Disability Income Protection Plan

Transcription

1 Title Benefits Plan Body Disability Income Protection Plan

2 In This Summary... Introduction...3 Disability Case Management...4 Disability Council Limited Hours Program Vocational Rehabilitation Joining the Plan...6 Eligibility Pre-existing Conditions Reinstatement of Eligibility Disability Coverage During a Leave of Absence Enrollment Cost of Coverage Offsets to Your Disability Benefit Short-Term Disability (STD) Benefits...7 When Coverage Begins What STD Benefits Pay Taxes on Your Disability Benefits Filing Claims If You Become Disabled Again Long-Term Disability (LTD) Benefits...9 When Coverage Begins What LTD Benefits Pay How Long Your Benefits Continue How Social Security Affects Your LTD Benefits Receiving LTD Benefit Payments Taxes On Your LTD Benefits Filing Claims If You Become Disabled Again Other Important Provisions Disabilities Extending Beyond 6 Months Disabilities Not Covered Specified Injuries or Sickness Limitation When Eligibility to Participate Ends When Your Benefits Will End Death Benefit Impact on Other Benefits Your Rights Under the Plan Definitions

3 Introduction Advocate Health Care is committed to providing you with a level of replacement income during an illness or injury. That is why we provide this comprehensive disability plan to you at no cost. Your disability benefits are designed to provide continuing income if you cannot work because of a certified disability. Your disability plan is made up of two parts Short-Term Disability (STD) and Long-Term Disability (LTD). STD benefits provide protection for you during illness or injury up to six months. LTD benefits provide protection for you after you ve been disabled for six months, as long as you remain disabled and meet the eligibility requirements of the plan. Definition of Disability During the first 24 months of your certified illness or injury, you are considered disabled if you cannot perform the essential function of your regular job as a result of your illness or injury. The Disability Council will make this determination. If you have not totally returned to your regular job after 24 months of a certified illness or injury, your eligibility for disability benefits will be re-evaluated. You must be unable to work at any job (not just with Advocate Health Care) for which you are reasonably qualified by your education, training or experience in order to continue to be eligible for long term disability benefits. The Disability Council will make this determination. 3

4 Disability Case Management The purpose of Disability Case Management is to ensure that eligible participants: Receive the appropriate benefit, and Return to work as quickly as possible. This process is managed through the Disability Council. Disability Council The Disability Council certifies your disability. This means that a clinical decision will be made regarding your disability. The Disability Council is a group of health care providers, nurses and vocational rehabilitation professionals who provide a range of services during your disability. These services can help you receive efficient and quality medical treatment so you can return to work as soon as appropriate. If your absence exceeds 15 calendar days, you must contact the Disability Council no later than the 15th day of absence to certify your period of disability. Your case will then be managed by a nurse who works with an occupational health provider to determine the appropriate time off for your disability. It is the Disability Council, not your physician, that determines your eligibility for benefits by certifying your disability. Your case will be continuously reviewed to determine if additional time off is necessary. The Council will work closely with your physician to make sure you are following all the recommended treatment plans. The Disability Council also provides additional disability management services. The Council may assist you in arranging medical services (such as therapy or home health care), provide personal support during your disability and determine work modifications or vocational rehabilitation services as necessary. The Disability Council may ask a disabled associate to undergo independent medical exams on an as-needed basis. Benefit continuation depends on following the recommendations of the Disability Council. The Disability Council offers a wide variety of services to you during your disability. The doctors, nurses and vocational professionals on the Disability Council can provide: Education Personal support Vocational Rehabilitation Limited Hours Program If you are receiving disability benefits, you may become eligible for the Limited Hours Program if: You have been disabled for a minimum of 30 days, and You are released by your doctor to work at least 50% of your normal scheduled hours per week and you can perform all your normal job duties (i.e., your disability is based on an hours restriction only). You will not be eligible for Limited Hours Program benefits if there are any physical restrictions on the work you can perform. 4

