Board Resolution 2021-12-14(a)

Appeal Procedures (Disability-Medical)

Administrative Staff Determination

1. Staff Determination
   The IMRF Administrative staff is responsible for the daily claims-processing function of the Fund, including processing of all claims for disability benefits.

Hearing

1. Petition
   Any person adversely affected by the disposition of a disability claim by the administrative staff may petition for a hearing before the Board of Trustees Benefit Review Committee. The petition must be in writing on a Form 5.70 "Request For A Hearing". A copy of this form is sent to the member at the time staff denies or terminates disability benefits. The completed 5.70 form should be returned to the Disability Manager in the IMRF Oak Brook office and must be received by IMRF no later than sixty-three (63) days after the date of the staff disposition letter. Failure to timely file a 5.70 form shall result in the staff disposition becoming a final administrative decision, for purposes of the Administrative Review Law, on the sixty-fourth (64th) day after the date of the staff disposition letter.
2. Acknowledgment of a Request For A Hearing
   Upon the filing of the Request For A Hearing, the Disability Manager shall send an acknowledgment of the Request.
3. Scheduling of Hearing
   Upon receipt of the Request For A Hearing, the Disability Manager will schedule the hearing as follows:
• If the Hearing Request indicates that additional medical information WILL NOT be submitted for consideration, the hearing will be scheduled for the next available meeting of the Board of Trustees Benefit Review Committee.
• If the Hearing Request indicates that additional medical information WILL be submitted for consideration, the hearing will be scheduled for the next available meeting of the Board of Trustees Benefit Review Committee following the review of the additional medical information. If the petitioner does not submit additional medical information within ninety-one (91) days from the date of receipt, by IMRF, of the Request For A Hearing Form 5.70, the Benefit Review Committee will consider the appeal at the first available meeting after the expiration of the foregoing ninety-one (91) day period.
4. Notification
   Upon scheduling of a hearing before the Benefit Review Committee, a petitioner shall be provided with written notice of the date, time and place of the hearing. Due to the volume of medical records, the petitioner will not routinely be provided with all of the documentation and other materials to be presented to the Benefit Review Committee by the administrative staff. However, copies of any or all of those materials will be provided to the petitioner or his/her representative upon request.
5. Continuances and Extensions of Time
• Continuance of the hearing date
  Continuances of the hearing date may be requested by the petitioner. IMRF staff is authorized to grant up to two (2) hearing continuances if the petitioner makes a written request at least five (5) business days prior to the scheduled date. Any additional continuances(s) of the hearing date may only be granted by the Benefit Review Committee. For such additional continuance(s), the petitioner is required to appear before the Benefit Review Committee on the scheduled date and request additional time.
• Other Extensions of Time

Additional medical information or other materials must be received by IMRF no later than twenty (20) days prior to the scheduled hearing date. All additional materials received less than twenty (20) days before the hearing date will be considered a “late submission”. Whenever a claimant makes a late submission, the Benefit Review Committee will proceed in one of three ways:

1. The Benefit Review Committee can proceed with the hearing and not consider the late submission;
2. The Benefit Review Committee can proceed with the hearing and choose to consider the late submission; or
3. The Benefit Review Committee can postpone the hearing until the earliest available future date in order to allow for consideration of the late submission.

If a hearing is postponed in order to allow for consideration of the late submission, any additional materials submitted within twenty (20) days of the re-scheduled hearing date WILL NOT be considered by the Benefit Review Committee or by the full Board of Trustees. In the event that a petitioner fails to appear on the scheduled hearing date, the Benefit Review Committee’s consideration of the appeal will be based solely upon the written materials that are already in the IMRF file and no hearing will be held.

6. Representation
   The petitioner may be represented by counsel or a designated spokesperson at the hearing. The Disability Manager or his/her designated representative shall present the IMRF administrative staff position.
7. Conduct of the Hearing
• Appearance
  The petitioner is not required to personally appear at the hearing and may be represented solely by the medical records and related documentation on file with IMRF. In the alternative, at the petitioner’s discretion, the petitioner or his representative may appear in person, or the hearing may be conducted via telephone or video conference.
• Procedures
  The Chairman of the Benefit Review Committee shall conduct a full and fair hearing, maintain order and make a sufficient record for a full and true disclosure of the facts and issues. Three members of the Benefit Review Committee shall constitute a quorum and a quorum is needed for all hearings. The hearing shall be informal and the rules of evidence shall not apply. Any part of the evidence may be received in written form. The Committee shall be provided with a copy of the Statement of Claim, a statement of the position of the administrative staff, which shall include the administrative staff determination, and such other documentation (medical records, etc.) as is available. Members of the Benefit Review Committee may ask questions necessary for better understanding of the facts or law. The hearing shall be open to the public unless the chair, for good cause shown and pursuant to the applicable provisions of the Open Meetings Act, shall determine otherwise. An IMRF employer (participating municipality or participating instrumentality) may provide written materials to IMRF staff for incorporation into the packet submitted to the Benefit Review Committee and the full Board of Trustees. Such documents are subject to the 20-day rule as provided in Section II(5)(b). An employer may also attend hearings of the Benefit Review Committee and meetings of the full Board of Trustees and can make audio recordings of said hearings and meetings. An employer also has standing to, in a separate proceeding, contest a rate increase that might be assessed due to a decision of the Benefit Review Committee and the full Board of Trustees. However, an employer normally does not have standing to actively participate in an individual’s appeal of an administrative staff determination.
• Record of Proceedings
  A record of proceedings shall be kept which shall be in the form of a non-verbatim summary report. The petitioner may obtain a verbatim record of the hearing taken by a court reporter by making a timely request and paying the actual cost entailed. The Disability Manager shall be the custodian of the documents and record of proceedings.
• Determination
  Upon conclusion of all evidence and arguments, the Benefit Review Committee shall, in private deliberation, make its decision as to the disposition of the claim. The vote of at least a majority of a quorum shall be required for any decision of the Benefit Review Committee. The Benefit Review Committee shall render one of the following decisions: affirmance of the administrative staff determination; reversal of the administrative staff determination; remand of the proceedings to the administrative staff for further investigation; or, in the case of a deadlock, continuation of the claim for consideration by the full Board of Trustees. The decision shall be in the form of a recommendation to the full Board of Trustees. Where an appeal is to be decided via Schedule H, any one member of the Committee can request that the matter be removed from said Schedule and placed on a future Committee agenda for hearing and recommendation.

Final Administrative Decision

1. Decision of the Full Board of Trustees
   The full Board of Trustees will consider the recommendation of the Benefit Review Committee in making the decision for the Fund as to the disposition of the appeal. The Board will also decide appeals in which a formal hearing has not been held before the Benefit Review Committee. At least five (5) affirmative votes shall be required for any decision of the Board of Trustees. The Board of Trustees shall render one of the following decisions: affirmance of the administrative staff determination or reversal of the administrative staff determination. The Board of Trustees will normally consider an appeal following receipt of the Benefit Review Committee's recommendation, or if the appeal concerns legal, as opposed to factual issues, after the expiration of the aforementioned ninety-one (91) day period.
2. Final Administrative Decision
   A decision of the Board of Trustees either affirming or reversing the determination of the administrative staff shall be a final administrative decision for purposes of review under the Illinois Administrative Review Act (735 ILCS 5/3-101 et seq.)
3. Notice of Decision
   The Disability Manager shall send written notice of the decision of the Board of Trustees to the petitioner and, if applicable, the petitioner’s representative.