Group Benefit Plan AETNA HEALTHCARE DMO NEW YORK SUMMARY PLAN DESCRIPTION (SPD) SUPPLEMENT EVIDENCE OF COVERAGE (EOC) DOCUMENT

Transcription

1 Group Benefit Plan AETNA HEALTHCARE DMO NEW YORK SUMMARY PLAN DESCRIPTION (SPD) SUPPLEMENT EVIDENCE OF COVERAGE (EOC) DOCUMENT EFFECTIVE January 1, 2011

2 SONY PICTURES ENTERTAINMENT GROUP BENEFIT PLAN SUMMARY PLAN DESCRIPTION SUPPLEMENT This document, together with the certificates, amendments and riders prepared by the insurance companies listed in Appendix A, constitutes the Summary Plan Description (SPD) as required by the Employee Retirement Income Security Act of 1974 ( ERISA ) under the Sony Pictures Entertainment Group Benefit Plan (the Plan ). The following information supercedes and replaces any similar information contained in any prior SPD and/or insurance-carrier-provided documents referenced above. You should keep this document with your other SPDs and insurance-carrier-provided materials for future reference. This summary does not cover every detail of the Plan. The Plan is operated according to the terms of a legal document called a Plan Document, which includes policies issued by insurance companies. In the event of a conflict between this summary and the Plan Document, the Plan Document will be followed. Sony Pictures Entertainment Inc. and its participating divisions and affiliates (the Company ) intends to maintain this Plan for eligible employees but reserves the right to change or end the Plan at any time. This summary is not a guarantee of employment or benefits nor is it an employment contract. ELIGIBILITY Eligible Employees Generally, you are considered an eligible employee and are eligible to participate in the DMO provided under the Plan if you satisfy the following requirements: Your employment with the Company is with a participating company listed in Appendix B You are not represented for collective bargaining with respect to the terms and conditions of your employment with the Company (i.e., you are non-union) You are, according to the Company s classification, either: A regular, full-time employee (regularly scheduled to work at least 21 hours per week over a five-day work week for an indefinite period) working in the United States Classified as a Show employee and your employment with the Company is with a participating company listed in Appendix A Covered under a Term Deal, provided that the Company s agreement with the producer with respect to the Term Deal expressly states that you are eligible to participate in this Plan A Term Deal II or SPA Term Deal employee and your employment is with a participating company listed in Appendix A In addition, generally, you are considered an eligible employee and are eligible to participate in the DMO provided under the Plan if you satisfy the following requirements: You are classified by the Company as a regular, full-time employee (regularly scheduled to work 21 hours per week over a five-day work week for an indefinite period) working in the United States, and 1

3 You are classified by the Company as: A production hire working in the State of California or New York who has received open enrollment materials for a given Plan Year or a personalized Certificate of Coverage (see Appendix C), and your employment is with a participating company listed in Appendix B-1 A production hire on an Imageworks production working in the State of California or New York who has received open enrollment materials for a given Plan Year or a personalized Certificate of Coverage (see Appendix C) and who has been employed for at least 30 days, and your employment is with a participating company listed in Appendix B-2 A project hire working in the State of California or New York who has received open enrollment materials for a given Plan Year or a personalized Certificate of Coverage (see Appendix C), and your employment is with a participating company listed in Appendix B-3 A creative services production hire or working in the State of California or New York who has received the open enrollment materials for a given Plan Year or a personalized Certificate of Coverage (see Appendix C), and your employment is with a participating company listed in Appendix B-3 Even if you satisfy the above requirements, you are not eligible to participate in the Plan if, according to the Company s classifications, you are: Eligible to participate in another health and welfare plan sponsored by the Company Employed pursuant to a Term Deal (except as specifically set forth above) An intern A temporary employee A consultant (except covered transitioning executives only as part of an express written agreement approved by the Executive Vice President, Global People & Organization) A production hire (except as specifically set forth above) A project hire (except as specifically set forth above) Represented for collective bargaining with respect to the terms and conditions of your employment with the Company A nonresident alien with no United States source income An employee hired under a special program such as a summer internship, a program for students or the disadvantaged, or a rehabilitation or training program; An employee performing services in a profession for which a guild has been established, irrespective of whether you are a member of such guild; eligible to become a member of such guild; and/or eligible to participate in the guild s benefit plan(s), if any. This exclusion has some exceptions. Please contact an SPE Benefits Connection Representative toll-free at SPE (4773) if you believe you may be entitled to coverage under an exception to this rule 2

