross Blue Shield administer payment. Other benefits
under the Plan are provided through insurance.
Eligibility for Benefits
See SECTION
II: PARTICIPATION for detailed information on:
• benefit eligibility
• disqualification,
ineligibility, denial, suspension, loss, or reinstatement
of benefits
Financial Information
The Plan’s assets are held in
a trust fund for the exclusive purpose of providing benefits
to covered participants and paying reasonable administrative
expenses. Assets and reserves are invested with financial
institutions in certificates of deposit, common stocks,
and bonds—all of which are authorized, approved,
and administered by the Board of Trustees.
Agent for Service
of Legal Process
If for any reason you wish to seek
legal action, you may serve legal process upon the Plan
Administrator, at the following address:
Board of Trustees
Teamsters Union 25 Health Services & Insurance Plan
16 Sever Street
Charlestown, MA 02129
Telephone: 617-241-9220
Plan Authority
The Board of Trustees has the right
to administer the Plan at its sole discretion.
This includes the right to make binding and conclusive determinations
regarding:
• who is eligible
for benefits
• the amount
of benefits payable
• the meaning
and applicability of Plan provisions
Similarly, the Board of Trustees
reserves the right to amend, modify, reduce, or discontinue
all or part of the Plan, according to the terms of the Plan
and Trust Agreement, by appropriate action, including:
• changing any
amounts contributed to the cost of providing benefits
• changing the
level of benefits provided
• changing the
class or classes of individuals eligible for benefits
• terminating
the Plan in its entirety or with respect to any covered class
or classes
Only the Plan Trustees may interpret
Plan provisions, including: determining eligibility for
benefits and the right to participate in the Plan; how
hours are credited; eligibility for any benefit; discontinuing
benefits; status as a covered or non-covered employee;
benefit levels; and interpreting the rules with respect
to a particular claim or application.
No one is authorized to speak on behalf
of, or to commit the Trustees on, any Plan-related matter,
without the expressed authority of the Trustees. This includes
local union officers, business agents, local union employees,
employers or employer representatives, TeamstersCare office
personnel, consultants, or attorneys.
Claims and Appeals
Under certain circumstances, you may
need to file a benefit claim. A claim is any request for
a Plan benefit, made by a claimant or by a representative
of the claimant, that complies with the Plan’s reasonable
procedure for making benefit claims.
Generally, you must file the claim
within 12 months of the date you received the service that
the claim covers. The following are exceptions to this
general rule:
• You must file prescription drug claims
within 60 days of the date when you receive the service that
the claim covers.
• You must file weekly disability claims
within 90 days of the date you are disabled.
• You must file
an accidental death & dismemberment claim within 90 days of
the loss.
Submitting a
Claim
Claims procedures vary somewhat, depending
on the benefit involved. If you intend to submit a claim,
first check the appropriate section of this Answerbook and refer to the following chart. If you need further
information, call Charlestown Member Services.
If you make a claim for benefits
under the Plan, you will be notified of the results and
of further instructions according to the following chart:
The times listed in the chart are
maximums. A period of time begins when the claim is filed.
Decisions will be made within a reasonable period of time
appropriate to the circumstances. “Days” means
calendar days.
Note that there are different types
of claims and each has specific rules, timeframes, and
procedures associated with it.
An “Urgent Care Claim” is
any claim for care or treatment where using the timetable
for non-urgent care determination could seriously jeopardize
the life or health of the claimant, or the ability of the
claimant to regain maximum function, or in the opinion
of the attending or consulting physician, would subject
the claimant to severe pain that could not be adequately
managed without the care or treatment that is being requested.
A “Pre-Service Claim” is
any claim for a health benefit (other than an Urgent Care
Claim) that, per the terms of the Plan, must be approved
before care is obtained.
A “Post-Service Claim” is
any claim for a Plan benefit that is for services already
received by the claimant.
A request to change an ongoing course
of treatment previously approved by the Plan (for example,
a request to increase the number of treatments or the time
period over which treatments will be given) will be processed
as a new claim—either Pre- or Post-Service, depending
on whether the Plan will require pre-approval of the new
treatment. However, if the ongoing course of treatment
also involves Urgent Care, the claim will require special
considerations, as indicated in the chart above.
