SAG-AFTRA Health SPD

Claims and Appeals

A Claim for benefits is a request for benefits made in accordance with the Plan’s Claims procedures outlined in this section. Simple inquiries about the Plan’s provisions unrelated to a specific Claim are not treated as Claims for benefits, nor are requests for prior approval of benefits that do not require such approval.

In addition, when you present a prescription to a pharmacy to be filled under the terms of the Plan, that request is not a Claim under these procedures. However, if your prescription request is denied in whole or in part, you may file an appeal of the denial by using the procedures outlined under “Health, Disability and Retroactive Removal of Coverage Appeals.”

Authorized Representatives

If you wish to designate an authorized representative to act on your behalf with respect to your Claim for benefits, you must complete the Plan’s Authorization for Release of Health Information Form. Please contact the Plan to request this form or download the current version from the forms section. If you designate an individual to act as your authorized representative, he or she may complete the Claim form for you if you are unable to complete the form yourself.

Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable. Any payment by the Plan directly to a Provider pursuant to a written election or purported assignments submitted by a Participant or a Dependent is provided at the discretion of the Board of Trustees as a convenience to the Participant or Dependent and does not imply an enforceable assignment of any benefits or the right to pursue a Claim or cause of action.

How to File a Claim

Claims for Hospital and Medical Benefits

When you use In-network Providers, the Provider will file the Claim for you. For out-of-network Claims, the Provider may file the Claim for you. If the Provider files the claim, all Claims from California Providers and facilities should be sent to:

Anthem Blue Cross

P.O. Box 60007

Los Angeles, CA 90060-0007

Claims from Providers and facilities in states outside California should be sent to the local Blue Cross and Blue Shield plan for the area where the Provider is located. The local plan claim submission addresses can be obtained by calling (800) 810-BLUE.

If you file the Claim, you must complete a Claim form and submit it to the Plan:

SAG-AFTRA Health

Plan P.O. Box 7830

Burbank, CA 91510-7830

Claim forms may be obtained from the Plan or downloaded from the forms section.

The Plan will accept Hospital expenses for up to 18 months after the date of service, and medical expenses for up to 15 months after the date of service. Any requests for payment of Hospital expenses submitted more than 18 months after the date of service or for payment of medical expenses submitted more than 15 months after the date of service will be considered time barred and will not be considered for payment.

If you receive treatment outside of the United States, submit a detailed bill (along with an English translation, if applicable) to the Plan. The bill should include the date that services were provided, a description of each service, the charge for each service and the reason treatment was provided. Be sure to also include the type of currency that was used when you paid for these services.

Before submitting a Claim form, be sure it is filled out properly. To avoid delay in the processing of your Claims, follow these steps:

Be sure to complete Part 1 of the Plan’s Claim form in full. Attach your Physician’s itemized bill to the completed Claim form.

You and the Physician should complete a separate form for each family member and for each illness, as applicable.

If you are seeing a Physician(s) for more than one illness or injury, you must submit a form for each illness or injury, as applicable.

Please answer all questions completely.

Make sure you or your authorized representative answer all questions about other insurance. Provide the name(s) of the other insurance, the address, identifying codes, and the name of the policyholder. Failure to provide information about other insurance and to answer questions honestly and completely may constitute fraud.

When you are covered by more than one plan, each plan will require a copy of all itemized bills with the diagnosis and corresponding EOBs. A copy of the operative and pathology reports is required for most surgical procedures. Please submit copies of the reports when you submit the surgeon’s bill.

Be sure to complete Part 3 of the Claim form if you wish the Plan to make payment directly to the Provider of services. An updated assignment of benefits is required every 12 months. Only the Participant can assign payment of benefits. This cannot be done by any other person, including your eligible Dependent(s). The Plan accepts “Signature on File” as a valid assignment of benefits, though we reserve the right to request the actual assignment.

If reimbursement for medical expenses and correspondence are to be handled by your business manager or accountant, please let us know in writing at the time you submit your first Claim form. We cannot give information to a third party without your written permission. An Authorization for Release of Health Information is available from the Plan or from the forms section.

Do not forget to sign the form. Your business manager or legal representative cannot sign for you unless he or she has power of attorney. If that is the case, please send a copy of the authorizing document.

If you have questions, contact the Plan at (800) 777-4013 or log in to your Benefits Manager and use the Plan’s secure message center.