4 The Company has the sole and complete discretionary authority to classify employees and other individuals performing services for the Company, and to determine whether the eligibility requirements set forth herein have been satisfied. Individuals who are not classified as members of an eligible category set forth above do not meet the eligibility requirements and are not eligible for benefits under the Plan, even if the Company later determines that their classification is erroneous, or should be retroactively revised. Please note that if a classification of an individual or group as ineligible is determined to be incorrect or is revised retroactively, the individual nevertheless will remain ineligible. This ineligible status will apply for all periods prior to the date the Company or other authority concludes that the classification was incorrect and should be revised. (See the applicable evidence of coverage document (EOC) for additional eligibility requirements.) Eligible Dependents The following dependents of eligible employees are eligible for DMO coverage provided by the Plan: Your legally married spouse Your qualifying domestic partner You or your qualifying domestic partner s unmarried dependent children who are: up to age 26 of age who meet the program s definition of an eligible dependent, regardless of full-time status through the end of the month in which your child attains age 26.Children for whom you are required to provide coverage under a qualified medical child support order (QMCSO). Please note that a copy of the Plan s QMCSO procedures is available at no charge from the Plan Administrator Your or your qualifying domestic partner s mentally or physically disabled adult dependent children who live with you and who are primarily dependent on you for support (validation of disability is required) With respect to you, your legally married spouse or your qualifying domestic partner, the term dependent children means your natural born children, stepchildren, children placed for adoption, adopted children, and foster children, provided you furnish more than 50 percent of their support. Eligible dependents may be enrolled in the DMO coverage provided by the Plan only if you (the employee) are enrolled in that coverage. For your qualifying domestic partner s children to be eligible to be enrolled in the Plan, you and your qualifying domestic partner must also be enrolled in the Plan. You may be required to submit proof of support on a periodic basis to the Plan Administrator. Your qualifying domestic partner ( as part of a registered domestic partnership ) is eligible if you complete an online affidavit of spousal equivalency and: You share a common residence Neither of you is married to someone else or is a member of another domestic partnership with someone else You are not related by blood in a way that would prevent marriage in California You both are at least 18 years of age You both are mentally capable of consenting to the domestic partnership You are of the same sex (or, in the case of an opposite-sex partnership, one or both are over age 62 and meet the eligibility criteria for Medicare benefits, and both have a valid Declaration of Domestic Partnership on file with the Secretary of State of California) Refer to the applicable EOCs for more information. 3

5 You must provide proof of your dependents eligibility on request. False or misrepresented eligibility information will cause both your coverage and your dependents coverage to be immediately and irrevocably terminated, and could be grounds for employee discipline, up to and including termination. In addition, if you misrepresent a dependent s eligibility status, you are personally liable for any and all ineligible claims paid for the ineligible dependent. The amount of any such claims may be, among other things, deducted from any medical or dental reimbursements to which you otherwise would be entitled. If you are married to another Company employee or your qualifying domestic partner also works for the Company, you may enroll as an employee or as a dependent under the Plan, but you may not enroll as both a dependent and an employee. Eligible dependents may be enrolled under only one employee s coverage under the Plan. You both are mentally capable of consenting to the domestic partnership You are of the same sex (or, in the case of an opposite-sex partnership, one or both are over age 62 and meet the eligibility criteria for Medicare benefits, and both have a valid Declaration of Domestic Partnership on file with the Secretary of State of California) Refer to the applicable EOCs for more information. You must provide proof of your dependents eligibility on request. False or misrepresented eligibility information will cause both your coverage and your dependents coverage to be immediately and irrevocably terminated, and could be grounds for employee discipline, up to and including termination. In addition, if you misrepresent a dependent s eligibility status, you are personally liable for any and all ineligible claims paid for the ineligible dependent. The amount of any such claims may be, among other things, deducted from any medical or dental reimbursements to which you otherwise would be entitled. If you are married to another Company employee or your qualifying domestic partner also works for the Company, you may enroll as an employee or as a dependent under the Plan, but you may not enroll as both a dependent and an employee. Eligible dependents may be enrolled under only one employee s coverage under the Plan. NOTICE REGARDING THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 The Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) is a federal law providing, among other things, portability of health care coverage for individuals who change jobs or who otherwise lose their group health care coverage. When losing such coverage, individuals may wish to choose coverage available under the Consolidated Omnibus Budget Reconciliation Act ( COBRA ), or Continuation Coverage under any similar program and pay for it the entire time it is offered to avoid a 63-day break in coverage and, as a result, fail to qualify as an eligible individual under HIPAA. Future HIPAA protections may be jeopardized if individuals choose not to take COBRA coverage, do not exhaust COBRA coverage or purchase a conversion policy. Special Enrollment Periods If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this Plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 31 days 4

