The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
above and claims and appeals guidance issued by the Department of Labor, you will be deemed
to have exhausted the internal claims and appeals process and you may initiate an external
review or bring suit under section 502 of ERISA. However, this strict adherence rule does not
apply if the violation is:
• very minor,
• non-prejudicial,
• attributable to a good cause or matters beyond the Plan’s control,
• made in the context of an ongoing good faith exchange of information, and
• not reflective of a pattern or practice of noncompliance.
If the claims procedures have not been strictly adhered to, you have the right to request a written
explanation of the violation from the Claims Administrator. Within 10 days after receipt of your
request, the Claims Administrator will provide you an explanation of the basis, if any, for
asserting the violation should not cause the internal claims and appeals process to be deemed to
be exhausted. If an external reviewer or court rejects your request for immediate review, you will
be able to resubmit your claim and pursue the internal claims process.
General Rules for Internal and External Claims
• Your initial claim, any request for review of an adverse benefit determination, and any
request for external appeal must be made in writing, except for requests for review of
adverse benefit determinations relating to Urgent Claims, which may also be made orally.
• You must follow the claim-and-review procedure contained in this SPD carefully and
completely and you must file your claim before any applicable deadlines. If you do not
do so, you may give up important legal rights.
• Your casual inquiries and questions will not be treated as claims or requests for a review
or submissions to the external appeal process,
• You may have a lawyer or other representative help you with your claim at your own
expense (the Claims Administrator or U.S. Bank may require written authorization to
verify that an individual has been authorized to act on your behalf, except that for Urgent
Claims a health care professional with knowledge of the claimant's medical condition
will be permitted to act as an authorized representative).
• You are entitled to receive, upon request and free of charge, reasonable access to, and
copies of, all documents, records, and other information relevant to any adverse benefit
determination. You will also be allowed to review the claim file and present evidence and
testimony as part of the internal claims and appeal process.
• You must comply with any additional requirements for filing a claim (e.g., using a
specific claim form) imposed by the Claims Administrator.
Exhaustion of Administrative Remedies
The exhaustion of the claim-and-review procedure (with the exception of the external claim
review process) is mandatory for resolving every claim and dispute arising under this Program
prior to initiating legal action (except if the internal claim and appeal process is deemed
exhausted under the rules in the section “Failure to Strictly Adhere to Internal Claims and
Appeals Process”). In any legal action brought after you have exhausted the administrative
remedies, all determinations made by the Claims Administrator, U.S. Bank or other fiduciary,
shall be afforded the maximum deference permitted by law.
118