Claims for Mental Health and Substance Abuse Benefits

When you use In-network Providers for inpatient care, alternative levels of care or outpatient therapy, the Provider will file the Claim for you. When you use an Out-of-network Provider for outpatient therapy, you or your Provider should submit Claims directly to Beacon Health Options. Do not send Claim forms to the Plan.

Beacon Health Options

Latham Claims

P.O. Box 1290

Latham, NY 12110

You may download Claim forms from the forms section or request a form by calling the Plan.

Follow the instructions on the Claim form carefully and answer all questions completely. This will expedite the processing of the Claim. If you would like benefits to be paid directly to the Provider, be sure to sign the form in the space provided.

Claims for Prescription Drug Benefits 

If you use a non-participating retail pharmacy for your prescription drugs, you must file a Claim with Express Scripts. Claim forms may be requested by calling the Plan or they may be downloaded from the forms section. Alternatively, you may call Express Scripts at (800) 903-4728.

Non-participating retail pharmacy Claims should be submitted to:

Express Scripts, Inc.

Attention: Commercial Claims

P.O. Box 14711

Lexington, KY 40512-4711

You will be reimbursed the amount that would have been charged by a participating pharmacy less the required Copay.

If your prescription drug coverage is provided under the medical benefits, submit your Claims to the Plan. A prescription drug Claim should include a medical Claim form, a copy of the prescription and the original receipt.

Claims for Dental Benefits

When you use an in-network Dentist, the Dentist will file the Claim for you. When you use an out-of-network Dentist, you or your Dentist should submit Claims directly to Delta Dental. Do not send Claim forms to the Plan.

Delta Dental of California

Claims Department

P.O. Box 997330

Sacramento, CA 95899-7330

Claim forms may be downloaded from the forms section or from Delta Dental’s website, www.deltadentalins.com/sag-aftra. Forms may also be requested by calling the Plan. Follow the instructions on the Claim form carefully and answer all questions completely. This will expedite the processing of the Claim. If you would like for benefits to be paid directly to the Dentist, be sure to sign the form in the space provided.

If your estimated charges are less than $300, the Claim form serves as a statement of actual charges. You must complete the employee section while your Dentist completes the Dentist’s section. Send the completed form to Delta Dental after services are performed.

If your estimated charges are $300 or more, the form may serve as a pre-treatment estimate of charges. You must complete the employee section while your Dentist completes the Dentist’s section before treatment begins. The form should then be sent to Delta Dental. After review, a statement indicating the benefits payable under the Plan will be returned to you and your Dentist. When the work is completed, your Dentist should indicate on the statement the specific services performed, the date performed and the actual charges.

Claims for Vision Benefits

If an Exam Plus eye exam is received through a VSP Provider, the Provider will file the Claim for you. If you use a non-VSP Provider, you should request a copy of the bill showing the amount of the eye examination.

Send the bill to:

VSP Vision

Attention: Non-Member Doctor Claims

P.O. Box 385018

Birmingham, AL 35238-5018

Be sure to include the Participant’s name, mailing address and ID number, as well as the patient’s name, relationship to Participant and date of birth.

Claims for Life Insurance or AD&D Benefits

In the event of your death, your Dependent or beneficiary should provide a certified copy of your death certificate, and, if appropriate, evidence of the accidental nature of death to the Plan. In the event of any other loss that may be covered under the AD&D benefit, you should notify the Plan promptly. You should also contact the Plan if you are applying for an accelerated life insurance payment. A Claim form will be sent to you.

General Information About Claims

Types of Claims

A Pre-service Claim is a Claim for a benefit for which the Plan requires approval before medical care is obtained. For Hospital and medical benefits, prior approval is required for the following:

  • Bariatric surgery;
  • Eyelid, nasal and certain breast surgeries;
  • Gender reassignment surgery;
  • Neuro-psychological testing;
  • Organ transplants;
  • Outpatient private duty nursing; and
  • Sleep studies.

Certain prescription drugs also require prior approval. The pharmacy will tell you if a drug requires prior approval, or you may search Express Scripts’ website for the name of a drug to learn if approval is required.

An Urgent Care Claim is any Claim for medical care or treatment where the application of the time period for making a Pre-service Claim determination meets one of the criteria below:

  • Could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or
  • In the opinion of a Physician with knowledge of the patient’s medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Claim.