6 after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. 5

7 To request special enrollment or obtain more information, contact an SPE Benefits Connection Representative toll-free at SPE (4773). Individuals who have questions about HIPAA may contact The Centers for Medicare & Medicaid Services (CMS) toll-free at The CMS website also provides answers to your questions about the provisions of HIPAA, which can be found at the following Internet address: Individuals may also contact CMS directly, by mail, at: The Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD As always, individuals with questions or concerns relating to their coverage are encouraged to contact their insurance carrier directly. The phone number of your insurance carrier can be found on your dental identification card. Children s Health Insurance Program Effective April 1, 2009, you will also have a HIPAA Special Enrollment Right if your dependent child: Loses eligibility under a state-run Children s Health Insurance Program or a Medicaid program, or Becomes eligible for premium assistance under a state-run Children s Health Insurance Program For more information, contact an SPE Benefits Connection Representative at SPE (4773). THE COST OF YOUR COVERAGE (BEFORE-TAX CONTRIBUTIONS) The cost of employee and dependent coverage under the Plan is paid partially by the Company and partially by employees. The cost of dependent coverage is paid by those employees who elect dependent coverage or who are subject to a qualified medical child support order. For your convenience, your share of the cost of your coverage is deducted from your pay before taxes are withheld. If, for any reason, the cost of your coverage is not deducted from your pay, it is your responsibility to make payment. Failure to do so will result in automatic cancellation of your coverage. When your contributions are before-tax, they are deducted from your pay like this: Your Pay - Dental Plan Contributions = Taxable Pay - Federal & State Income Tax & FICA Withholding = Take-Home Pay Your share of the cost of dental coverage is paid before your taxable pay is calculated. As a result, your taxable pay is reduced. Lower taxable pay means lower taxes and higher take-home pay. During annual enrollment you will receive details about the cost of Plan coverage for the coming Plan Year. 6

8 If you elect health care coverage for your qualifying domestic partner or any eligible dependents of your qualifying domestic partner, IRS regulations require that you pay federal income taxes on the fair market value of this coverage. That means you will make contributions for those dependents on an after-tax basis, and you will be charged imputed income on the amount the Company contributes toward their coverage under the Plan. The amount of your imputed income is accrued and added to your gross income each pay period. Imputed income is subject to federal, state and local income tax withholding and is reflected in your year-end W-2 statement. The imputed income amount equals the value of the coverage provided to your qualifying domestic partner (and eligible children, if any), as determined by SPE s actuarial consultant. Employees who live in states in which civil unions or same-sex marriages are recognized might not be subject to state and local income taxes on any domestic partner imputed income. You are encouraged to speak with a tax advisor to discuss the impact of imputed income on your tax situation. IMPORTANT NOTICE ABOUT THE WOMEN S HEALTH AND CANCER RIGHTS ACT Federal law requires a group health plan to provide coverage for the following services to an individual receiving plan benefits in connection with a covered mastectomy: Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prosthesis and treatment of physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes) The Plan will determine the manner of coverage in consultation with you and your attending doctor. Coverage for breast reconstruction and related services is subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the Plan. STATEMENT OF NEWBORNS AND MOTHERS RIGHTS Under federal or state law, as applicable, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Additionally, plans and health insurance issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your health plan administrator. 7

