Claims Procedures

Claims Procedures

Updated December 1, 2019

If your Benefits Statement from the YMCA Retirement Fund does not reflect your understanding of your participation dates or account balances and the YMCA Retirement Fund’s Customer Service Department confirms that it reflects the YMCA Retirement Fund’s records, if you do not receive the benefits you expected or if your application for benefits is denied, you may file a claim for benefits with the YMCA Retirement Fund within the six-year period beginning on the date that you knew or should have known of the material facts on which the claim is based. It is expected that any claimant has the same knowledge of the facts as the applicable participant and beneficiary.

You can file a claim by writing a letter to the following address: YMCA Retirement Fund, Attn: Claims Review Panel, 120 Broadway, New York, NY 10271.

If you file a claim for benefits and your claim is denied, you will receive a written determination from the Claims Review Panel of the YMCA Retirement Fund. If you wish to appeal the decision, you may do so in writing to the Board’s Benefits and Operations Committee. The Benefits and Operations Committee will review your appeal and notify you in writing of their decision regarding the claim. If your claim is for disability retirement benefits, separate procedures apply and your claim will be processed by the Disability Administrator, an insurance carrier.

For full details of our claims procedures, please see below.

Claims Procedures For The YMCA Retirement Fund Retirement Plan And the YMCA Retirement Fund 403(b) Savings Plan

Set forth below are claims procedures with respect to the YMCA Retirement Fund Retirement Plan (“Retirement Plan”) and the “YMCA Retirement Fund 403(b) Savings Plan (“403(b) Savings Plan”) (collectively, the “Plan”), sponsored by the YMCA Retirement Fund (“Fund”). There are separate procedures for general claims and for disability claims.

General claims will initially be reviewed by the Claims Review Panel, which is made up of members of the YMCA Retirement Fund Management who have been appointed by the President. Appeals of the Claims Review Panel’s determination will be heard by the Benefits and Operations Committee, which is comprised of members of the YMCA Retirement Fund Board of Trustees.

Disability claims will be reviewed by the Disability Administrator, the insurer selected by the YMCA Retirement Fund.

The Board of Trustees, or its delegate, has the exclusive right to interpret the Plan, and its decisions are conclusive and binding upon all parties.

Beginning July 1, 2006, the Retirement Plan, but not the 403(b) Savings Plan, became subject to the Employee Retirement Income Security Act of 1974, as amended (“ERISA”). The below claims procedures are intended to comply with ERISA §503 and ERISA Regulations §2560.503-1.

General Claims Procedures

The Board and Fund Management will endeavor to administer the Plan fairly and consistently and to pay all benefits that Participants or beneficiaries are properly entitled to receive. To this end, the Claims Review Panel and the Benefits and Operations Committee will apply administrative processes and safeguards designed to ensure that (1) benefit claim determinations are made in accordance with the Plan documents; and (2) Plan provisions are applied consistently with respect to similarly situated individuals.

How Do You Bring a Claim?

You, your beneficiary or anybody authorized to act on your behalf, has the right to bring a claim for benefits. If for any reason you wish to file such a benefits claim, it must be made in writing to the Claims Review Panel, which will review claims. You may mail your benefits claim to the following address: YMCA Retirement Fund, Attn: Claims Review Panel, 120 Broadway, New York, NY 10271.

How Will You Know When Your Claim is Determined?

If your claim is approved, you will receive benefits and a notification from a representative of the Fund that your claim is approved.

The Claims Review Panel will notify you in writing within 90 days after receiving the claim if it makes an “adverse benefit determination.” The term “adverse benefit determination” includes any of the following: a denial of, reduction of or termination of, or a failure to provide or make a payment (in whole or in part) for, a benefit.

If special circumstances warrant extension of the 90-day processing period, the Claims Review Panel will notify you within the initial 90-day period and indicate the date that the benefit determination will be rendered. Extensions cannot be longer than 90 days after the end of the initial 90-day period beginning when the claim is filed. You may also agree to a further extension of the time period within which the Claims Review Panel must decide the claim.

