M.J. Day – Appeals

You, or your authorized representative, have the right to appeal a denial of your claim and have your claim reviewed again by the Board of Trustees. An appeal must be filed with the Plan no later than 180 days after the date the claim was initially denied.

Your appeal must be in writing and explain the reasons you disagree with the decision on your claim. When filing an appeal, you may:

• Submit additional materials, including comments, statements, or documents in support of your appeal;
• Request a review of all relevant information pertaining to claim (free of charge);
• Request a copy of any internal rule, guideline, protocol, or other similar criteria on which the denial was based; and
• Request a copy of any explanation of the scientific or clinical judgment (if any) on which the denial was based.

Where to File an Appeal

Send your written appeal to:

Michael J. Day Machinists Retiree Health Investment Plan
c/o Health Services and Benefit Administrators
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568

Appeal Decisions

If you file your appeal on time and follow the required procedures, a new, full, and independent review of your claim will be made by the Board of Trustees. The Trustees will not consider or defer to the initial decision in making their determination about the appeal.

A determination will be made at the Trustees’ next regularly scheduled quarterly meeting following receipt of your appeal.  If the Trustees deny your appeal, you will receive a notice providing:

• The specific reason(s) for the decision;
• The reference(s) to Plan provision(s) on which the decision was based;
• A statement that you have a right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA); and
• A statement that you have the right to look at and/or copy (free of charge) any rule, guideline, protocol, or similar criteria, any scientific or clinical judgment, and any documents, records, or other information relevant to your claim.

Following issuance of a decision on appeal, there is no further right under these procedures to appeal or arbitrate the decision.

If you are not satisfied with the appeal decision after the Plan’s appeals process has been exhausted, you have the right to file a civil action against the Plan in accordance with Section 502(a) of ERISA. However you must exhaust your administrative remedies as outlined in this SPD. Failure to exhaust your administrative remedies will preclude further judicial review.

Authorized Representative

You may appoint in writing an authorized representative to act on your behalf in pursuing a claim or appeal, including a healthcare professional with knowledge of your medical condition. There is no required signed form for this purpose. In the case of a claim involving urgent care, a healthcare professional with knowledge of your medical condition will be permitted to act as an authorized representative without written authorization.

Contact the Trust Fund Office to appoint an authorized representative.