9 COVERAGE DURING A LEAVE OF ABSENCE Your dental coverage may be continued while you are on an approved leave of absence protected by the Family and Medical Leave Act (FMLA). FMLA is a federal law enacted in 1993 that provides for an unpaid leave of absence for up to 12 weeks during any 12 month period if you experience one of these events: The birth or adoption of a child, or placement of a foster child in your home A serious health condition affecting your child, spouse or parent (this does not include parents-in-law) A serious health condition that makes you unable to perform your job The call to active military duty or other qualified exigency as part of the reserves or federal national guard of your spouse, child or parent In addition, FMLA allows up to 26 weeks of unpaid leave of absence to care for an injured service person who is your spouse, child, parent or next-of-kin. To be eligible for an FMLA leave, you must have completed 1,250 hours of active work during the 12- consecutive-month period before your leave is scheduled to begin. Any paid or unpaid leave time taken during the year is counted against your annual FMLA allowance. You must provide 30 days notice when the need for an FMLA leave is foreseeable. When the need for a leave comes up unexpectedly, you must provide as much advance notice as possible. Medical certification regarding your or a family member s serious health condition may be required. While you are away from work on an FMLA leave, your coverage under the Plan continues for the duration of your approved leave period. You must make arrangements to make required health care benefit contributions on a regular basis while you are away from work. If your coverage contributions are not made for 30 days, your health coverage may be canceled. You will be notified of a potential coverage cancellation. If the Company elects to make your contributions while you are on leave, you will reimburse the Company through payroll deduction when you return to work. If you do not return to work, you must repay the Company the cost of Company-paid health coverage provided during your leave, unless you are not able to return to work due to the continuation, recurrence or onset of a serious health condition, or other circumstances beyond your control. If you return to work when your leave ends, the Company must restore you to your former position or an equal position with equal pay, benefits and terms and conditions of employment. For full details on FMLA provisions in your state and how they affect your coverage under the Plan, contact an SPE Benefits Connection Representative toll-free at SPE (4773). 8

10 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) As required by USERRA, if you take a leave of absence to serve in the uniformed services, you may elect to continue group health care coverage for yourself (and your covered dependents, if any) for up to 24 months from the date your leave of absence begins. Your USERRA continuation coverage terminates earlier if one of the following events occurs: You fail to pay any premium within the required time period You lose your USERRA rights due to a dishonorable discharge or other conduct specified in USERRA You fail to report to work or to apply for reemployment following the completion of your service in the uniformed services within the time period required by USERRA as described in the following chart If Your Period of Uniformed Service is: Less than 31 days (or if you are absent for purposes of an examination to determine your fitness to perform uniformed service) More than 30 days but less than 181 days More than 180 days You Must Report to Work/Submit an Application for Reemployment No Later Than: The beginning of the first regularly scheduled work period on the day following the completion of your service (or examination) after allowing for safe travel home and an eight-hour rest period or, if that is unreasonable or impossible through no fault of your own, as soon as possible.* 14 days after completion of your military service or, if that is unreasonable or impossible through no fault of your own, as soon as possible.* 90 days after completion of your service.* *If you are hospitalized for or are recovering from an injury or illness incurred or aggravated as a result of your service, the applicable time periods begin when you have recovered from your injuries or illness rather than on completion of your service. The maximum period for recovery generally is two years from completion of service. USERRA and COBRA USERRA and COBRA coverage run concurrently, which means that they begin at the same time. However, COBRA coverage can continue for up to 18 months (and for longer periods under certain circumstances) while, as noted above, USERRA coverage can continue for up to 24 months. In addition, COBRA coverage is subject to early termination for additional reasons that do not apply to USERRA coverage. Payment of Premiums If you elect to continue health coverage under USERRA, you must pay 102% of the full premium for the coverage elected (the same rate as COBRA). However, if your uniformed service period is less than 31 days, you are not required to pay more than the amount that you pay for such coverage as an active employee. 9

