United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

UFCW Calumet Region Insurance Fund

Claim Appeal Procedure

If you believe you have been improperly denied benefits provided for under the Plan, you are entitled to a full and fair review of your claim.

The procedure to follow to file an appeal is summarized here. For more detailed information, refer to the Health Benefits Plan Claim Procedures page of this website.

If your initial claim is denied, you will be given a written explanation within the period of time allowed by law. The explanation will provide:

  • the specific reason(s) for the denial, including a reference to the specific Plan provision on which the denial is based;
  • a description of any additional material or information required for you to show you are entitled to benefits;
  • an explanation of the procedure to be followed if you do not agree with the denial, including a statement of your right to file suit under ERISA, if you file an appeal and it is denied;
  • any internal rule, guideline, protocol or other similar criterion that was used in making the denial decision, or a statement that this information will be provided upon request;
  • an explanation of any scientific or clinical judgement for the denial decision if it was based on a medical necessity, experimental treatment or other exclusion or limit, or a statement that this information will be provided upon request; and
  • if your claim is an urgent claim, a description of the expedited review process available to you (in the case of an urgent care claim, we may provide this explanation orally and give you a written explanation later).

If you do not agree with the claim denial decision, you may file an appeal within one year of the date of the denial. To file an appeal, send a written statement that includes your reasons for appealing the denial decision and any supporting documents not previously furnished. If you need a description of any additional information to assist you in filing an appeal, contact the Fund Office. Send your appeal to:

Fund Administrator
Claim Appeal
UFCW Unions and Employers
Midwest Health Benefits Fund
18861 90th Avenue, Suite A
Mokena, IL  60448-8178

 
The Plan will make its decision within the period of time allowed by law. You will be advised in writing of the decision. The decision(s) that you receive from the Fund Administrator or from the Appeal Committee of the Board of Trustees will be written in a clear and understandable manner and will include a specific reason for the decision.

You have the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA) following a denial of a claim on appeal.
 

(Updated 09/26/13)