You’ll be notified in writing
of the claim decision. If your claim is denied, the notification
will include:
For All Types of Claims
• the specific
reasons for the denial
• the specific
Plan provisions on which the denial is based
• a description
of any additional material or information necessary for the
claim to be completed and an explanation of why such material
or information is necessary
• a description
of the Plan’s review procedures and the time limits
applicable to such procedures, including your right to bring
a civil action in court (under Section 502 of ERISA) following
a claims denial on review
• 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 related to the
claim
For Medical, Dental, Prescription
Drug, Hearing, and Weekly Disability Claims Only
• a description
of any internal rules, guidelines, protocols, or other similar
criteria that were relied upon in the decision-making, OR
a statement that the decision was based on the applicable
items mentioned above, and that copies of the applicable
material will be provided upon request, free of charge
• an explanation
of the scientific or clinical judgment used in the decision
in the case of a decision regarding medical necessity, experimental
treatment or similar exclusion or limit, applying the terms
of the Plan to your medical circumstances, OR a statement
that such explanation will be provided upon request, free
of charge
For Medical, Dental, Prescription
Drug and Hearing Claims Only
• for a claims
denial involving an urgent care claim, a description of the
expedited review process applicable to such claims
If you have any questions
about a denied claim, you should contact the
Plan Administrator.
Appealing a Claim
You or your authorized representative
may appeal a denied claim according to the
chart below:
You may submit written comments,
documents, records, and other information relevant to
the claim. In addition, you will be provided, upon request
and free of charge, reasonable access to, and copies
of, all documents, records, and other information relevant
to the claim.
A document is considered “relevant
to the claim” if it:
• was relied
upon when making the benefit determination
• was submitted,
considered, or generated in the course of making the benefit
determination, without regard to whether it was relied upon
in making the benefit determination
• demonstrated
compliance with the administrative processes and safeguards
designed to ensure and to verify that benefit determinations
are made in accordance with Plan documents and that Plan
provisions have been applied consistently with respect to
all claimants; or
• constituted
a statement of policy or guidance with respect to the Plan
concerning the denied treatment option or benefit.
In case of medical, dental, prescription
drug, hearing and weekly disability claims, your appeal
will be reviewed by the TeamstersCare Medical Review
Committee who had no role in the initial claim denial
and the review will be an independent one without giving
the original denial any special consideration.
If a medical judgment is involved,
the person reviewing your appeal will consult with a healthcare
professional who has appropriate training and experience
in the field of medicine involved in the medical judgment
and who had no role in the initial claim denial. The medical
or vocational experts whose advice was obtained will be
identified.
The review will take into account
all comments, documents, records, and other information
submitted or considered in the initial benefit determination.
If your appeal is denied, you will
be notified electronically or in writing. Such notice
will include the following:
For all types of claims:
• the specific
reasons for the denial
• the specific
Plan provisions on which the decision was based
• your right
to request access to or copies of all information relevant
to your claim
• your right
to bring a civil action in court
• notice of any
available voluntary appeals procedures
For medical, dental, prescription
drug, hearing and weekly disability claims, the notice will
also include:
• a description
of any specific internal rules, guidelines, protocols, or
other similar criteria that were relied on in making the
decision, OR a statement that the decision was based on the
applicable items mentioned above, and copies of the applicable
material will be provided upon request, free of charge
• an explanation
of the scientific or clinical judgment used in the decision
in the case of decisions regarding medical necessity, experimental
treatment or similar exclusion or limit, applying the terms
of the Plan to your medical circumstances, OR a statement
that such explanation will be provided upon request, free
of charge.
You and the Plan may also have other
voluntary alternative dispute resolution options, such
as mediation. One way to find out what may be available
is to contact your local U.S. Department of Labor Office
and your state insurance regulatory agency.
If the Plan Administrator fails to
follow the claims appeals procedures as outlined above,
you have the right to bring a civil action in court.
Final Notes
If you have questions about your benefits,
or if you do not understand the Plan because you cannot
speak English, contact TeamstersCare for help—or
have someone do this for you.
The Answerbook is designed to make your benefits as clear to you as possible.
However, nothing written in the Answerbook is meant to reinterpret, add to, or change in any way
the legal provisions expressed in the Plan and in the Agreement
and Declaration of Trust or in any insurance policies purchased
by Teamsters Union 25 Health Services & Insurance Plan.
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