11 Whom to Contact If you leave employment to enter military service, you should contact People & Organization to determine whether you have health care coverage continuation rights under USERRA. SPE-SPECIFIC LEAVE OF ABSENCE REQUIREMENTS Coverage continuation rules depend on the type of leave you take and whether or not you are receiving pay during your leave. If you have questions regarding your entitlement to any type of leave of absence, contact People & Organization at or toll-free at HOW TO FILE A BENEFIT CLAIM When you receive dental care from a network provider, your provider should automatically file a claim for you. If you receive care or treatment from an out-of-network provider (if applicable), you usually have to pay the provider directly when you receive care and then file a claim with the claims administrator for reimbursement of your eligible expenses. Your claim must include the appropriate paperwork and receipts. If you receive reimbursement from another source, such as your spouse s plan, your claim must include the explanation of benefits from that plan. Be sure to keep a copy of everything for your records. Most claim forms can be obtained by clicking the Documents & Forms link on the SPE Benefits Connection website at or by calling an SPE Benefits Connection Representative toll-free at SPE (4773). You may also obtain forms by calling the claims administrator directly at the number on your ID card. California only: You must submit claims that you incur during the benefit Plan Year within 12 months after the benefit Plan Year ends. For example, assume you incur a claim in October Because the benefit Plan Year ends on December 31, 2009, you have until December 31, 2010, to submit your claim for reimbursement. The Plan does not pay claims that are submitted after the 12-month deadline. Timeframes for Benefit Determinations The timeframes for benefit determination for dental benefits depend on the type of claim. Type of Claim Initial Deadline for Claims Review Time for You to Provide Additional Information Urgent 72 hours 48 hours None Urgent, concurrent care 24 hours* 45 days None Pre-service 15 days 45 days 15 days Post-service 30 days 45 days 15 days Administrative 30 days 45 days 15 days *Applies only when claim is submitted at least 24 hours before end of approved treatment. Extensions for Claims Review, if Necessary 10

12 Urgent claims: Care is urgent if a delay in treatment could seriously jeopardize the participant s life, health or ability to regain maximum function. Also, care may be urgent if, in a doctor s opinion, the participant would be subjected to severe pain if care or treatment were not provided. If you require care that is classified as urgent, but do not submit enough information for the claims administrator to make a determination, the claims administrator will notify you within 24 hours. You have 48 hours after that time to supply any additional information. Until you supply this information, the time limits that apply for the review are suspended (or tolled ). Concurrent care decisions: These are decisions involving an ongoing course of treatment over a period of time or a number of treatments. If you or your dependent is undergoing a course of treatment, or is nearing the end of a prescribed number of treatments, you may request extended treatment or benefits. If the course of treatment involves urgent care and you submit a request at least 24 hours before the expiration of the authorized treatments, the claims administrator will respond to your claim within 24 hours. If you reach the end of a pre-approved course of treatment before requesting additional benefits, the normal pre-service or post-service time limits apply, as described below. Pre-service determinations: A pre-service determination requires receipt of approval of benefits in advance of obtaining care. If you request a review for pre-service benefits but do not submit enough information for the claims administrator to make a determination, the claims administrator will notify you within 15 days. You have 45 days after that to supply any additional information. Until you supply this information, the time limits that apply to the claims administrator are tolled. Post-service claims: A post-service determination is made for benefits after you already received care or treatment. A post-service determination does not require advance approval of benefits. Administrative claims: Claims that are not claims for a specific benefit under the Plan are called "administrative claims" (e.g., you believe that you are being charged too much for the benefit coverage you elected). Because your claim is not for the payment of a specific benefit under the Plan, your claim is treated as an administrative claim. Administrative claims must be submitted to the claims administrator within 90 days from the date you know or should have known that there is an issue, dispute, problem or other claim with respect to the Plan. If a claim involves a Plan change or amendment, you are considered to know about your claim when the change or amendment is first communicated to participants in the Plan, and the 90-day period for filing a claim begins on the date the change is first communicated, whether or not the change or amendment has become effective by that date. If you do not file an administrative claim by the applicable deadline and in the proper manner, your claim will expire and be automatically denied if it is subsequently filed. In this case, you may not be able to proceed with a lawsuit based on that claim. Example: If you have an urgent dental situation, the claims administrator must respond to your initial request for benefits within 72 hours, and no extensions are permitted. If the claims administrator needs more information from you to make a determination, you will have 48 hours from the time you are notified to supply that information. The time period during which you are gathering that additional information does not count toward the time limits that apply to the claims administrator. If Your Claim Is Denied If your claim for benefits is denied (either in whole or in part), the claims administrator will send you a written explanation of the denial. In the case of an urgent claim, this can include oral notification, as long as you are provided with a written notice within three days. This explanation will contain the following information: 11