The Plan generally determines whether your Claim is an Urgent Care Claim. Alternatively, any Claim that a Physician with knowledge of your medical condition determines is an Urgent Care Claim within the meaning described above shall be treated as an Urgent Care Claim.

A Concurrent Care Claim is a Claim that involves an approved, ongoing course of treatment for a specific period of time or a specific number of treatments. If the Claim involves urgent care, it will be treated as an Urgent Care Claim. Otherwise, it will be subject to the time periods for Pre-service Claims as outlined below.

A Post-service Claim is a Claim submitted for payment after health treatment has been obtained.

Disability Claims are Claims that require a finding of total disability as a condition of eligibility. Under the Plan, this would be a Claim for the waiver of life insurance premium or coverage under the total disability extension. With regard to the waiver of life insurance provision, MetLife reserves the right to have a Physician examine you while you are totally disabled.

 

Initial Determination

When you submit a Claim, the Plan has a certain amount of time to make a determination regarding payment of the Claim. The time to make a determination may be extended if necessary due to matters beyond the Plan’s control. For example, an extension may be available if the Plan needs additional information from you or your Physician to make its determination.

You will be notified of the circumstances requiring the extension. Refer to the table below which outlines these time periods and any available extensions.

Notice of Determination

For all Claims, you will receive written notice of the Plan’s determination, which will notify you of your rights under ERISA and include the following:

 

HEALTH CLAIMS

How long does the Plan have to make a determination when you file a Claim?

15 days.

72 hours.

30 days.

45 days.

Are there any extensions available?

Yes, one 15-day extension.

No.

Yes, one 15-day extension.

Yes, two 30-day extensions. You will be notified of the first extension within 45 days. You will be notified of any second extension within the first 30-day extension.

What happens if the Plan needs additional information?

The Plan will tell you what information is needed within five days of receipt of the Claim. You have 45 days to respond.

The Plan will tell you what information is needed within 24 hours of receipt of the Claim. You have 48 hours to respond.

The Plan will tell you what information is needed within 30 days of receipt of the Claim. You have 45 days to respond.

The Plan will tell you what information is needed within the time periods outlined above. You have 90 days to respond.

If additional information is requested, when must the Plan make its determination?

Within 15 days of the earlier of:

  • the day you respond; or
  • the end of the 45-day response period.

Within 48 hours of the earlier of:

  • the day you respond; or
  • the end of the 48-hour response period.

Within 15 days of the earlier of:

  • the day you respond; or  
  • the end of the 45-day response period.

Within 30 days of the earlier of:

  • the day you respond; or
  • the end of the 90-day response period.
  1. The specific reason(s) for the determination and reference to any specific Plan provision(s) on which the determination is based.
  2. A description of any additional material or information necessary to perfect the Claim and an explanation of why the material or information is necessary.
  3. A description of the appeal procedures and applicable time limits.
  4. A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review.
  5. If an internal rule, guideline or protocol was relied upon in making the determination, a statement that a copy of the rule is available upon request at no charge.
  6. If the determination was based on the absence of Medical Necessity, or because the treatment was an Experimental or Investigational Procedure, a statement that an explanation of the scientific or clinical judgment for the determination is available upon request at no charge.
  7. For Urgent Care Claims, the notice will describe the expedited review process applicable to Urgent Care Claims. Urgent care determinations may be provided orally and followed with written notification.

Appeals

Eligibility, Life Insurance and AD&D Appeals

If your Claim for a life insurance benefit or AD&D benefits is denied in whole or in part, you will be notified, in writing, within 90 days of receipt of your Claim. In addition, decisions that involve eligibility for coverage and application of certain administrative rules that do not involve a specific Claim for benefits, will be made within 90 days of receipt of your request. In some instances, an additional 90 days may be required. If additional time or information is needed, you will be notified in writing of the reasons. In no case will the extension exceed 180 days from the date your Claim was received.

