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December 27, 2016 | Print | Site Map | Help
 

Pension Plan

 
Right of Appeal and Determination of Disputes
  1. No Participant, Pensioner, Beneficiary or other person shall have any right or claim to benefits under the Pension Plan, other than as specified in the Pension Plan. If any person shall have a dispute with the Board of Trustees as to eligibility, type, amount or duration of such benefits, the dispute shall be resolved by the Board of Trustees under and pursuant to the Pension Plan, and its decision of the dispute shall be final and binding upon all parties thereto.
  2. Except as noted below, any person whose application for benefits under the Plan has been denied in whole or in part, or whose claim to benefits or against the Fund is otherwise denied, must be notified of such denial, in writing of the denial, within 90 days after receipt of the application or claim. An extension of time not to exceed an additional 90 days may be required by special circumstances. If so, notice of the extension, indicating what special circumstances exist and the date by which a final decision is expected to be made available, must be furnished to the claimant prior to the expiration of the 90-day period.

    If an application for disability benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) is denied, the applicant will be notified of the denial, in writing 45 days after receipt of the application or claim for such disability benefits. This 45-day period may be extended for up to an additional 30 days if it is determined that such an extension is necessary due to matters beyond the control of the Plan and the applicant is notified prior to the end of the initial 45-day period, in writing, of such extension and the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If prior to the end of the first 30-day extension period, it is determined that, due to matters beyond the control of the Plan, a decision cannot be made within the extension period, the period for making the decision may be extended for up to an additional 30 days, provided that the applicant is notified, prior to the end of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to make a decision. This notice will be in writing and will specifically explain the Plan provisions on which the entitlement to such disability benefits is based, the unresolved issues that prevent a decision, and the additional information needed to resolve those issues; and the applicant will be given at least 45 days within which to provide the specified information.

    The period of time within which a benefit determination is required to be made will begin at the time an application for benefits is filed with the Fund Office without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended, as permitted above, due to an applicant’s failure to submit information necessary to make a determination, the period for making the benefit determination will be tolled from the date on which the notification of the extension is sent to the applicant until the date on which the applicant responds to the request for additional information.

    The notice of denial must be set forth in a manner calculated to be understood by the claimant (1) the specific reason or reasons for the denial; (2) specific reference to pertinent Plan provisions on which the denial is based; (3) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why that material or information is necessary; and (4) appropriate information as to the steps to be taken if the claimant wishes to submit his or her claim for review, and (5) a statement of the claimant’s right to bring civil action under §502(a) of ERISA.

    In addition to the above, for a claim for disability benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a), the written notification of the benefit denial will include the specific rule, guideline, protocol or other similar criterion relied upon in making the adverse determination.
  3. Any person may petition the Board for a review of the denial of his claim. A petition for review must be in writing, must state in clear and concise terms the reason or reasons for disputing the denial, must be accompanied by any pertinent documentary material not already furnished to the Fund, and must be filed by the petitioner or his duly authorized representative with the Secretary of the Board within 60 days after the petitioner received notice of the denial. In the case of a claim for disability benefits under whose application for benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a), the petitioner or the petitioner’s duly authorized representative must file his or her petition for reconsideration within 180 days. The petitioner or his duly authorized representative will be permitted to review pertinent documents and submit issues and comments in writing.
  4. Upon good cause shown, the Board may permit the petition to be amended or supplemented and may grant a hearing on the petition before a hearing panel consisting of at least one Employer Trustee and one Employee Trustee to receive and hear any evidence or argument which cannot be presented satisfactorily by correspondence. The petitioner or his duly authorized representative will be permitted to review pertinent documents. The failure to file a petition for review within the 60-day period (180-day period for disability benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a)), or the failure to appear and participate in any hearing, will constitute a waiver of the claimant’s right to review of the denial, provided that the Board may relieve a claimant of any waiver for good cause if application for relief is made within one year after the date shown on the notice of denial.
  5. Upon request, the petitioner or the petitioner’s duly authorized representative will be provided, free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the petitioner’s claim for benefits. A document, record or other information shall be considered relevant to a petitioner’s claim if it was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the benefit determination; demonstrates that the benefit determination was made in accordance with the Plan provisions and that such provisions have been applied consistently with respect to similarly situated claims; and, in regards to disability benefits under Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a), the Plan’s policy or guidance with respect to the benefit denial (whether or not it was relied upon in making the benefit determination) and other relevant information. Relevant information also includes identification of any medical or vocational expert whose advice was obtained on behalf of the Plan in connection with the adverse benefit determination, without regard to whether the advice was relied upon in making the benefit decision.

    The review of the determination will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim without regard to whether such information was submitted or considered in the initial benefit determination.

    In the case of a Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) disability determination, the petitioner shall have access to relevant documents, records and other information relevant to the petitioner’s claim, including any statement of policy or guidance with respect to the Plan concerning the denial of such disability benefits, without regard to whether such advice or statement was relied upon in making the benefit determination. The Board of Trustees will not afford any deference to the initial benefit determination. If the adverse benefit determination is based in whole or in part on a medical judgment, the Board of Trustees shall consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment. Such consultant shall be different from any individual consulted in connection with the initial determination and shall not be the subordinate of any such person.
  6. A decision by the Board shall be made at the first regularly scheduled quarterly Trust meeting after the Trust’s receipt of the petition for review, except that an extension of time until the next meeting may be required if the appeal was received within thirty (30) days of the Trust meeting. If special circumstances require a further extension of time for processing, a benefit determination will be rendered no later than the third meeting following the Trust’s receipt of the petition for review and the Trustees will provide the petitioner with a written notice of the extension, describing the special circumstances and the date as of which the benefit determination will be made prior to the commencement of the extension. The Trustees will notify the petitioner of the benefit determination as soon as possible but not later than 5 days after the benefit determination is made.

    The petitioner will be advised of the Board’s decision in writing. The decision must include specific reasons for the decision, written in a manner calculated to be understood by the petitioner and specific references to the pertinent Plan provisions on which the decision is based. It will also include a statement that the petitioner is entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to the claim for benefits. The notification of a benefit determination in regards to a Subsections 3.06.c., 6.05.b.(3) and 6.06.f.(1)(a) disability benefit will include the above, along with the specific rule, guideline, protocol or other similar criterion relied upon in making the adverse determination.
  7. The denial of an application or claim to which the right to review has been waived, or the decision of the Board with respect to a petition for review, will be final and binding upon all parties, including applicant, claimant or petitioner and any person claiming under the applicant, claimant or petitioner, subject only to judicial review as provided in Subsection a. The provisions of this Section will apply to and include any and every claim to benefits from the Fund, and any claim or right asserted under the Plan or against the Fund, regardless of the basis asserted for the claim, regardless of when the act or omission upon which the claim is based occurred, and regardless of whether or not the claimant is a “Participant” or “Beneficiary” of the Plan within the meaning of those terms as defined in ERISA.

References to specific section(s) of the Plan can be found in the Official Plan Document under Plan Documents on this website.

Contact Plan Administrator

Telephone NumberPhone:
(866) 894-3705

ContactEmail:
paintersinfo@hsba.com

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Dublin, CA 94568-7756

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