* Administering Health, Pension and Vacation Benefits For the Men and Women Who Help Build the Southwest *
This section describes the procedures for filing claims for Pension and Disability benefits from the Southwest Carpenters Pension Trust. This section describes the procedure for you to follow if your claim is denied in whole or in part and you wish to appeal the decision.
These procedures only apply to a “claim for benefits.” A claim for benefits includes:
What is NOT a “Claim for Benefits”
Certain inquiries, questions and requests regarding eligibility or available benefits made before an application for benefits is completed are not subject to the time limits that apply to Claims and carry no right to appeal.
Claims must be received at the Administrative Office located at:
Southwest Carpenters Pension Trust
533 South Fremont Avenue
Los Angeles, CA 90071-1706
FAX (213) 739-9369
An authorized representative, such as the holder of power of attorney or a court-appointed conservator, may complete the claim form for you if you are unable to complete the form yourself. A form can be obtained from the Administrative Office to designate an authorized representative. The Administrative Office may request additional information to verify that this person is authorized to act on your behalf.
The deadlines for processing your claim for benefits will vary depending on whether your claim is for a Pension benefit or a Disability benefit.
Pension claims will be decided and notice of the decision given to you within a reasonable period of time, not later than 90 days after receipt of the claim by the Administrative Office.
This period may be extended one time for up to 90 days, provided that the Administrative Office both: (1) determines that special circumstances require the extension; and (2) notifies you, prior to the expiration of the initial 90-day period, of the circumstances requiring the extension of time and the date by which a decision on your claim may be expected.
Disability Benefit Claims will be decided and notice of the decision given to you within a reasonable period of time, not later than 45 days after the receipt of the claim by the Administrative Office.
This period may be extended two times by the Administrative Office for up to 30 days each, provided that the Administrative Office both: (1) determines that such an extension is necessary due to matters outside the control of the Administrative Office; and (2) notifies you, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which a decision on your claim may be expected.
Any notice of extension shall explain the criteria on which the entitlement to benefits is based, the unresolved issues that prevent a decision on the claim, and any additional information needed to resolve those issues.
A claim is “received” for purposes of these rules when the signed benefit application form is received by the Administrative Office, although additional information, including election forms, tax forms, retirement declarations, etc. may be required before an initial determination can be made on the application. The Administrative Office will specify what additional information may be needed.
If your claim is received without all the information needed to process your claim, you will be notified by the Administrative Office of what additional information is needed and you will be given additional time to supply the missing information. The time periods for making decisions discussed in paragraphs 1 and 2 above are suspended from the date you are notified of the need to supply missing information until the date you respond to the notice to the Administrative Office.
In the case of a claim for pension benefit you will be given 90 days to provide the missing information. If such information is not received by the Administrative Office within the 90-day extension period, the claim will be denied, and a new application must be filed with the Administrative Office.
In the case of a claim for a Disability Pension benefit you will be given at least 45 days to provide the missing information. If such information is not received by the Administrative Office within the 45-day extension period, the claim will be denied, and a new application must be filed with the Administrative Office.
If your claim for benefits is denied in whole or in part, the Administrative Office will provide you a written notification setting forth:
In addition, for Disability Claims, the following additional information, as necessary:
You may appeal a denial of your claim for benefits by filing a written review request with the Pension Appeals Committee at the Administrative Office. The Trust’s Benefits Committee serves as the Pension Appeals Committee. The deadlines for filing an appeal will vary depending on whether your claim is for a Pension benefit or a disability benefit. Each appeal must be delivered to the Administrative Office by First Class Mail or personal delivery.
You have 60 days following receipt of notification of an adverse determination to file an appeal of a denied claim for Pension benefits. You have 180 days following receipt of notification of an adverse determination to file an appeal of a denied claim for Disability Pension benefits.
Any request for review received by the Administrative Office after these time frames is untimely and subject to denial on review on that basis alone.
You will be given the opportunity to submit written comments, documents, records and other information relating to the claim. The Administrative Office will provide you, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim. The review of the claim will take into account all comments, documents, records and other information you submit relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. The review will be conducted by the Pension Appeals Committee and their decision will be independent of the initial denial. The Pension Appeals Committee will not include the same individual who made the initial decision nor the subordinate of such individual.
The Administrative Office will take steps to ensure and to verify that your benefit claim determinations are made in accordance with governing Plan documents and that these Plan provisions have been applied consistently with respect to you and other similarly-situated claimants.
A determination on review is required to be made by the Pension Appeals Committee no later than the date of the meeting of the Pension Appeals Committee that immediately follows receipt of the request for review by the Administrative Office, unless the request for review was filed within 30 days preceding the date of such meeting. In such a case, a benefit determination on review may be made no later than the date of the second meeting following the receipt of the request for review. If special circumstances require a further extension of time for processing, a benefit determination on review shall be rendered not later than the third meeting of the Pension Appeals Committee following the receipt of the request for review. If special circumstances require such an extension, the Administrative Office will notify you in writing of the extension, describing the special circumstances and the date on which the benefit determination on review will be made. If an extension is due to your failure to submit information necessary to decide the claim, the period for making the determination on review will be suspended from the date on which the notification or extension is sent to you until the date on which you respond to the request for additional information. Notice of the benefit determination on review will be given not later than five days after such a determination is made.
The Administrative Office will provide you with written notification of the determination on review. If the determination is adverse, the written notice will set forth:
In carrying out their responsibilities under the Plan, the Trustees have discretionary authority to interpret the terms of the Plan and to interpret any facts relevant to the determination, and to determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan and in accordance with the Trustees’ intent in adopting those Plan provisions. Any interpretation or determination made under this discretionary authority will be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.
Any Participant or other person seeking or obtaining the benefits of the Plan agrees that the Trust may recoup, offset other payments due from the Plan, or obtain any other appropriate remedy, including recouping costs of collection and punitive damages, if applicable, with respect to (1) any amounts paid by the Plan in excess of the amounts payable under the Plan, or (2) any amounts paid as a result of fraud, misrepresentation or concealment, including by means of false or incomplete information in an application. In addition to recovering the excess amounts paid, the Trust is required to recover interest at the Plan’s rate of return from the date of the overpayment until the date of repayment.
You may not file a lawsuit to obtain benefits until you have exhausted all of the claim and appeal procedures and a final decision has been made on your appeal, or until the appropriate time frame described above has elapsed without a final decision being rendered on your claim or appeal for benefits. You must bring any suit under Section 502 of ERISA within one year of the exhaustion of your claim and appeal administrative remedies as described in the preceding sentence. These procedures are intended to comply with ERISA § 503 and Regulations developed by the United States Department of Labor at 29 CFR § 2560.503-1 effective for benefit claims filed with the Administrative Office on and after January 1, 2002.