The notice of determination will contain specific reasons for the determination and a specific reference to the provisions of the Plan or policy on which the determination is based. If you disagree with the determination you may appeal within 180 days of the date of the decision. In addition, if you have not been notified of action taken on your Claim within 180 days from the date it was received by the Plan, you may treat the Claim as having been denied and may make an appeal in the following ways:

  • Administrative review of a determination to deny. If you received an adverse determination on your Claim or your eligibility/administrative issue and you have additional medical or other information to provide in support of your Claim or request, you may request an administrative review by the Plan. Your request must be submitted in writing to the chief executive officer of the Plan within 60 days of notice of the denial of the Claim or other adverse determination and accompanied by the additional medical or other information upon which you rely. While you are not required to go through the step of an administrative review, if you have additional information to support your Claim or request, we encourage you to first attempt to resolve the issue through this process.
  • Appeal of a determination to deny. If you have no additional medical or other information or you feel the Claim or other eligibility/administrative request has been incorrectly denied, initially or after administrative review as outlined above, you may appeal to the Appeals Committee of the Board of Trustees. An appeal to the Appeals Committee must be submitted in writing to the chief executive officer within 180 days of the initial denial of the Claim or 180 days of the administrative review denial, whichever is later, and accompanied by a statement giving the reasons the denial is believed to be incorrect.

A determination by the Plan on an administrative review, or by the Appeals Committee on an appeal, shall be made within 60 days after the receipt of the request. An additional 60 days may be required for special study. However, the determination will be made no later than 120 days after your request is received. The notice of the determination will contain specific reasons for the determination and a specific reference to the provisions of the Plan on which the determination is based.

If you have not been notified of action taken on your appeal within the 120-day period, you may treat the appeal as having been denied and may initiate a lawsuit as described under the heading “Your Rights Under ERISA.”

Health, Disability and Retroactive Removal of Coverage Appeals

If your health Claim or Disability Claim is denied in whole or in part, you may ask for a review. You may also request a review if the Plan has retroactively removed your health coverage. In accordance with federal law, the Plan provides both an internal and external appeals process; however, the external appeals process is only available in certain circumstances. 

Under the internal process, your Claim determination notice will tell you where to send an appeal. If your denied Claim is for Hospital or medical benefits, or for coverage under the total disability extension, you may appeal one time to the Appeals Committee of the Board of Trustees. You may also appeal to the Appeals Committee if your health coverage was retroactively removed.

If your denied Claim is for another type of benefit, there are two levels of internal appeal. The first is to the appropriate benefit partner organization, as listed below. If your Claim is denied after the first review, you may file a second appeal with the Appeals Committee.

Health, Disability and Retroactive Removal of Coverage Appeals

Dental Delta Dental
Hospital/Medical Utilization Management Review Anthem Blue Cross
Life Insurance Premium Waiver MetLife
Mental Health and Substance Abuse Beacon Health Options
Prescription Drug Express Scripts
Vision VSP

Your initial request for review must be made in writing within 180 days after you receive notice of the denial. Specific information on how to file an appeal with these organizations is contained in their Claim denial notices.

Appeals involving Urgent Care Claims may be made verbally by calling one of the numbers outlined in the table below.

URGENT CARE APPEALS

Hospital

Anthem Blue Cross

(800) 274-7767

Mental Health and Substance Abuse

Beacon Health Options

(866) 277-5383

Prescription Drug – Clinical Appeals

Express Scripts

(800) 864-1135

All Other Benefits

Plan

(800) 777-4013

If your appeal is for a Concurrent Care Claim, the Plan will provide continued coverage for the course of treatment during the appeal process.

Internal Appeal Process

You have the right to review documents relevant to your Claim. You will be provided with any new material considered during the appeal.

Someone other than the person who originally denied the Claim will review your appeal. The determination will be made on the basis of the record, including any additional documents and comments submitted by you. If your Claim was denied on the basis of a medical judgment, such as lack of Medical Necessity, a health care professional with appropriate training and experience in a relevant field of medicine will be consulted. Any such health care professional shall not be an individual who was consulted in connection with the Claim denial, nor a subordinate of any such individual.

Notice of Determination on Internal Appeal

The table below outlines the timing for the internal appeal determination.

The Plan may waive the internal appeal process and proceed to the expedited external review procedures if your attending Provider determines that your appeal is urgent because it involves a medical condition for which the time period for completion of the appeal would seriously jeopardize your life or health, or your ability to regain maximum function.

HEALTH CLAIMS

How much time do I have to appeal?

180 days.

180 days.

180 days.

180 days.

How may I make the appeal?

Anthem Blue Cross and Beacon Health Options

Verbally or in writing.

All others

In writing.

Verbally or in writing.

Beacon Health Options

Verbally or in writing.

All others

In writing.

In writing.

How long does the Plan have to make a determination on my appeal?

One level

30 days.

Two levels

15 days for each level.

One level only

72 hours.