13 The specific reason for the denial Specific references to plan provisions on which the denial is based A description of additional material or information that you may need to revise the claim and an explanation of why such material or information is necessary A specific description of the Plan s review procedures and applicable time limits, including a statement of your rights to bring a lawsuit under ERISA Depending on the type of claim, the explanation may also contain the following information: If the denial is based on an internal rule, guideline or protocol, the denial will say so and state that you may obtain a copy of the internal rule, guideline or protocol, free of charge on request If the denial is based on an exclusion for medical necessity or experimental treatment, the denial must explain the scientific or clinical basis for determination, applying the terms of the Plan to the medical circumstances, or state that such an explanation will be provided on request, free of charge If the denial involves urgent care, you will be provided an explanation of the expedited review procedures applicable to urgent claims Appealing a Denied Claim If your claim for benefits is denied, you have the right to appeal the denial. To make an appeal, call the claims administrator and ask why your claim was denied. You may discover that a simple error was made. If so, you may be able to correct the problem right over the telephone If this does not resolve your claim, write directly to the claims administrator to have your claim submitted to the claims administrator s level 1 appeals review committee. Be sure to explain why you think your claim should be paid and provide all relevant details. If your claim is denied by the level 1 appeals review committee, you may ask the claims administrator to submit your claim to the claims administrator s level 2 appeals review committee. Timing of Your Appeal If you make a claim for benefits and the claims administrator denies that claim, you have the right to appeal the denial. The appeal procedures must generally be exhausted before you can enforce your rights under ERISA (see Statement of ERISA Rights on page 23 for details). You have 180 days from the time that you receive a claim denial from the claims administrator to file an appeal. Failure to file an appeal within this timeframe will result in a waiver of your rights to have your claim reconsidered on appeal. Following are the timeframes that apply when you file an appeal. Type of Claim Time To Appeal from Date Claim Is Denied Time for Decision on Appeal Urgent claims 180 days 72 hours None Pre-service claims Post-service claims 180 days for each level of appeal 180 days for each level of appeal Two levels of appeal: 15 days from receipt of the appeal for each level Two levels of appeal: 30 days from receipt of the Extensions for Claims Administrator, If Necessary None None 12

14 appeal for each level Administrative 90 days for each level of appeal Two levels of appeal: 30 days from receipt of the appeal for each level None Pre-service claims. There are two levels of appeal. Level 1 appeal: You may file a level 1 appeal with the claims administrator within 180 days if your initial claim for benefits is denied and you would like to appeal that denial. Your appeal must be considered within 15 days, with no extensions Level 2 appeal: If your first appeal is denied by the claims administrator, you may file a level 2 appeal with the claims administrator within 180 days, and your appeal must be considered within an additional 15 days, with no extensions Post-service claims. There are two levels of appeal. Level 1 appeal: You may file a level 1 appeal with the claims administrator within 180 days if your initial claim for benefits is denied and you would like to appeal that denial. Your appeal must be considered within 30 days, with no extensions Level 2 appeal: If your first appeal is denied by the claims administrator, you may file a level 2 appeal with the claims administrator within 180 days, and your appeal must be considered within an additional 30 days, with no extensions Administrative claims. There are two levels of appeal. Level 1 appeal: You may file a level 1 appeal with the claims administrator within 90 days if your initial claim is denied and you would like to appeal that denial. Your appeal must be considered within 30 days, with no extensions Level 2 appeal: If your first appeal is denied by the claims administrator, you may file a level 2 appeal with the claims administrator within 90 days, and your appeal must be considered within an additional 30 days, with no extensions Additional Information about the Appeal Process In filing an appeal, you have the opportunity to: Submit written comments, documents, records and other information relating to your claim for benefits Have reasonable access to and review, on request and free of charge, copies of all documents, records and other information relevant to your claim Have all relevant information considered on appeal, even if it was not submitted or considered in your initial claim If benefits are still denied on appeal, the notice that you receive from the final review level (level 2 review) will provide: The specific reasons for the denial Reference to the plan provisions on which the decision was based A statement that you may receive, on request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim 13

