Claims Adjudication
When an application for disability benefits is made by a Member, it is subject to initial and ongoing review and adjudication. The Program assigns a Case Manager to each claim to manage this process, and to provide information and guidance to the Member.
The Case Manager is authorized to make all claim decisions, including approving or denying claims, and partially rating or terminating benefits. The Case Manager will communicate the claim decision or any change in benefits to the Member in writing.
If, following a claim decision, new medical evidence and/or claim documentation becomes available, the Member may submit such evidence to the Case Manager for reconsideration. A reconsideration review is an adjudication of any new medical evidence or claim documentation by the same Case Manager.
A Member can initiate a reconsideration review by making a written request to the Program (must be submitted within 60 calendar days of the Date of Decision; new evidence/documentation must be submitted within 120 calendar days). The Case Manager will communicate this process to the Member in the claim decision letter and will continue to work with the Member throughout the reconsideration process.
If the final decision of the Case Manager is to deny a claim or terminate or partially rate benefits under the terms of the Disability Plan and the Member disagrees with the decision, the Member may appeal.
If new medical evidence becomes available during the appeal process, the claim will be referred back to the Case Manager for a reconsideration review.
A first level appeal is a review of all the claim information on a Member's file by the Program's Manager of Disability Benefits, or designate. A request for a first level appeal must be submitted to the Program within 60 calendar days of the Date of Decision or the reconsideration decision (whichever applies). The Manager of Disability Benefit's decision will be communicated to the Member within 30 calendar days of receipt of the first level appeal request.
The Member can request a final appeal if he or she is not satisfied with the claim decision after a first level appeal. A final appeal is a review of the existing claim information by an independent Appeal Panel. The Member will participate in the selection of the panel member(s) from a list of eligible medical and non-medical professionals approved by the Board of Trustees (Disability Fund). A request for a final appeal must be submitted to the Program within 60 calendar days of the first level appeal decision. The decision of the Appeal Panel will be final and conclusive.
Date of Decision—this is the date of the decision made by the Case Manager.
Deadline to request reconsideration review—60 days from the Date of Decision.
Deadline to submit new medical evidence and/or claim documentation—120 days from the Date of Decision.
First Level Appeal deadline—60 calendar days from the Date of Decision or the date of a reconsideration decision.
Final Appeal Deadline—60 calendar days from the date of the first level appeal decision.
Key deadlines will be communicated to the Member in writing.