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Administrative and ERISA information

Administrative and ERISA information for the ExxonMobil Dental Plan

Q. What other information do I need to know about the Plan?

A. This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.

The formal name of the Plan is the ExxonMobil Dental Plan.

Plan sponsor and participating affiliates

The ExxonMobil Dental Plan is sponsored by:

Exxon Mobil Corporation
5959 Las Colinas Blvd
Irving, Texas 75039-2298

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Dental Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.

Certain employees covered by collective bargaining agreements do not participate in the Plan.

Basic Plan information

Plan administrator

The Plan Administrator for the ExxonMobil Dental Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, ExxonMobil. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o ExxonMobil by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).

Administrator-Benefits
P.O. Box 64111
Spring, TX 77387-4111

For Service of Legal Process: 

Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218

Claims administrator

The claims administrator, Aetna, provides information about claims payment, providers participating in the Dental PPO, and benefit pre-determinations.

Claims fiduciary and appeals

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for dental appeals. You may contact the claims fiduciary as follows:
 
AETNA
P,O Box 14463
Lexington, KY 40513

Claim decisions and appeals procedures

In the previous section, we explained how you and the plan share responsibility for paying for your eligible dental services. 

When a claim comes in, your employer decides how you and the plan will split the expense. We also explain what you can do if you think we got it wrong.

Claims are processed in the order in which they are received.
 

Claim procedures

You or your dental provider are required to send us a claim in writing. You can request a claim form from us. We will review that claim for payment to the provider or to you as appropriate.
 
The table below explains the claim procedures as follows:
 
Notice  Requirement  Deadline 
Submit a claim 
  • You should notify get a claim form from our self-service website or call us
  • The claim form will provide instructions on how to complete and where to send the forms
  • You must send us notice and proof as soon as reasonably possible
  • If you are unable to complete a claim form, you may send us: 
  • A description of services
  • Bill of charges
  • Any dental documentation you received from your dental provider
Proof of claim

When you have received a service from an eligible dental provider, you will be charged. 

The information you receive for that service is your proof of loss. 
  • A completed claim form and any additional information required by your employer
  • You must send us notice and proof as soon as reasonably possible
Benefit payment 
  • Written proof must be provided for all benefits
  • If we challenge any portion of a claim, the unchallenged portion of the claim will be paid promptly after the receipt of proof of loss.
  • Benefits will be paid as soon as the necessary proof to support the claim is received
 
If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be accepted if it is filed as soon as possible. Unless you are legally incapacitated, late claims will not be covered if they are filed more than 24 months after the deadline.
 

Communicating our claim decisions

The amount of time that we have to tell you about our decision on a claim is shown below.

Post-service claim 

A post service claim is a claim that involves dental care services you have already received.

 

Type of notice

Post-service claim

Initial decision by us

30 days

Extensions

15 days

If we request more information

30 days

Time you have to send us additional information

45 days

Adverse benefit determinations

We pay many claims at the full rate negotiated charge with in-network providers and the recognized charge with out-of-network providers, except for your share of the costs. But sometimes we pay only some of the claim. And sometimes we don’t pay at all. Any time we don’t pay even part of the claim, that is called an “adverse benefit determination” or “adverse decision”.

If we make an adverse benefit determination, we will tell you in writing.
 

The difference between a complaint and an appeal 

A complaint

You may not be happy about a dental provider or an operational issue, and you may want to complain. You can call or us. Your complaint should include a description of the issue. You should include copies of any records or documents that you think are important. We will review the information and provide you with a written response within 30 calendar days of receiving the complaint. We will let you know if we need more information to make a decision.

An appeal

You can ask us to review an adverse benefit determination. This is called an appeal.

 

Appeals of adverse benefit determinations

Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for appeal must be made in writing within 180 days from the date of the notice.

The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit.

  • You can appeal by sending a written appeal to the address on the notice of adverse benefit determination. You need to include:
  • Your name
  • The employer’s name
  • A copy of the adverse benefit determination
  • Your reasons for making the appeal
  • Any other information you would like us to consider

Another person may submit an appeal for you, including a dental provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your dental provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by contacting us. The form will tell you where to send it to us. You can use an authorized representative at any level of appeal.

 
If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision. 
 

Timeframes for deciding appeals

The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision.

 

Type of notice

Post-service appeal

Initial decision by us

30 days

 

Exhaustion of appeals process

You must complete the appeal process with us before you can take these actions:

  • Appeal through an external review process.
  • Pursue arbitration, litigation or other type of administrative proceeding.

 

External review

External review is a review done by people in an organization outside of Aetna. This is called an external review organization (ERO). Sometimes, this is called an independent review organization (IRO).

 

You have a right to external review only if:

  • Our claim decision involved medical judgment.
  • We decided the service or supply is not medically necessary or not appropriate.
  • We decided the service or supply is experimental or investigational.
  • You have received an adverse determination.

 

If our claim decision is one for which you can seek external review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will describe the external review process. It will include a copy of the Request for External Review form at the final adverse determination level.

 

You must submit the Request for External Review form:

  • To Aetna
  • Within 4 months of the date you received the decision from us
  • And you must include a copy of the notice from us and all other important information that supports your request

 

You will pay for any information that you send and want reviewed by the ERO. We will pay for information we send to the ERO plus the cost of the review.

 

Aetna will contact the ERO that will conduct the review of your claim.

The ERO will:

  • Assign the appeal to one or more independent clinical reviewers that have the proper expertise to do the review
  • Consider appropriate credible information that you sent
  • Follow our contractual documents and your plan of benefits
  • Send notification of the decision within 45 calendar days of the date we receive your request form and all the necessary information

 

We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud.

 

How long will it take to get an ERO decision?

We will tell you of the ERO decision not more than 45 calendar days after we receive your Notice of External Review Form with all the information you need to send in.

 

Recordkeeping

We will keep the records of all complaints and appeals for at least 10 years.

 

Fees and expenses

We do not pay any fees or expenses incurred by you when you submit a complaint or appeal.

 
Statute of limitations
 
After you have received the response to the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending. 

No implied promises

Nothing in this SPD says or implies that participation in the ExxonMobil Dental Plan is a guarantee of continued employment with the company.

Future of the Plan

ExxonMobil expects to continue the Plan. However, ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the Plan or any of its provisions at any time and for any reason. A change may also be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.

Expenses incurred before the effective date of a plan change or termination will not be affected. Expenses incurred after a plan is terminated will not be covered. If the Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference. If all claims and expenses are paid and there's still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of employees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the Plans.

Your rights under ERISA

As a participant in the ExxonMobil Dental Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a plan participant, you shall be entitled to:

Receive information about your plan and benefits

  • Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Dental Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Dental Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
  • Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Dental Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies.
  • Receive a summary of the Dental Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent actions by dental plan fiduciaries

In addition to creating rights for Dental Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Dental Plan, called fiduciaries of the Dental Plan, have a duty to do so prudently and in the interest of you and other Dental Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

Enforce your rights

  • If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision, without charge, and to appeal any denial, all within certain time schedules.
  • Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Dental Plan documents or the latest summary annual report from the Dental Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
  • If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. Any such lawsuit must be brought within one year of the date on which an appeal was denied. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with your questions

If you have any questions about your Dental Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call Benefits Administration. 

If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

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