15 A statement describing any additional appeal procedures and a statement of your rights to bring suit under ERISA (see Statement of ERISA Rights on page 23 for details) Depending on the type of claim, the notice that you receive from the final review level may also contain the following information: If the denial is based on an internal rule, guideline, or protocol, the denial will say so and state that you can obtain a copy of the rule, etc., free of charge on request If the denial is based on an exclusion for medical necessity or experimental treatment, the denial will explain the scientific or clinical basis for determination, applying the terms of the Plan to the medical circumstances, or state that such an explanation will be provided on request, free of charge At both the initial claim level and on appeal you may have an authorized representative submit your claim for you. In this case, the claims administrator may require you to certify that the representative has permission to act for you. The representative may be a health care or other professional. However, even at the appeal level, neither you nor your representative has a right to appear in person before the claims administrator or the review panel. LIMITS ON LEGAL ACTIONS If your claim for benefits or administrative claim is denied on the final level of appeal, you generally may file a lawsuit under ERISA regarding your claim, provided that you comply with the deadlines for filing a lawsuit described in this section. If you wish to file a lawsuit, you must do so by the earlier of the date that is 12 months after the date your claim was denied on appeal or the date that is 12 months from the date a cause of action accrued. A cause of action accrues when you know or should know that the claims administrator or Sony Pictures Entertainment as Plan Sponsor clearly denied or otherwise repudiated your claim. Third Level of Voluntary Appeal If the Plan Administrator continues to deny your claim following its review of your second level of appeal, but you nevertheless believe that you are entitled to a Plan benefit, you (or your authorized representative on your behalf) may ask the SPE Benefits Committee to review your claim. You may file for a third level of voluntary appeal, in writing, with the SPE Benefits Committee by contacting: Sony Pictures Entertainment, Plan Administrator c/o SPE People & Organization/Total Rewards West Washington Boulevard, SPP 3900 Culver City, CA Telephone: (310) Fax: (310) Be sure to include all of the information described above in the section titled Additional Information about the Appeals Process. This level of benefit claims review is entirely voluntary. You are not required to pursue your claim for a Plan benefit using this voluntary process. Please note that this voluntary process is available only after you fully follow the claim and appeal procedures with the appropriate administrator above. If you decide to pursue your claim for a Plan benefit through this voluntary process, please be aware that: 14

16 The Plan will not assert a failure to exhaust administrative remedies if you decide to pursue resolution of your claim in court rather than through this voluntary process The Plan will agree that any statute of limitations applicable to pursuing your claim in court will be tolled (suspended) while your claim is being processed through this voluntary process No fees or costs are imposed on you as a part of this voluntary process You may be asked to confirm in writing that your participation in this process is totally and completely voluntary and that you exhausted your claim and appeal rights with the Plan Administrator This voluntary process consists of one level of review, as described below. If you decide to pursue your claim through this voluntary process, your failure to follow these procedures may result in a denial of your claim for a Plan benefit. The SPE Benefits Committee (or its delegate) has full discretion to grant or deny any claim made under this voluntary process in whole or in part. 15

17 How To Make a Claim under This Voluntary Appeal Process Under this voluntary process, you (or your authorized representative on your behalf) must file your appeal of the denial of a Plan benefit with the Plan within 60 days of the date on which the Administrator issued its decision denying the appeal you made under the procedures described above. Your voluntary appeal must be made in writing and must be delivered to the SPE Benefits Committee at the address listed above either using first-class U.S. mail postage pre-paid, electronically, by fax or by hand-delivery. Review of Your Voluntary Appeal On receipt of your voluntary appeal in writing, the SPE Benefits Committee (or its delegate) will review your appeal within a reasonable period of time, but not later than 90 days after its receipt of the appeal. The SPE Benefits Committee may extend the review period for your voluntary appeal for up to an additional 90 days if special circumstances require an extension of time. If an extension is required, the SPE Benefits Committee will notify you in writing before expiration of the initial 90-day period of the reason for the extension and the date by which the SPE Benefits Committee expects to render its decision. Your rights during this voluntary appeal are the same as during the Plan s mandatory appeal. See Additional Information about the Appeals Process. The SPE Benefits Committee (or its delegate) has full discretion to grant or deny your voluntary appeal in full or in part following its review. During its review, the Benefits Committee will: Take into account all comments, documents, records and other information submitted by you or your authorized representative relating to your claim without regard to whether such information was previously submitted or considered by the Plan Administrator in its decision about your claim Review your claim in a manner that does not afford deference to the initial decision to deny your claim Consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, if the initial decision to deny your claim was based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate Notice of Decision on Voluntary Appeal You will be notified in writing of the determination of the SPE Benefits Committee (or its delegate) on your voluntary appeal. If the SPE Benefits Committee (or its delegate) decides to deny your voluntary appeal, you will receive a written notice explaining in detail why your voluntary appeal was denied. This notice will include: The specific reason for the denial Specific references to Plan provisions on which the denial is based If an internal rule, guideline, protocol or similar criterion was relied on in making the denial: The specific rule, guideline, protocol or similar criterion, or A statement that a copy of such will be provided to you free of charge on request If the denial is based on a medically necessary, experimental or investigational treatment or similar exclusion or limit: An explanation of the scientific or clinical judgment, including an application of Plan terms to your medical circumstances, or A statement that such explanation will be provided free of charge on request 16