5 The Disability Council, in most cases, will follow your doctor s recommendation. If you choose to not return to work under this program, your disability benefits will end. In addition, if you have exhausted all time off available under the Family and Medical Leave Act (FMLA), your employment will be terminated. You may participate in the Limited Hours Program for up to 12 weeks or a total of 60 days. During that time, your STD benefit will be reduced by any income you receive while working on a limited-hours basis. While you are participating in the Limited Hours Program, the Disability Council will regularly contact you to discuss your progress, offer support, answer any questions you may have and certify additional days for your continued participation in the program, if necessary. Medical updates will be requested on an asneeded basis as determined by the Disability Council. If a medical update is not received within 14 calendar days of the request, you may be sent home without pay, and you will be considered to have voluntarily resigned unless your absence is approved under the Family and Medical Leave Act. Vocational Rehabilitation Vocational Rehabilitation is for associates who, because of their permanent restrictions, are unable to perform their previous job on an accommodated basis. Vocational Rehabilitation offers the following services: Vocational Evaluation to determine your vocational strengths, aptitudes and interests. Career Counseling to help you find different vocational goals and/or training options. Job Readiness Training to help you prepare for a job search either inside or outside of Advocate Health Care. If, after you have exhausted your FMLA leave and if you are eligible to participate in Vocational Rehabilitation and do not do so, you will be considered to have voluntarily terminated your employment and thus not be eligible for disability benefits. If you are unable to report to work due to illness or injury while participating in the Limited Hours Program, you must call the Disability Council immediately. Failure to notify the Disability Council may result in a delay in benefit payments. 5

6 Joining the Plan Eligibility Your eligibility to participate in the Disability Income Protection Plan depends on your length of employment in a benefits eligible status. If you are a regular Full-Time or regular Part-Time A associate, you are eligible for coverage on the first day you are actively at work after you have worked for six continuous months as a regular Full-Time or regular Part-Time A associate. No other associates are eligible for coverage under this plan. Pre-existing Conditions If you have a condition that requires medical treatment during the calendar month before you become eligible and you become disabled as a result of that condition during your first five days of coverage under the plan, a plan benefit will not be paid for that disability. Reinstatement of Eligibility If your employment with Advocate Health Care terminates and you later return to work, there is a six month waiting period before you become eligible for disability benefits. If your employment terminates and you are receiving severance and you return to a benefits eligible status within six months, this six month waiting period will not apply. Disability Coverage During a Leave of Absence Your disability coverage will continue while you are on an authorized leave of absence. Enrollment You must elect to enroll in disability coverage when you first become eligible. If you don t, you will not be able to enroll in this coverage at a later date. Cost of Coverage You and Advocate BroMenn share the cost of your disability coverage. Offsets to Your Disability Benefit Other sources of income that are payable to you because of your disability will reduce your disability benefit. These other sources may include: Social Security disability benefits (primary only see page 11 for more information) Social Security retirement benefits Any benefits paid under a mandatory state disability law or any similar compulsory benefit act or law Any disability income benefits you are eligible for under any other group insurance plan or any governmental retirement system as a result of your job with any employer Any income you receive under the Limited Hours Program (see page 5 for more information), and Any damages recovered (less any reasonable legal fees and costs associated with the recovery) due to an act or omission of a third party, but only to the extent that such damages represent your loss of income. If you are paid any such benefits in a lump sum, for purposes of determining the amount of the offset, the lump sum will be prorated over the period of time it would have been paid if not in a lump sum or over a period of 60 months if such period cannot be determined. 6