If the Claims Review Panel denies your claim, the notice to you will include: (1) the specific reason or reasons for the denial; (2) the specific Plan provisions or documents that the denial is based on; (3) a description of additional material or information that you must provide to assert the claim and an explanation as to why you must do so; (4) a description or a copy of these procedures and relevant time limits; (5) a statement of your right to appeal the Claims Review Panel’s decision within 60 days of the “adverse benefit determination” to the Benefits and Operations Committee; and (6) for the Retirement Plan, a statement that you have the right to bring a civil action under ERISA § 502(a) in federal court within the one-year period following the date of a notice of the denial of your appeal by the Benefits and Operations Committee.

What Are Your Rights if Your Claim is Denied?

a. After receipt of a notice denying a claim for benefits, you may appeal the Claims Review Panel’s decision to the Benefits and Operations Committee. In order to do so, you must submit a written request for review to the Benefits and Operations Committee within 60 days after the date that the denial is received. You may also submit written comments, documents, records, and other information related to the claim for benefits in the appeal. In addition, after receipt of a notice denying a claim for benefits, you have a right, upon request and free of charge, to review and receive copies of all documents, records, and other information relevant to the claim for benefits. A document, record, or other information is “relevant” for this purpose if: (1) it was relied upon in making the benefit determination; (2) it was submitted, considered, or generated in the course of making the benefit determination (even if it was not relied upon in making the benefit determination); and (3) it demonstrates compliance with the administrative processes and safeguards in making the benefit determination.

b. Upon receipt of an appeal, the Benefits and Operations Committee will examine your claim, along with all comments, documents, records, and other information that you submit relating to the claim, regardless of whether it was submitted or considered in the initial benefit determination. The Benefits and Operations Committee must then make a benefit determination no later than the date of the Benefits and Operations Committee quarterly meeting that follows the Fund’s receipt of a request for a review. If a request for review is filed within 30 days before the meeting date, then the benefit determination may be made no later than the date of the second meeting following the Fund’s receipt of the request for review. If special circumstances (such as the need to hold a hearing) as determined by the Benefits and Operations Committee require a further extension of time for processing, a benefit determination will be made not later than the third meeting of the Benefits and Operations Committee following the Fund’s receipt of the request for review. If an extension is needed, you will be provided with written notice of the extension, describing the special circumstances and the date as of which the benefit determination will be made, prior to the commencement of the extension. You may also agree to a further extension of the time period within which the Benefits and Operations Committee must decide the claim. You will be notified of the Benefits and Operations Committee decision concerning your appeal as soon as possible, but no later than five (5) days after the benefit determination.

c. The Benefits and Operations Committee’s final decision will be in writing. If your claim on appeal is approved, you will receive benefits and a notification from the Benefits and Operations Committee that your claim is approved. If your appeal is denied, the notice must include:
(1) the specific reason or reasons for the denial; (2) the specific Plan provision on which the determination was based; (3) a statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the your benefit claim, and (4) for the Retirement Plan, a statement that you have the right to bring a civil action under ERISA § 502(a) in federal court within the one-year period following the date of the notice of the denial of your appeal by the Benefits and Operations Committee. See paragraph (a) above for a description of what information is “relevant.”

d. You are prohibited from filing a lawsuit concerning your benefit claim until you have exhausted the claim procedures described above. This provision is enforceable under ERISA with respect to Retirement Plan benefit claims.

Contact Information for General Claims:

Claim requests may be submitted to the Claims Review Panel at the address below:

YMCA Retirement Fund
120 Broadway
New York, NY 10271
Attention: Claims Review Panel
Fax: 646-458-2550

Appeal requests may be submitted to the Benefits and Operations Committee at the address below:

YMCA Retirement Fund
120 Broadway
New York, NY 10271
Attention: Benefits and Operations Committee
Fax: 646-458-2550

Disability Retirement Claims Procedures

How Do You Bring a Disability Retirement Claim?

The Retirement Fund has retained an insurance company specializing in disability benefits to act as the claims fiduciary and assist in processing disability claims (“Disability Administrator”).

You or anyone authorized to act on your behalf has the right to file a claim for disability retirement benefits with the Disability Administrator. If for any reason you wish to file a claim for disability retirement benefits, it must be made in writing to the Disability Administrator on the disability forms provided by the Disability Administrator or through the online application provided by the Disability Administrator.

How Will You Know When Your Disability Retirement Claim is Determined?

