How do I appeal a decision of the Fund?

Appealing a Decision of the Fund

Every now and then you get the unpleasant news that an expense you had was denied. You’ve called the Fund office and still have not been able to work it out.  Is there any avenue left for you to take? Sometimes, the answer is yes.

First you need to answer a few questions:

  1.  Is the benefit normally covered?
  2. Am I sure there are no exclusions that apply?
  3. Did I meet all of the requirements to be eligible and if not, were my circumstances unique?
  4. Did I receive the denial less than 180 days ago?

If the answers to all of these questions are yes, then you may want to consider sending in a letter of appeal.

Now, you need to do your homework.   Make sure that what you are putting in writing is factual.   Attach supporting documentation attesting to those facts.   If it’s a dental appeal, have your dentist help you by supplying you with a written narrative explaining why your situation is unique . If all is in order your appeal will be reviewed by the Funds’ Trustees at their next quarterly meeting.   Your request needs to be timely, so make sure that you’ve included everything that you think might be helpful.

The Trustees can only entertain the facts surrounding your particular situation.  Many times the Fund receives a letter that simply states “I’m appealing the denial of ……”.  Well, logically thinking  – what could you do with this?  Be precise and lay out your case so that the Trustees can clearly see your point.  The Trustees can’t help you if your only basis for the appeal is what you think should have happened.

Don’t confuse your request for new benefits with an appeal for denied benefits. The Trustees periodically review your plan of benefits, and when circumstances are right to add something new, it’s done in a manner consistent with fairness for all. A forward-looking effective date is the first thing established so that all members of the Fund will have equal access.

(To submit at appeal please send it to the address listed here)