One level

Usually appeals will be decided at the next Appeals Committee meeting.* You will be notified within five days of the determination.

Two levels

30 days for each level.*

One level

Usually appeals will be decided at the next Appeals Committee meeting.* You will be notified within five days of the determination.

Two levels

30 days for each level.*

* If your first or second level internal appeal is received within 30 days of the next regularly scheduled Appeals Committee meeting, it will be considered at the second regularly scheduled meeting following receipt of your request. In special circumstances a delay until the third regularly scheduled meeting following receipt of your internal appeal may be necessary.

Important Note: 

External review is not available for every Claim denial or internal appeal denial.

If you submit an appeal or other request for review and we need additional information to evaluate your request, we will contact you to advise what additional information is needed and the timeframe within which the information must be provided. If you do not provide the information within that timeframe, the appeal/ request for review will be decided based upon the information provided.

The determination on any review of your Claim will be provided to you in writing. If the internal appeal is denied, the notice will explain the reason for the determination as described in items 1, 4, 5 and 6 under “Notice of Determination.” Upon request, you will be provided with the identification of medical or vocational experts, if any, that gave advice to the Plan on your Claim.

External Review Process

If your internal appeal is denied, you may file a request for external review with the Plan under the circumstances outlined below.

  • The initial Claim denial or internal appeal denial involved medical judgment. Examples include determinations of Medical Necessity, appropriateness, health care setting, level of care and experimental or investigational status.

  • Your health coverage was retroactively removed, unless this occurred because you did not meet the Plan’s eligibility requirements. Retroactive removal of coverage due to eligibility reasons is not eligible for external review.

The Plan will accept requests for external review in accordance with federal law.

Preliminary Review

The Plan will complete a preliminary review of the request. In addition, to the requirements outlined above, all of the following additional requirements must be met:

  • For Pre-service and Urgent Care Claims, you were covered under the Plan at the time the health care service or other benefit was requested. For Post-service Claims, you were covered under the Plan at the time the health care service or other benefit was provided.

  • The initial Claim denial or the internal appeal denial do not relate to the failure to meet the Plan’s eligibility requirements.

  • You have exhausted the Plan’s internal appeal process, unless you are not required to do so under federal law or in accordance with a request for an expedited external review.

  • You have submitted a completed External Appeals Form.

Notice of Preliminary Review

The Plan will issue a written notice after completion of the preliminary review. If your internal appeal denial is not eligible for external review, the notice will include the reasons for this as well as contact information for the U.S. Department of Labor’s Employee Benefits Security Administration. If your request for external review is not complete, the notice will describe the information or materials needed to make it complete.

The table below outlines the timing for the preliminary external review steps.

Notice of Preliminary Review

Request external review

Patient (or authorized representative)

Four months after receipt of internal appeal denial.

Preliminary review

Plan

Five business days after receipt of request.

Notice of preliminary review decision

Plan

One business day after making decision.

Provide additional information for external review

Patient (or authorized representative)

The later of:

  • The end of the four-month filing period; or
  • 48 hours following receipt of notice of preliminary review decision.

Assignment to an Independent Review Organization (IRO)

In accordance with federal law, the Plan will assign an accredited independent review organization (IRO) to conduct the external review. The IRO will notify you, in writing, when the organization receives the external review request.

This notice will include a statement that you may submit additional information in writing for the IRO to consider. The information should be submitted within 10 business days of receiving the notice. The IRO may accept and consider additional information submitted after 10 business days, though it is not required to do so.

The Plan will provide the IRO with any documents and information used in denying the Claim or denying the internal appeal within five business days after the external review is assigned to the IRO. If the Plan fails to do so, the IRO may terminate the external review and make a decision to reverse the denial. Within one business day after making such decision, the IRO must notify you and the Plan.

Upon receipt of any information submitted by you in connection to the external review, the IRO will forward it to the Plan within one business day. Upon receipt, the Plan may reconsider its Claim denial or internal appeal denial. The Plan will provide written notice to you and the IRO if it reverses its previous decision within one business day of such reversal. Thereafter, the IRO will terminate the external review proceedings.

