Review and Appeals (Adjuncts)

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If a member adjunct disagrees with a benefit or eligibility determination made by the PSC-CUNY Welfare Fund or parties contracting with the Fund to insure components of the program, the member has a right to request a review.

Type of Review

If the adverse determination involves eligibility for benefits, the review should be requested of the Fund Office. The request must be in writing and filed within 60 days of the initial determination. The request should include any new information or documented extenuating conditions that you feel will impact the course of the review.

A decision will be made about a claim of eligibility and the particiant wil be notified in writing of that decision within 90 days. Under special circumstances, another 90 days may be needed to review a claim, and there will be notification of the extension.

If a claim of eligibility is denied, in whole or in part, notice will include:

  • the specific reasons for the denial;
  • the plan provision(s) on which the decision was based
  • what additional information may relevant, and
  • which procedures should be followed to get further review or file an appeal.

If the adverse determination involves provision of or payment for benefits, the review should be directed to the appropriate insurance carrier (Empire or HIP). The request must be in writing and filed within 30 days of the determination or receipt of notice of the determination. The request should include any new information, medical data or documented extenuating conditions that may impact the course of the review.

Type of Appeal

In the event that a review is negative, the participant may appeal.

  1. An appeal of a negative eligibility decision must be directed to the PSC-CUNY Welfare Fund Board of Trustees within 60 days of the completion of the initial review.
  2. An appeal of a negative benefits decision must be directed to the carrier. The carrier is obligated to inform the participant of the appeals process, which may typically extend as far as the State Insurance Department. These matters are not subject to review by the PSC-CUNY Welfare Fund Board of Trustees. The Fund Office will cooperate with provision of any available materials or with clarification of terms, but is not a party to the process.

An appeal to the Board of Trustees must be in writing and should include any new information or arguments that may affect the proceedings.

Appeals are reviewed by a committee of the Board which convenes as necessary. A decision will be made on an appeal within 90 days of its receipt by the Fund Office and determination that necessary information is provided. Under special circumstances, another 90 days may be required, and notice will be given.

If an appeal is denied, in whole or in part, the participant will be told:

  • the specific reasons for the denial;
  • the plan provision(s) on which the decision was based.
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