When you submit a claim for benefits, the Fund’s claims administrator will determine if you are eligible and will calculate the amount of the benefit that is payable, if any. If for any reason your claim is denied, in whole or in part, the claims administrator will, within 30 days of the receipt of your claim, provide you with a written notice containing the following information:

• The specific reason(s) why your claim or a portion of it was denied;
• Reference to the Plan provision(s) on which the denial was based;
• A description of any additional information or material needed to perfect your claim and an explanation of the reason that it is needed;

In addition, for health care and loss of time claims the notice will include.

• A statement that an internal rule, guideline, protocol or similar criteria was relied upon, if applicable, and a statement that a copy is available to you at no cost upon request.
• If your claim was denied based upon the determination that the services provided to you were not medically necessary or experimental in nature and, therefore excluded under the Plan, you will be advised that an explanation of the scientific or clinical judgment on which the decision was based is available at no cost upon request.

If you are dissatisfied in any way with this decision, you may request a review of this decision by submitting a written appeal to the Board of Trustees, which must be received no later than 180 days after you receive this notification. Send your appeal to:

Board of Trustees of the Operating Engineers
Local 139 Health Benefit Fund
PO Box 160
Pewaukee, WI 53072-0160

Your appeal should state your name, OEF number, the date of the decision you are appealing, precisely what part of the decision you are appealing, and the reason(s) for your appeal. You should submit any written comments, documents, and records that support your claim, even if not considered in the initial benefit denial. You are entitle to receive, upon request and free of charge, reasonable access to, and copies of, relevant information regarding the claim determination. If a rule, guideline, protocol, or similar criterion has been relied upon in making this determination, you have a right to receive, at no cost, a copy of such. If the plan consulted an expert in considering your claim, the identity of such expert will be provided upon request.

In the event you request a hearing, you can appear in person or you can choose a representative to appear on your behalf. You will be notified, in writing, of the date, time, and place of your hearing and you have the right to present any additional information not previously submitted. If you don’t request to appear before the Trustees, or if you do not appear for a scheduled hearing, the Trustees will proceed to consider your appeal based upon the written information that is submitted.

A determination on your appeal will be made at the Trustees next regularly scheduled quarterly meeting if the request for review is received within 30 days prior to that meeting. The Board of Trustees will notify you of their decision in writing within 5 days of reaching a decision. The decision of the Board of Trustees on review shall be final and binding and there is no further level of appeal under Plan procedures.

A determination on your appeal will be made at the Trustees next regularly scheduled quarterly meeting if the request for review is received within 30 days prior to that meeting. The Board of Trustees will notify you of their decision in writing within 5 days of reaching a decision. The decision of the Board of Trustees on review shall be final and binding and there is no further level of appeal under Plan procedures.

If you receive an adverse determination from the Board of Trustees on review, you have the right to bring a civil action under section 502(a) of ERISA within 2 years (24 months) following the date of the written decision. Jurisdiction and venue of any lawsuit filed against the Fund or its Trustees shall be the United States District Court for the Eastern District of Wisconsin.

Please refer to the Summary Plan Description book for full details of the claim review and appeal procedure.