C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d P l a n

Claims

 

 

You should file all claims through the Health Fund Office or as the Office directs. You are required to complete, sign and return one medical and one dental claim form per family each calendar year as directed by the Health Fund Office so that your records are set up for claims submitted later in the year.

 

A written copy of the claims procedure is provided automatically, at no charge, as a separate document.

 

You should keep copies of all your medical and dental expenses, claims and Explanation of Benefits (EOB) forms in case the Health Fund Office needs more information, or if you want to appeal a denied claim. The Health Fund Office may charge you if the staff has to research prior claims payments.

 

You have 365 days from the day you incurred a covered expense to file your claim. For instance, if you have medical treatment on July 1, 2001, you have until June 30, 2002 to file your paperwork. If you’re filing a claim for Weekly Disability Income (WDI), you have 90 days from the date the disability began to file your claim.

 

The Health Fund pays claims to you unless;

 

·            the claim is over $5,000, or

·            the provider tells the Health Fund Office that you’ve assigned payment to him or her.

 

A Bit of Information

The Health Fund Office understands that filling out forms can be boring and tedious. So why do you have to do it? Because the Health Fund is responsible for managing the money entrusted to it for your benefits.

 

Note: New laws about claims and appeals take effect January 2002. The Health Fund Office will send you revised information at no cost to you.

 

 

 

The Claims Process Step-by-Step

Medical and Dental

Death

Disability

Complete, sign and return one green and one yellow form per family every calendar year as directed by the Health Fund Office.

 

Send the insurance claim form that you get from each provider to the Health Fund Office whenever you receive care.

You or your beneficiary must:

 

·         Call the Health Fund Office to notify it of the death.

·         Compete, sign and return the paperwork along with the certified (original) death certificate.

Weekly Disability Income (WDI)

Total & Permanent  (T&P) Disability

Get a claim form from the Health Fund Office for your doctor to complete, sign and return to the Health Fund Office.

·         Apply to Social Security

·         Notify the Health Fund Office within 90 days after you receive your Social Security Award.

·         Apply to the insurance company for Waiver of Premium

 

The Claims Process Timetable

Within 90 days of filing a fully and properly completed and signed claim…

 

Note: Only you — or your beneficiary, if you died — may sign the claim form. Forms signed by anyone else will be returned for a correct signature.

Your claim will be paid or you’ll be told:

  • Up to an extra 90 days is needed to decide your claim, or
  • Your claim has been denied

 

If your claim is denied, you’ll be told why. If your claim form was returned to you for being incomplete you can resubmit it as long as it is within 365 days of the date on which you incurred the expense. 

Within 90 days of getting notice that your claim was denied…

Send a written request to the Health Fund Office to ask for a review. You can submit other paperwork along with your request and you’ll have the right to examine any plan documents that apply to your case.

 

If you’re claiming an Accidental Death & Dismemberment (AD&D) or life insurance benefit contact the insurance company to request a review and send a copy to the Health Fund Office.

At the next meeting of the Board of Trustees which is at least 30 days after receiving your request for a review…

The Health Fund Office will respond or will ask to review your appeal no later than the third Board of Trustees meeting after receiving your request.

 

Claims relating to insurance will be decided by the insurance company.

Within 90 days after your claim appeal is denied on review…

You may request in writing that your claim be sent to arbitration.


 

Reimbursing the Health Fund

If your claim indicates that you suffered an injury that was accidental, work-related, or caused by someone else, the Health Fund Office will send you a How, When and Where (HWW) form to complete, sign and return. Before your claim can be processed, your completed HWW form must be received by the Health Fund Office.

 

One of three things will happen when the Health Fund Office receives your completed HWW form:

 

  1. If the claim is work-related, you have to submit your claim to your Workers’ Compensation carrier. If Workers’ Compensation denies or your employer contests your claim, you must sign the Health Fund’s standard Workers’ Compensation Reimbursement Agreement and send it to the Health Fund Office with a copy of the Workers’ Compensation denial or the ”contest of liability.”
  2. If the claim is a result of a motor vehicle accident, you must send the Health Fund Office its standard signed Reimbursement Agreement, a copy of the declaration page of your auto insurance policy and a copy of the police report.
  3. For any claim that someone else may be liable for, the Health Fund’s standard Reimbursement Agreement must be signed and returned to the Health Fund Office before any claims will be processed. While you pursue the parties who may be legally liable for your illness or injury, the Health Fund Office will process and pay your claim.

 

In such cases the Health Fund will be entitled to be reimbursed any money it paid to or for you and your dependents when the claim is resolved, even if you will not recover any money after the reimbursement or haven’t signed the reimbursement agreement. The Health Fund may reduce its reimbursement claim if you do not have enough proceeds to pay your attorney’s fee, but never by more than 20 percent. Once your claim is resolved, the Health Fund won’t pay any future benefits for that injury or accident.

 

If you or your dependents fail to reimburse the Health Fund as required, the Health Fund may reduce future benefits due you or your family members to get reimbursed for the amount it paid in benefits, costs and legal fees.

 

 

Arbitration

If you don’t hear from the Health Fund Office within any of the time frames shown on the Claims Process Timetable on page 14, you may assume your claim has been denied and move on to the next step in the review/arbitration procedure. You must pay half the arbitration filing fee within 15 days of requesting arbitration. Later, the arbitrator may find that you must pay part of his or her fee.

 

Arbitration is mandatory, which means that you must go through the process before bringing suit against the Health Fund. But it’s not binding — if you’re not satisfied with the outcome, you may go to court.

 

The arbitrator will consider whether or not the Health Fund’s Trustees acted in accordance with the provisions of the Connecticut Carpenters Health Fund Plan document and if their decision was backed up with proper evidence.

 

 

C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d