2013 XGS Office SPD.pdf - US Xpress

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fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights. If your claim for a welfare benefit is denied or ignored, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court, provided that you have exhausted your administrative appeal rights. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous. Assistance With Your Questions. If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest Area <strong>Office</strong> of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Claims Procedures Specific claim procedures for medical benefits are set forth in the medical Evidence of Coverage document. Specific claim procedures for long-term disability benefits, accidental death and dismemberment benefits and group term life insurance benefits are set forth in the certificates of insurance that describe those benefits. Specific claim procedures for dependent care assistance benefits and medical reimbursement benefits are set forth in the separate summary of those benefits. The following claim procedures apply to dental and vision benefit claims. References to the insurance carrier refer to Delta Dental Plan of Tennessee for dental benefits and VSP for vision benefits. If you are required to obtain pre-approval from your insurance carrier as a prerequisite to obtaining a benefit, you should follow the pre-approval procedures established by the insurance carrier. If you contact your insurance carrier to obtain pre-approval but you fail to follow the pre-approval procedure for filing a pre-service claim, the insurance carrier is required to notify you of this failure and the proper procedure for filing the pre-service claim. A pre-service claim is a benefit claim that requires some form of pre-approval by the insurance carrier. The notice is required to be provided to you as soon as possible but not later than 5 days after the failure, or, in the case of an urgent care claim (see below), within 24 hours of the failure. The notice may be given to you orally, unless you request a written notice. 14
You may designate a representative to act on your behalf in pursuing a benefit claim or appealing a denial of a benefit claim by contacting your insurance carrier. Even if you have not formally designated a representative, your physician or licensed health care professional may act on your behalf as your authorized representative if the benefit claim is an urgent care claim (see below). The period within which the insurance carrier is required to decide your claim depends upon the type of claim being made. There are generally three types of claims that can be made under the Plan – a pre-service claim, an urgent care claim, and a post-service claim. Pre-Service Claim – A pre-service claim is a claim for a benefit which requires some form of preapproval by the insurance carrier. The insurance carrier must decide a pre-service claim within 15 days. This 15 day period may be extended for up to an additional 15 days if the insurance company determines the extension is necessary for reasons beyond its control. The insurance carrier is required to notify a claimant in writing if there is an extension. Urgent Care Claim – An urgent care claim is a pre-service claim where application of the normal period for deciding pre-service claims could jeopardize the life, health or ability to regain maximum function of the claimant, or would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is being claimed. The insurance carrier is required to decide an urgent care claim within 72 hours. Post-Service Claim – A post-service claim is any claim that is not a pre-service claim. It would include a claim in which the medical procedure has already occurred and the claimant is seeking payment of it or reimbursement for it. The insurance carrier is required to decide a post-service claim within 30 days. This 30 day period may be extended for up to an additional 15 days if the insurance carrier determines the extension is necessary for reasons beyond its control. The insurance carrier is required to notify a claimant in writing if there is an extension. In addition, some special rules apply where the insurance carrier has already approved an ongoing course of treatment over a period of time or number of treatments. First, if the insurance carrier reduces or terminates coverage for the course of treatment before it otherwise would have ended, that reduction or termination is a benefit denial. The insurance carrier must notify the claimant sufficiently in advance of the reduction or termination to allow the claimant to appeal the decision (see Appealing a Claim below) and to obtain a decision on the appeal. Second, if the claimant requests an extension of the course of treatment at least 24 hours before the course of treatment ends and it is an urgent care situation (see Urgent Care Claim above), the insurance carrier must notify the claimant within 24 hours of its decision on the extension request. If your claim is allowed, the insurance carrier will notify you who has been paid and the amount that has been paid, or will be paid, in the case of a pre-service claim. If your claim is denied in whole or in part, you will receive a written notice which must include the following information: 1. The specific reason or reasons for the denial of all or any portion of the claim. 2. The specific provisions of the coverage certificate, subscriber contract, the Plan and any other document, on which the denial is based. If the decision to deny benefits is based, in whole or in part, on a specific internal rule, guideline, protocol or similar criteria, either a copy of the document will be provided to you or you may request a copy of such document from the insurance carrier at no charge. If the decision to deny benefits is based, in whole or in part, on an exclusion or limitation that the treatment is experimental or investigational, or that the treatment is not medically necessary, either an explanation that applies the appropriate terms to your medical circumstances, and which details the scientific or clinical judgment that led to the decision to deny benefits will be provided to you or you may request such an explanation from the insurance carrier at no charge. 15
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Page 3 and 4: The enrollment periods for the Plan
Page 5 and 6: copy of the certificate of insuranc
Page 7 and 8: 2. Significant Curtailment of Cover
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Page 11 and 12: 4) Your spouse becomes entitled to
Page 13: In addition, the Plan will make ben
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Page 19: Please contact the Benefits Departm
Page 29 and 30: OFFICE SHORT TERM DISABILITY • Up

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