HOW TO FILE A CLAIM
Much of the delay in processing claims can be directly related to incomplete or incorrectly completed claim forms being submitted to the Fund. If you follow the instructions outlined below, you will be helping the Fund provide you with the fastest claim service possible.
The benefits described in this Booklet have a heading for each type of benefit and state who may be covered for that benefit (for example, "Member only," "Member and Spouse only," etc.). For any limitations in your particular plan, please refer to the Summary of Benefits Schedule.
When a Claim Form is Not Needed:
IN ALL OTHER CASES, USE A
CLAIM FORM AND FOLLOW
2. FOR MEDICAL EXPENSES:
For your convenience, the Fund has developed a single claim form which may be used for most of your medical expenses. These forms may be obtained either from the Fund office, the Fund's web site or from your Local Union. All you need to do is check the appropriate block at the top of the claim form and follow the instructions given above to obtain your benefits.
3. FOR WEEKLY DISABILITY BENEFITS:
4. FOR DEATH BENEFITS:
5. FOR MEMBER TOTAL DISABILITY EXTENDED DEATH BENEFITS:
This is a special form obtained only from the Fund office. This form must be completed yearly in order to qualify for coverage.
6. FOR VISION BENEFITS:
The Vision Form may be obtained from the Fund office, the Fund's web site or your Local Union.
7. FOR PHARMACY BENEFITS:
Use your Prescription Drug Card when obtaining your prescription. If the pharmacy does not accept your card, you may still have your prescription filled (or refilled) and file a completed "Direct Pay Card" with the Fund. The “Direct Pay Cards" are obtained from the Fund office for reimbursement by the Pharmacy Card Company. Keep in mind that when using the "Direct Pay Cards" your deductible may be larger because your druggist is charging you whatever the market will bear, but the Pharmacy Card Company will only pay you the Usual, Customary and Reasonable allowance for the prescription.
8. FOR DENTAL BENEFITS:
Because most of the Fund's eligible participants have been receiving dental treatment on a regular basis, all you need generally do to obtain a Dental Claim Form is call the Fund office or print one from the Fund's web site. If, however, any of the following conditions exist, you may be required to be examined by a dentist selected by the Fund prior to beginning treatment:
9. HOW SOON SHOULD YOU FILE YOUR CLAIM? As soon as you can!
Written proof of loss must be furnished to the Fund within ninety (90) days after the date of such loss. Failure to furnish said proof within such time shall not invalidate or reduce any claim if it was not reasonably possible to give proof within such time, providing the Fund's liability position has not been prejudiced by the late filing.
All benefits provided by the Fund will be paid promptly upon receipt of proof of loss. Any benefit payable for loss of the Member's life will be payable to the Member's beneficiary; other benefits will be payable to the member, or the member may assign these other benefits to the Provider of Service.
In the event of an overpayment, either to you or to a "Provider of Service" on your behalf or on a Family Member's behalf, the Fund reserves the right to reduce subsequent Family Member benefit payments by the amount of such overpayment.No claim will be honored or payable unless the claim is received in and filed with the Fund office prior to December 31st of the third year immediately following the year in which the loss was incurred or services were rendered. No action at law or in equity shall be brought to recover the allowable benefits prior to the expiration of sixty (60) days after proof of loss has been furnished nor shall such action be brought at all unless brought prior to December 31st of the third year immediately following the year in which the loss was incurred.