External Review Decision

The IRO will review all information and documents received within the required time frames and will use experts where appropriate to make coverage determinations under the Plan. The IRO is not bound by any decisions or conclusions reached during the initial benefit denial or the internal appeal. In addition to the documents and information provided, the IRO will consider the following, as it determines appropriate, when making its decision:

  • Your medical records;
  • The attending health care professional’s recommendation;
  • Reports from appropriate health care professionals and other documents submitted by the Plan, you or your treating Provider(s);
  • The terms of the Plan (unless contrary to applicable law);
  • Appropriate medical practice guidelines, including evidence-based standards;
  • Any applicable clinical review criteria developed and used by the Plan (unless contrary to the Plan or applicable law); and
  • The opinion of the IRO’s clinical reviewer.

The IRO will provide written notice of the final external review decision to you and the Plan within 45 days after the IRO receives the external review request. Such notice will include: (i) an explanation of the primary reason(s) for the IRO’s decision; (ii) references to the evidence or documentation considered in reaching the decision, including the rationale for the decision and any evidence-based standards that were relied on in making the decision; (iii) the binding effect of the decision with a statement that judicial review may be available to you; and (iv) current contact information for any applicable office of health insurance consumer assistance or ombudsman.

Expedited External Review

Expedited external review is available for the following cases:

  • You or your Dependent have a medical condition for which the time period for completion of the standard external review would seriously jeopardize your or your Dependent’s life, health or ability to regain maximum function, as determined by your attending Physician; or
  • The internal appeal denial concerns an admission, availability of care, continued stay, or health care item, service, or other benefit for which you or your Dependent received emergency services, but have not been discharged from a Provider’s facility.

You must file a request for expedited external review. The request should be filed with the following benefit partner organizations:

EXPEDITED EXTERNAL REVIEW

Hospital

Anthem Blue Cross

(800) 274-7767

Mental Health and Substance Abuse

Beacon Health Options

(866) 277-5383

Prescription Drug – Clinical Appeals

Express Scripts

(800) 864-1135

All Other Benefits

Plan

(800) 777-4013

Upon receipt of the request, the preliminary review will be performed as soon as possible without regard to the five business days allowed for the non-expedited process. A notice of determination will be sent as soon as the preliminary review is completed.

If the request is eligible for expedited external review, the Plan or its designee shall assign an IRO in accordance with the external review procedures and transmit or provide all required documents and information by secure email, by telephone, by fax or by any other available method.

The IRO must provide its final external review decision in accordance with the external review standards described previously and provide notice of such decision as expeditiously as you or your Dependent’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request.

Reversal of Denial

In the event the Claim denial or the internal appeal denial is reversed by the Plan, its designee or the IRO, the Plan will provide coverage or payment for the Claim in accordance with applicable law and regulations, but it reserves the right to pursue judicial review or other remedies available or that may become available to the Plan under applicable law and regulations.

90-Day Limitation on When a Lawsuit May Be Filed

You may file a lawsuit to obtain benefits only after you have exhausted the Claims and appeals process set forth above with the exception of the external review process, which is voluntary. However, if you have requested an external review, you may not file a lawsuit until the external review process is concluded. You may also file a lawsuit if the Plan or IRO does not reach a decision, or notify you that an extension is necessary within the appropriate time periods described previously.

A lawsuit may not be filed more than 90 days after the earlier of: (i) the date you receive the Plan’s or IRO’s written decision on your appeal; or (ii) the end of the appeals and extension time periods previously described.

Discretionary Authority

The Board of Trustees (or the chief executive officer or any committee, if authorized by the Board) has the exclusive right, power and authority, in its sole and absolute discretion, to administer, apply and interpret this Plan and to decide all matters arising in connection with the operation or administration of the Plan.

Without limiting the generality of the foregoing, the Board (or its designee) has the sole and absolute discretionary authority to:

  • Take all actions and make all decisions with respect to the eligibility for, and the amount of, benefits payable under the Plan to Participants or their beneficiaries;
  • Formulate, interpret and apply rules, regulations and policies necessary to administer the Plan or other Plan documents in accordance with their terms and to interpret and apply the provisions of the Collective Bargaining Agreements;
  • Decide questions, including legal or factual questions, relating to the calculation and payment of benefits under the Plan or other Plan documents;
  • Resolve and/or clarify any ambiguities, inconsistencies and omissions arising under the Plan or other Plan documents;
  • Process, and approve or deny, benefit Claims and rule on any benefit exclusions; and
  • Decide questions as to whether services rendered are services covered under the Plan.

All determinations made by the Board (or its designee) with respect to any matter arising under the Plan and any other Plan documents shall be final and binding.