Health plan & appeal guide

TMT Bac Local Union 7 Welfare Fund C/o Daniel H. Cook Associates, in

New York, NY · Form 5500 filing, plan year 2024

Self-funded · federal rules The Local 7 Tile Industry Welfare Fund · 789 people

Your employer pays the claims from its own money, so federal law (ERISA) applies — not your state’s insurance rules.

How we know · high confidence
  • The filing lists stop-loss insurance (Prudential Retirment Insurance And Anniuty). Employers buy stop-loss only when they pay claims out of their own money.
  • The filing says benefits are paid from a trust the plan controls.
  • No medical insurance contract is on file (Schedule A).
  • Empire Healthchoice Assurance is paid to process this plan's claims (Schedule C), the usual setup when an employer pays claims itself.

Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.

  1. Send your appeal here

    Self-funded plan (federal rules)

    This is a union health fund run by trustees. It pays claims from the fund's own money, so federal law (ERISA) applies, not state insurance law.

    Your appeal

    The fund office (Board of Trustees)

    TMT BAC LOCAL UNION 7 WELFARE FUND C/O DANIEL H. COOK ASSOCIATES, IN
    ATTN: BOARD OF TRUSTEES, APPEALS
    1040 AVENUE OF THE AMERICAS,
    24TH FL.
    NEW YORK, NY 10018
    (212) 505-5050

    Union funds decide appeals through the trustees. If your denial letter gives a different appeal address, use that one.

  2. Know your deadlines

    • Internal appeal to the fund office180 days from the denial
    • Independent external review4 months from the final denial

    Dates you enter stay on this device.

  3. What happens next

    1. Internal appeal to the fund office

      File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.

    2. Independent external review

      If they say no again, request external review within 4 months of that final denial. The plan must send it to an independent review organization it contracts with. Some states let self-funded plans use the state's program instead. Your denial letter has to tell you where to send it. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.

    3. Urgent? Ask for an expedited review

      If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.

    4. If the plan stalls or ignores the rules

      Call the Department of Labor's benefits advisors. They enforce these rules for employer plans and can contact the plan for you, free. After the appeals are finished, a lawyer can sue under ERISA if the denial was wrong.

  4. Get free help

    External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.

    If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.

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