7 Short-Term Disability (STD) Benefits When Coverage Begins If you are unable to perform your job because of a certified non-work related illness or injury, you may be eligible to receive STD benefits or participate in the Limited Hours Program. Your STD benefits or Limited Hours Program benefits will begin after your absence exceeds 30 calendar days. If you work less than half of your scheduled hours and go home sick, that day is counted toward your first 30 days of absence. You must elect to use Paid Time Off (PTO) days (or Sick Bank after 30 days, if applicable) to supplement your income until STD or partial disability begins. PTO may also be used to supplement disability benefits (not to exceed 100 percent of base pay). What STD Benefits Pay STD benefits equal 50% of your base pay (excluding shift differential) for the first six months of a certified illness or injury. The maximum STD benefit payable is $3,230 per pay period (for up to 22 weeks). Definition of Base Pay Your STD and LTD benefits are calculated using your base pay. Base pay is your hourly rate of pay at the time you become disabled. Base pay doesn t include overtime, shift differential or any other premium pay. STD Benefits An Example Your STD benefits are based on your FTE status at the time your disability starts. If your FTE status is Full Time (80 hours per pay period), your STD benefits are calculated as follows: Multiply your FTE status by 50%: Eligible Hours STD Coverage Percentage Hours per pay period of STD Benefits 80 hours/pay period 50% 40 hours/pay period Multiply the hours per pay period of STD by your straight time hourly rate. This will equal your gross disability benefit. Remember all your regular deductions, including taxes will be taken from your STD benefits. Taxes on Your Disability Benefits Beginning the last 30 days of STD, your disability benefit payments will be exempt from FICA taxes. However, the benefits will still be subject to federal, state and local income taxes, as applicable. 7

8 Filing Claims 1. If you are absent as a result of illness or injury for more than 15 calendar days, you must call HR Direct no later than the 15th day of absence to certify your time away from work. Failure to report such absences to HR Direct and your supervisor may result in disciplinary action. 2. When an absence exceeds 30 calendar days it must be certified with the Disability Council in order for benefits to be paid. It is your responsibility to call HR Direct to certify your absence. Consideration for disability benefit payments will not be made on a retrospective basis. This means that the Council will only provide benefits for a certified disability from the day you notify them and any days thereafter. Failure to call on a timely basis will result in forfeiture of benefits for the days preceding your call to HR Direct, regardless of the diagnosis. There is no precertification process for disability benefits. You must call HR Direct when it is medically necessary for you to begin your period of disability. This includes leaves for maternity and elective surgeries. 3. Once you call HR Direct, various forms will be sent to you. These forms must be completed by yourself and your physician to begin your disability leave of absence. If you do not fill out the forms (or have them filled out on your behalf) and return them to the Disability Council within the specified time, disability benefits will not be paid and you will also be considered to have voluntarily resigned unless your absence is approved under the Family and Medical Leave Act. 4. The Disability Council may call you and/or your physician to discuss your case (see page 4 for more information). 5. When benefits begin, the Disability Council will regularly contact you to discuss your progress, offer support, answer any questions you may have and certify additional days for your leave, if necessary. Medical updates will be requested on an as-needed basis as determined by the Disability Council. It is your responsibility to obtain this information. If a medical update is not received within 14 calendar days of the request, your disability benefits will cease, and you will be considered to have voluntarily resigned unless your absence is approved under the Family and Medical Leave Act. 6. The Disability Council uses Advocate s payroll system to process your benefits. Checks will be processed and issued according to your assigned pay cycle. Any partial benefit payments will be directed to the next scheduled cycle for you. If You Become Disabled Again Upon Your Return To Work If you become disabled again you must call HR Direct to certify your illness or injury. Your period disability will be considered the same period of disability if you meet the following criteria: You must be off again with the same or related diagnosis, and You must have been back to work for no more than 10 scheduled work days or 14 calendar days. A new period of disability begins: If you become disabled again after returning to work for more than 10 scheduled work days or 14 calendar days, or Due to a cause unrelated to the previous disability and you return to active work for at least one day. 8