If your claim is approved you will receive written notification from the Disability Administrator. Alternatively, if the Disability Administrator makes an “adverse benefit determination,” you will receive written or electronic notification within 45 days after the date you filed a claim for disability retirement benefits in accordance with these procedures. The term “adverse benefit determination” means any of the following: a denial of, reduction of or termination of, or a failure to provide or make a payment (in whole or in part) for, a disability retirement benefit.

If it is determined that special circumstances warrant extension of the 45-day processing period, the Disability Administrator will notify you during the initial 45-day period and advise you of the expected benefit determination date. The initial extension of time cannot be longer than 30 days after the end of the initial 45-day processing period.

If the Disability Administrator determines that a decision cannot be made before the end of the initial 30-day extension period, then the period for making the decision may be extended for an additional 30 days. Both the initial 30-day extension and any subsequent 30-day extension must be necessary (as determined by the Disability Administrator within its discretion) due to matters beyond the control of the Disability Administrator, the Retirement Fund, or the Plan.

The Disability Administrator will notify you of the need for a 30-day extension of the processing period before the expiration of the initial 45-day processing period and/or the initial 30-day extension. The notice will specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevented deciding the disability retirement claim, and the additional information needed to resolve those issues. You will be given at least 45 days to provide the information or to submit to a requested examination.

If an extension occurs because you did not submit information, the period for making the benefit determination will be further extended for a period determined by the number of days from the date that the Disability Administrator sent the extension notice to you until the date that the Disability Administrator receives your response to the request for additional information or the date the extension period ends, whichever is earlier.

Notice that a disability retirement claim is denied will include: (1) the specific reason or reasons for the denial; (2) the specific Plan provision(s) or document(s) upon which the denial is based; (3) a description of any additional necessary material or information that you must provide to perfect the claim and an explanation as to why such material or information is necessary; (4) an explanation of any scientific or clinical judgment relied upon to decide the claim or a statement that such an explanation will be provided free of charge; (5) if applicable, the reason for not following the views of the treating professional, medical, or vocational experts, or a disability determination by the Social Security Administrator; (6) the specific internal rules, guidelines, protocols, or other similar criteria of the Plan relied upon to make the adverse benefit determination or, alternatively, a statement that such rules, guidelines, protocols or other similar criteria of the Plan do not exist; (7) a statement that you are entitled, upon request and free of charge, reasonable access to copies of all documents, records, and other information relevant to your claims; (8) a description or copy of these procedures and relevant time limits; (9) a statement that you have a right to appeal the Disability Administrator’s decision; and (10) for the Retirement Plan, a statement of your right to bring a civil action under ERISA § 502(a) in federal court following a denial of your appeal. The Notice will be provided in a culturally and linguistically appropriate manner.

What Are Your Rights if Your Disability Retirement Claim is Denied?

a. After receipt of a notice denying a claim for disability retirement benefits (or failure to receive notice that a claim was denied or approved within the applicable time limits, which is considered a denial), you may appeal the Disability Administrator’s decision.

b. In order to appeal, you must submit a written request for review to the Disability Administrator within one hundred and eighty (180) days after you receive the denial notice. You may also submit written comments, documents, records, and other information related to the disability claim in the appeal. In addition, after receipt of a denial notice, you have the right, upon request and free of charge, to review and receive copies of all documents, records, and other information relevant to the disability claim. A document, record, or other information is “relevant” for this purpose if: (1) it was relied upon in making the benefit determination; (2) it was submitted, considered, or generated in the course of making the benefit determination (even if it was not relied upon in making the benefit determination); and (3) it demonstrates compliance with the administrative processes and safeguards in making the benefit determination.

c. The disability claim form will be reviewed anew on appeal. No deference will be given to the original denial. The review will be conducted by a reviewer of the Disability Administrator that is separate from (and not subordinate to) the Disability Administrator’s reviewer that denied your original disability claim. If the decision is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, then the review will include consultation with a health care professional who has appropriate training and experience in the field of medicine involved, and who has not consulted with respect to (and is not subordinate to someone who has consulted with respect to) the original denial. Upon your request, any medical or vocational experts consulted in connection with the disability retirement claim will be identified, without regard to whether their advice was relied upon in making the determination.

