(a) Purpose. — This section sets forth the procedures for the denial of a claim for retirement benefits under the chapter.

(b) Filing of claim for benefits. — For the purposes of this section, a claim is a request for a benefit by a participant or beneficiary of any of the Funds. A claim is filed when the procedure established by the Board for the initiation of claims has been met. Until such procedure has been established, a claim shall be deemed filed when a written communication is made by a claimant (or the claimant’s authorized representative) which is reasonably calculated to bring the claim to the attention of the Board and the written communication is received by the Board.

(c) Written notice of denial. —

(1) The Board shall provide to every claimant whose claim for benefits is wholly or partially denied a written notice setting forth in a manner calculated to be understood by the claimant:

(A) The specific reason or reasons for the denial;

(B) Specific reference to pertinent provisions of applicable law, regulations, or Fund procedures on which the denial is based;

(C) A description of any material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and

(D) Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review.

(2) If the claim is wholly or partially denied, written notice of the decision, meeting the requirements of paragraph (1) of this subsection, shall be furnished to the claimant within a reasonable time after receipt of the claim by the Board.

(3) If written notice of the denial of a claim is not furnished in accordance with paragraph (2) of this subsection within a reasonable time, the claimant shall be deemed to have exhausted his or her administrative remedies for the purpose of instituting proceedings for relief in the Superior Court for the District of Columbia, unless the claimant chooses to avail himself or herself of the procedures set forth in subsection (d) of this section.

(4) For the purposes of paragraphs (2) and (3) of this subsection, a reasonable period of time shall be no more than 90 calendar days after receipt of the claim by the Board, unless special circumstances require an extension of time for processing the claim. If such an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90-calendar-day period. In no event shall such extension exceed a period of 90 calendar days from the end of such initial period. The written notice of extension shall indicate the special circumstances requiring an extension of time and the date by which the Board expects to render the final decision.

(d) Review. —

(1) The Board shall establish and maintain a procedure for each Fund, by which a claimant or his or her duly authorized representative has reasonable opportunity to appeal a denied claim to the Board, and under which full and fair review of the claim and its denial may be obtained. Every such procedure shall include, but not be limited to, provisions that permit a claimant or his or her duly authorized representative to:

(A) Request a review upon written application to the Board;

(B) Review pertinent documents; and

(C) Submit issues and comments in writing.

(2) Such procedures may establish a limited period within which a claimant must file any request for review of a denial claim. Such time limits must be reasonable and related to the nature of the benefit which is the subject of the claim and to other attendant circumstances. In no event may such a period expire less than 60 calendar days after receipt by the claimant or written notification of the denial of a claim.

(3) A decision by the Board or his or her designees shall be made no later than 90 calendar days after the Board’s receipt of a request for review, unless special circumstances require an extension of time for processing, in which case a decision shall be rendered as soon as possible, but not later than 120 calendar days after receipt of a request for review. If such an extension of time for review is required because of special circumstances, written notice of the extension shall be furnished to the claimant prior to the commencement of the extension.

(4) The decision on review shall be in writing and shall be written in a manner calculated to be understood by the claimant. The written decision shall include specific reasons for the decision and shall cite specific references to the pertinent provisions of applicable law, regulation, or Fund procedures on which the decision is based.

(5) The decision on review shall be furnished to the claimant within the appropriate time prescribed in paragraph (3) of this subsection. If the decision on review is not furnished within such time, the claim shall be deemed denied on review.

(e) Reasonableness. — For purposes of this subchapter, a procedure will be deemed to be reasonable only if it does not contain any provision, and is not administered in a way, which unduly inhibits or hampers the initiation or processing of a claim for benefits.

(Nov. 17, 1979, 93 Stat. 866, Pub. L. 96-122, § 191; as added July 2, 1982, D.C. Law 4-123, § 2(b), 29 DCR 2084; Mar. 13, 2004, D.C. Law 15-105,§ 33(c), 51 DCR 881; Apr. 13, 2005, D.C. Law 15-354, § 3(e), 52 DCR 2638.)

1981 Ed., § 1-751.

D.C. Law 15-105 validated a previously made technical correction.

D.C. Law 15-354, in subsec. (b), substituted “Board” for “Mayor” and “Director of Personnel”; in subsec. (c), substituted “Board” for “Mayor” and, in subsec. (d), substituted “Board” for “Mayor” and “Mayor or his or her designee”.

Delegation of authority under Law 4-123, see Mayor’s Order 83-245, October 14, 1983.