9 Long-Term Disability (LTD) Benefits When Coverage Begins Your LTD coverage begins when you have been certified as disabled and received STD/Limited Hours Program benefits for six months. What LTD Benefits Pay If you have been certified as disabled for 180 days under the provisions of STD benefits, you will be eligible to receive LTD benefits. LTD benefits continue as long as you remain disabled generally until age 65 (for exceptions, see right). LTD benefits equal 50% of your base pay (as defined on page 7). This benefit will be offset any other source of income (as described on page 6). The minimum LTD benefit payable is $50.00 per month; the maximum LTD benefit payable is $3,230 per pay period. How Long Your Benefit Continues If you are entitled to receive LTD benefits, payments will begin on the 181st day of your certified disability. How long you receive LTD benefits depends on your age when you become certified as disabled. If you become certified as disabled at... Age 61 or before reach age 65 Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and over Your LTD benefits will continue until you are no longer certified as disabled or, if sooner, you... receive benefits for three years and six months receive benefits for three years receive benefits for two years and six months receive benefits for two years receive benefits for one year and nine months receive benefits for one year and six months receive benefits for one year and three months receive benefits for one year 9

10 How Social Security Affects Your LTD Benefits Your LTD benefits will be reduced by any Social Security disability benefits you receive for yourself. You must apply for Social Security disability benefits immediately in order for your LTD benefits to continue to be paid. If your claim for Social Security is denied, you must reapply to Social Security within 60 days to have the claim reconsidered. You are required to follow these two steps to appeal a claim: Request for Reconsideration. Request your local Social Security office to review your case by completing a Request for Reconsideration Form from Social Security within 60 days of the date you are denied initial benefits. Administrative Law Judge Hearing. If your Request for Reconsideration is denied, you must request an Administrative Law Judge Hearing by completing a special form from Social Security within 60 days of the date you receive a denial notice. You must provide the Disability Council with evidence of your application and appeal for Social Security benefits and evidence of any denial, appeal and/or award letters. If you do not provide satisfactory proof to the Disability Council, your LTD benefits will end. If you do not return to work, you will be considered to have voluntarily resigned. The Disability Council will begin taking an estimated Social Security offset effective at the beginning of the twelfth month of total disability benefits including STD benefits. If you receive an award for Social Security benefits after your LTD benefits have begun, you must repay the plan any retroactive Social Security disability award. If you do not repay Advocate Health Care within four weeks after you receive the award, you will not receive any future disability benefits until you repay the plan, and if you are participating in an Advocate-sponsored Medical and/or Dental plan, you will assume the full cost for your Health Care Continuation Coverage. If you choose to hire an attorney to represent you while you are trying to obtain Social Security disability benefits, the plan will reduce the amount you owe Advocate Health Care by the amount of your actual attorney s fees (up to a maximum of $6,000) if you are eventually granted Social Security disability benefits. If you receive a cost-of-living increase to your Social Security disability benefit after your LTD benefit has been calculated, your LTD benefit will not be reduced for this cost-of-living adjustment. Receiving LTD Benefit Payments LTD benefit payments will be made on a biweekly basis to coincide with payroll schedules. The Social Security award is multiplied by 12 and divided by 26 pay periods to provide accurate offsetting dollars. The bi-weekly benefit payments provide the convenience of certain payroll deductions and direct deposit. LTD Benefits An Example Assume your eligible base pay is $800 per pay period at the time you become disabled. You are also eligible for a Social Security disability benefit of $400 a month. Here is how you would calculate your LTD benefit. Multiply your eligible base pay by 50% (the LTD benefit) to determine your gross benefit per pay period. Eligible Base Pay LTD Coverage Percentage Gross Benefit $ % $ Subtract other income you are eligible to receive to find your net monthly benefit. Social Security Disability Benefit Converted = $ per pay period. Gross Benefit Social Security Disability Benefit LTD Plan Benefit per pay period $ $ Your disability benefit premiums will be waived once LTD benefits begin. Waiver of premiums will continue until the end of any period for which benefits are payable. 10