d. Upon receipt of an appeal, the Disability Administrator will review the disability retirement claim anew, along with all comments, documents, records, and other information submitted by you relating to the claim, regardless of whether such items were submitted or considered in the initial benefit determination. The Disability Administrator must then issue a final decision within 45 days after the date that you filed an appeal in accordance with these procedures. The clock begins running on the date that you properly file a written appeal, regardless of whether you included all of the information necessary to make a benefit determination on your appeal. The Disability Administrator has discretion to extend this period because of a lack of information necessary to make a decision. If the Disability Administrator determines that special circumstances require an extension of the 45-day period, the Disability Administrator must notify you in writing before the end of the initial 45-day period, indicating the special circumstances warranting an extension for processing the appeal and the expected date of the benefit determination. The extension may not be more than 45 days after the end of the initial 45-day period. If an extension occurs because of your failure to submit needed information, the period for making the benefit determination on review will be further extended for a period determined by the number of days from the date the Disability Administrator sent the extension notice to you until the date the Disability Administrator receives your response to the request for additional information or the date the extension period ends, whichever is earlier.

e. Before the Disability Administrator can deny your appeal, you have the right to receive for review, free of charge, and be provided with a reasonable opportunity to respond to any new or additional evidence considered, relied upon, or generated, or any new or additional rationale in support of an adverse decision, before an adverse decision is rendered.

f. The Disability Administrator will provide you with written or electronic notification of its final decision. If your appeal is approved, you will receive benefits or a letter from the Disability Administrator advising you of the approval. If your appeal is denied, the denial notice will include: (1) the specific reason or reasons for the denial; (2) the specific Plan provision(s) or document(s) upon which the denial is based; (3) a statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the claim for benefits; (4) for the Retirement Plan, a statement that you have the right to bring a civil action under ERISA § 502(a) in federal court within the one-year period following the date of the denial notice and the date on which that period expires; (5) if applicable, the reason for not following the views of the treating professional, medical, or vocational experts, or a disability determination by the Social Security Administrator; (6) the specific internal rules, guidelines, protocols, or other similar criteria of the plan relied upon to make the adverse benefit determination or, alternatively, a statement that such rules, guidelines, protocols, or other similar criteria of the plan do not exist; and (7) if the adverse benefit determination is based upon a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request. The Notice will be provided in a culturally and linguistically appropriate manner.

g. A document, record, or other information is “relevant” for this purpose if: (1) it was relied upon in making the benefit determination; (2) it was submitted, considered, or generated in the course of making the benefit determination (even if it was not relied upon in making the benefit determination); and (3) it demonstrates compliance with the administrative processes and safeguards in making the benefit determination.

h. You are prohibited from filing a lawsuit concerning your disability claim until you have exhausted the claim procedures described above. This provision shall be enforceable under ERISA beginning July 1, 2006 with respect to Retirement Plan disability claims.

Contact Information for Disability Retirement Claims:
You (or your authorized representative) must contact the Customer Service Department via Live Chat or call us directly at 800-RET-YMCA (800-738-9622), Monday through Friday from 9:00am to 5:00pm ET to obtain the phone number and website address for the Disability Administrator’s claims contact center. Once you (or your authorized representative) are provided with this information, contact the Disability Administrator to obtain the disability claims forms or access the online disability claims application. Disability claim forms should be submitted to the Disability Administrator at the address listed below:

Lincoln Life Assurance Company of Boston
Disability Claims
PO Box 7206
London, KY 40742-7206

Disability retirement appeal requests should be submitted to the Disability Administrator at the below address:

Lincoln Life Assurance Company of Boston
Attn: Appeal Review Unit
Group Benefits Disability Claims
PO Box 7213
London, KY 40742-7213

Compliance with Applicable Laws:
The above claims procedures are intended to comply with ERISA § 503 and the U.S. Department of Labor Regulation § 2560.503-1 and shall be construed, interpreted, and applied in accordance with such Section. Electronic notifications with respect to benefit claims will be made in compliance with applicable law.

Additional Information

These Claims Procedures are effective for claims filed after December 1, 2019. If you have any questions about the Claims Procedures which are not answered by this document, please contact the Customer Service Department via Live Chat or call us directly at 800-RET-YMCA (800-738-9622), Monday through Friday from 9:00am to 5:00pm ET. You should also review the summary of your legal rights under the federal pension law with respect to the Retirement Plan which appears in Appendix A of the Summary Plan Description for the YMCA Retirement Fund Retirement Plan.