Filing A Claim

REMEMBER:  INFORMATION IS THE KEY TO RESOLVING CLAIMS

HOW DO I FILE AND/OR APPEAL A CLAIM FOR TEMPORARY DISABILITY BENEFITS?

• Submitting Claims – Disability claims must be filed with the Claims Administrator through the Local or State representative where you are a member.  Claims by retirees must be filed directly with the Claims Administrator. The Plan Administrator will furnish a claim form upon request. There is no cost or fee for filing a claim. All claims for benefits will be determined by the Claims Administrator.  Claims for disability benefits must be filed within 90 days after the day you return to work or are released by your doctor, whichever occurs first. If you experience a “prolonged disability” (defined as a disability which lasts 30 days or longer), you may make a claim for partial payments, but not sooner than each 30 day period.

• Denial of Claims by the Claims Administrator – If your disability claim is denied in whole or in part, the Claims Administrator will notify you within 45 days of the day it receives your claim. If the Claims Administrator needs more time to review your claim, he or she may take up to an additional 30 days, but will notify you in writing, within the first 45-day period, of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. If, due to circumstances outside the control of the Plan, a decision can not be made within the additional 30-day period, another 30-day extension may be taken, but the Claims Administrator will again notify you in writing of the reason for the extension and the date by which a decision will be made.

• First Appeal to the National Director – If your disability claim is denied by the Claims Administrator, you may appeal to the National Director to have your claim reconsidered for payment. Your appeal must be filed within 180 days of the day you receive notice that your claim has been denied by the Claims Administrator.  You may submit written comments, documents, records, and any other information you believe is relevant to your claim. These submissions will be taken into account when determining the final disposition of your claim regardless of whether they were submitted or considered in the initial benefit determination. You may request, at no charge to you, reasonable access to and copies of all documents, records and other information relevant to your claim. If the advice of any medical or vocational expert was obtained on behalf of the Plan in connection with your claim, such experts will be identified, regardless of whether their advice was relied upon in denying your claim. The review by the National Director will not afford deference to the initial claim denial. The review will not include the Claims Administrator, nor any individual who is the subordinate of the Claims Administrator. If the denialof your claim was based in whole or in part on a medical judgment, the National Director will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. This health care professional will not be an individual who was consulted in connection with the initial denial of your claim, nor will it be a subordinate of that individual.  You will be notified of the decision of the National Director within 45 days after the receipt of your appeal. If the National Director determines that additional time is necessary, you will be notified in writing within the initial 45-day period of the special circumstances requiring the extension and the date by which the National Director expects to resolve your claim. In no event will the extension exceed 45 days.

• Second Appeal to the Committee – If your disability claim is denied by the National Director, you may appeal to the Committee on Claims of the Board of Directors (the “Committee”) to have your claim reconsidered for payment.  Your appeal must be filed within 180 days of the day you receive notice that your claim has been denied by the National Director. You may submit written comments, documents, records, and any other information you believe is relevant to your claim. These submissions will be taken into account when determining the final disposition of your claim regardless of whether they were submitted or considered in the initial benefit determination. You may request, at no charge to you, reasonable access to and copies of all documents, records and other information relevant to your claim. If the advice of any medical or vocational expert was obtained on behalf of the Plan in connection with your claim, such experts will be identified, regardless of whether their advice was relied upon in denying your claim. The review by the Committee will not afford deference to the initial claim denial. The review will not include the Claims Administrator, the National Director, nor any individual who is the subordinate of the Claims Administrator or National Director. If the denial of your claim was based in whole or in part on a medical judgment, the Committee will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. This health care professional will not be an individual who was consulted in connection with the initial denial of your claim, nor will it be a subordinate of that individual. You will be notified of the decision of the Committee within 45 days after the receipt of your appeal. If the Committee determines that additional time is necessary, you will be notified in writing within the initial 45-day period of the special circumstances requiring the extension and the date by which the Committee expects to resolve your claim. In no event will the extension exceed 45 days. The decision of the Committee shall be final and binding upon all parties, unless you voluntarily elect to appeal to the Board of Directors.

• Voluntary Third Appeal to the Board of Directors – If your disability claim is denied by the Committee, you may, but are not required to, appeal to the Board of Directors to have your claim reconsidered for payment. You may appeal to the Board of Directors only after you have appealed to the National Director and to the Committee. Your appeal must be filed within 180 days of the day you receive notice that your claim has been denied by the Committee. Any statute of limitations or other defense based on timeliness is tolled during the time that your appeal to the Board of Directors is pending, and the Plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to appeal to the Board of Directors. If you elect to appeal to the Board of Directors, the decision of the Board of Directors shall be final and binding upon all parties. Additional information about appealing to the Board of Directors is available upon written request to the Plan Administrator.

IN THE EVENT OF DEATH FROM A COVERED ACCIDENT, HOW DOES MY BENEFICIARY FILE AND OR APPEAL A CLAIM? 

• Submitting Claims – Death and dismemberment claims must be filed with Sun Life and Health Insurance Company (“Sun Life”) through the Home Office.  The Plan Administrator will furnish a claim form upon request. There is no cost or fee for filing a claim. All claims for death and dismemberment benefits will bedetermined by Sun Life. Claims for death benefits (including benefits for spouses and dependents) must be filed within 1 year of the date of death. Claims for deathbenefits must include a copy of the certified death certificate and, if performed, a copy of the autopsy and/or medical examiners report (including the toxicology report). Claims for dismemberment benefits must be filed within 90 days after the day you return to work.

Appeal of Claims – If your claim for death or dismemberment benefits is denied, you may appeal to Sun Life to have your claim reconsidered for payment.  Your appeal must be filed within 180 days of the day you receive notice that your claim has been denied. You may submit written comments, documents, records, and any other information you believe is relevant to your claim. These submissions will be taken into account when determining the final disposition of your claim regardless of whether they were submitted or considered in the initial benefit determination. You may request, at no charge to you, reasonable access to and copies of all documents, records and other information relevant to your claim. You will be notified of the decision of Sun Life within 60 days after the receipt of your appeal. If Sun Life determines that additional time is necessary, you will be notified in writing within the initial 60-day period of the special circumstances requiring the extension and the date by which Sun Life expects to resolve your claim. In no event will the extension exceed 60 days. The decision of Sun Life shall be final and binding upon all parties.

• Denial of Claims – If your claim for death or dismemberment benefits is denied in whole or in part, Sun Life will notify you within 90 days of receipt of the claim. If Sun Life needs more time to review your claim, it may take up to an additional 90 days, but will notify you in writing, within the first 90 day period, of the circumstances requiring the extension and the date by which a decision will be made.

THE PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT ("ERISA") FOR THE AMERICAN POSTAL WORKERS ACCIDENT BENEFIT ASSOCIATION PLAN (THE "PLAN").  THIS DOCUMENT SUPERSEDES THE DISABILITY AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS DESCRIBED IN THE CERTIFICATE OF BENEFITS OF THE AMERICAN POSTAL WORKERS ACCIDENT BENEFIT ASSOCIATION PLAN, CHARTER CONSTITUTION, BY-LAWS, RITUAL & CERTIFICATE OF BENEFITS DATED AUGUST 2006, AND IN ANY OTHER SOURCE.

AMERICAN POSTAL WORKER ACCIDENT BENEFIT ASSOCIATION PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR DISABILITY AND ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS AS REVISED DECEMBER 2008 IS AVAILABLE ON THIS WEB SITE (SUMMARY PLAN DESCRIPTION) AND HAS BEEN MAILED TO EVERY MEMBER VIA FIRST CLASS MAIL TO THEIR ADDRESS OF RECORD.

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