11 Filing Claims 1. At the beginning of your third month of certified disability, the Disability Council will provide you with LTD benefit forms. These forms include a Long Term Disability Benefit Application, Attending Physician s Statement, Reimbursement Agreement and Social Security Status Form and must be returned within 30 days. 2. Complete the forms and return them to the Council. Be sure to have your physician fill out the physician section of the forms. You will not receive any LTD benefits until you complete and return all of the forms. 3. Contact your local Social Security Administration office to apply for Social Security disability benefits (see How Social Security Affects Your LTD Benefits, page 11). Proof of application for Social Security benefits must be provided within 30 days of the start of long term disability or LTD benefits will not be paid. The Disability Council may be helpful in directing you to the Social Security office nearest you. 4. Remember, it is the Disability Council, not your physician, that determines your eligibility and certifies benefits. The Disability Council will notify you regarding your LTD benefits after the required information has been reviewed. If the Disability Council does not certify disability benefits, you will receive a letter explaining the reason for the denial and the appeals process. If your appeal is denied, you will be considered to have voluntarily resigned as of the date of the appeal denial. 5. Medical updates will be requested on an asneeded basis as determined by the Disability Council. If a medical update is not received within 14 calendar days of the receipt of the request, your disability benefits will cease and you will be considered to have voluntarily resigned. Also, the Council may do phone updates in lieu of medical updates, and you must be available for case management. If You Become Disabled Again If you are certified as disabled from the same illness or injury within six months after your return to work following a long term disability, you will immediately begin to receive LTD benefits. If you return to work for six months or more and then are certified as disabled from the same illness or injury or if you are certified as disabled from a different illness or injury within six months of your last certified disability you will first receive five months of STD benefits and then, if eligible, LTD benefits. 11

12 Other Important Provisions Disabilities Extending Beyond 6 Months After you have been disabled and have not returned to work for six months, your employment with Advocate Health Care will end. However, even though your employment has ended, you will continue to receive disability benefits as long as you are certified as disabled up to the age specified on page 9. For information regarding participation in other benefit plans, refer to the plan summary booklet for each plan. If you are able to return to work from a certified disability, your prior service will be reinstated for benefits purposes. Disabilities Not Covered Like most disability plans, this plan does not pay benefits for disabilities resulting from: Commission of a felony War or act of war (declared or undeclared), insurrection or rebellion Intentionally self-inflicted injuries or sickness, or Active participation in a riot. Specified Injuries or Sickness Limitation Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused or contributed to by one or more of the following, or medical or surgical treatment of one or more of the following: Mental disorders Substance abuse, or Other limited conditions. However, if you are confined in a Hospital solely because of a Mental Disorder at the end of the 24 months, this limitation will not apply so long as you remain continuously confined. When Eligibility to Participate Ends Your eligibility to participate in the disability plan ends: At the end of your last day of active employment with Advocate Health Care due to termination of employment unless you are currently receiving any form of disability benefits from this plan. If you change to an ineligible employment status. If you enter the armed forces of any country (except for temporary duty of 30 days or less). Upon your death. (See Death Benefit below for information on a benefit your beneficiaries may receive if you die.) If a specific coverage or benefit is discontinued. When Benefits Will End Your benefits will end if: You are unavailable for active case management at the Disability Council s discretion You are not following your physician s recommended treatment plan to aid in your recovery or return to work You no longer reside in the United States. The Disability Income Protection Plan is discontinued, or Advocate has knowledge that you are working, interviewing for or have accepted another job. You may not convert your disability coverage to individual coverage. Death Benefit If you received LTD benefits for at least 180 consecutive days and you die, your spouse/ domestic partner (or dependent children under age 21 if you are not married) will receive a total lump sum death benefit equal to three months of disability payments. 12

13 Impact on Other Benefits For information on how disability affects your other benefits, refer to the If You Become Disabled section of the plan summary of each plan. Your Rights Under the Plan The Internal Revenue Service has determined that this plan is not subject to ERISA. This plan is a self-insured plan funded entirely by Advocate Health Care from its general assets. Because the plan is self-insured, it is not subject to state insurance laws. Appeal of a Denied Claim You will be notified in writing in 90 days (180 days in the case of special circumstances) if your claim for benefits is denied, in whole or in part. The written denial of claim will include the specific reason for denial, reference to specific plan provisions upon which the denial is based, a description of any additional materials or information necessary to process the claim and your right to have the claim reviewed. Within 60 days after receiving a denial notification, you may request, in writing, a review by the plan administrator. During this 60-day period, you may review pertinent documents and submit issues and comments to the plan administrator. Usually, you will receive written notice of the review decision within 60 days of your request. In unusual circumstances, the plan administrator may need another 60 days to reach a decision. You will be given specific reasons for the decision, with specific references to the pertinent plan provisions on which the decision is based. The review request and any legal processing relating to a claim that has been denied should be addressed to: Senior Vice President, Human Resources Advocate Health Care 2025 Windsor Drive Oak Brook, Illinois Plan Name Plan Sponsor Disability Income Protection Plan Plan Sponsor Identification Number Advocate Health Care Network Corporation 2025 Windsor Drive Oak Brook, Illinois Plan Year January 1 December 31 Plan Administrator Senior Vice President, Human Resources Advocate Health Care 2025 Windsor Drive Oak Brook, Illinois You can examine all plan documents at no charge. You may also obtain copies of plan documents and other plan information by writing to the plan administrator. The administrator may charge you a reasonable amount for the copies. 13

14 Definitions Domestic partner A partner as determined by the criteria described in the Domestic Partner Guide and used for the Advocate Welfare Plans (subject to the submission of appropriate documentation). Non-work related illness An illness or disease (including pregnancy), of a covered associate which results in temporary or total disability Non-work related injury An accidental bodily injury incurred by a covered associate which results, directly and independently of all other causes, in temporary or total disability Other limited conditions Means chronic fatigue conditions (such as chronic fatigue syndrome, chronic fatigue immunodeficiency syndrome, post viral syndrome, limbic encephalopathy, Epstein-Barr virus infection, herpes virus type 6 infection, or myalgic encephalomyelitis), any allergy or sensitivity to chemicals or the environment (such as environmental allergies, sick building syndrome, multiple chemical sensitivity syndrome or chronic toxic encephalopathy), chronic pain conditions (such as fibromyalgia, reflex sympathetic dystrophy or myofascial pain), shift work sleep disorder, carpal tunnel or repetitive motion syndrome, temporomandibular joint disorder, craniomandibular joint disorder, arthritis, diseases or disorders of the cervical thoracic, or lumbosacral back and its surrounding soft tissue, and sprains or strains of joints or muscles. Other limited conditions does not include neoplastic diseases, neurologic diseases, endocrine diseases, hematologic diseases, asthma, allergy-induced reactive lung disease, tumors, malignancies, or vascular malformations, demyelinating diseases, lupus, rheumatoid or psoriatic arthritis, herniated discs with neurological abnormalities that are documented by electromyogram and computerized tomography or magnetic resonance imaging, scoliosis, radiculopathies that are documented by electromyogram, spondylolisthesis, grade II or higher, myelopathies and myelitis, traumatic spinal cord necrosis, osteoporosis, discitis, Paget s disease. Physician A person licensed to practice medicine and render health care services within the scope of his or her license, including a doctor of osteopathy, a doctor of podiatry, a doctor of dentistry and a chiropractor This plan summary highlights the features of the Disability Income Protection Plan. It is based on the provisions described in the legal plan document, which governs the plan. If there are any discrepancies between this summary and the official plan document, the plan document will be the official reference. Advocate Health Care Network Corporation reserves the right to amend, modify or terminate the Disability Income Protection Plan at any time, for any reason. If such change or termination occurs, you will be notified promptly. Nothing in this plan gives any associate the right to be retained in the service of Advocate Health Care. Nor does this plan interfere with the right of Advocate Health Care to discharge or discipline an associate at any time. 14 Advocate Health Care 5/10