18 A statement of your right, on request and free of charge, to have reasonable access to and to obtain copies of all relevant documents (as defined by ERISA) If the SPE Benefits Committee does not respond to your voluntary appeal of a claim denial within 90 days, your voluntary appeal is deemed denied. The SPE Benefits Committee s decision (or deemed denial) is final and binding on you and/or your dependents. COBRA CONTINUATION COVERAGE The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Under the law, you and your dependents may continue Companyprovided group health coverage if it ends because of a life event known as a qualifying event. COBRA continuation coverage must be offered to each person who is a qualified beneficiary. A qualified beneficiary is someone who will lose health plan coverage because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Each qualified beneficiary who elects COBRA continuation coverage has the same rights under the Plan as other similarly situated individuals covered by the Plan who did not have a qualifying event. This includes the right to add dependents if they qualify for a HIPAA special enrollment period. If the Plan changes benefits, premiums, etc., continuation coverage changes accordingly. During annual enrollment, each qualified beneficiary has the same options with respect to COBRA coverage as active employees covered under the Plan. Eligibility for COBRA Continued Coverage If you are an employee, you become a qualified beneficiary if you lose your coverage under this Plan because either one of the following qualifying events occurs: Your hours of employment are reduced Your employment ends for any reason other than your gross misconduct If you are the spouse of an employee, you become a qualified beneficiary if you lose your coverage under the Plan because any one of the following qualifying events occurs: Your spouse dies Your spouse s hours of employment are reduced Your spouse s employment ends for any reason other than his or her gross misconduct Your spouse becomes entitled to Medicare (Part A, Part B or both) You become divorced or legally separated from your spouse 17

19 Your dependent children become qualified beneficiaries if they lose coverage under the Plan because any one of the following qualifying events occurs: You die Your hours of employment are reduced Your employment ends for any reason other than your gross misconduct You becomes entitled to Medicare (Part A, Part B or both) You and your spouse become divorced or legally separated Your child stops being eligible for coverage under the Plan as a dependent child The Company will offer COBRA continuation coverage to qualified beneficiaries only after it is notified in writing that a qualifying event occurred. You do not have to notify the Company when the qualifying event is the end of employment or a reduction of hours of employment, the death of the employee or entitlement to Medicare (under Part A, Part B or both). However, in the case of the other qualifying events (divorce or legal separation of you and your spouse or a dependent child s loss of eligibility for coverage as a dependent child), you must notify the Company, in writing, within 60 days after the qualifying event occurs. You must send this notice to Empire BCBS/Conexis, the COBRA Administrator. A notice mailed to the COBRA Administrator is considered provided on the date of mailing. The notice must include your name, the name of your spouse and/or dependent child, the nature of the qualifying event (e.g., divorce, legal separation or your child s loss of dependent status) and the date the qualifying event occurred. You will have to provide documentation such as a divorce decree that a qualifying event occurred. If notice is not provided during this 60-day notice period, your spouse or dependent child who loses coverage will not be offered the opportunity to elect COBRA continuation coverage. When the Company receives notice that a qualifying event occurred and supporting documentation is provided, COBRA continuation coverage is offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage begins on the date of the qualifying event. Contacting the COBRA Administrator Empire BCBS/Conexis PO Box Dallas, TX

20 Duration of COBRA Coverage COBRA continuation coverage is a temporary continuation of coverage. The duration of the coverage depends on the nature of the qualifying event that causes the loss of coverage: When the qualifying event is your death, your enrollment in Medicare (Part A, Part B or both), your divorce or legal separation, or a dependent child s loss of eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of your employment or reduction of your hours of employment, and you became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than you lasts for up to 36 months after the date of Medicare enrollment. For example, if you become entitled to Medicare eight months before your employment terminates, COBRA continuation coverage for your spouse and children can last for up to 36 months after the date of Medicare entitlement, which would be 28 months after the date of the qualifying event (36 months minus 8 months) When the qualifying event is the end of your employment or reduction of your hours of employment, COBRA continuation coverage lasts for up to 18 months There are three ways in which this 18-month period of COBRA continuation coverage can be extended. Disability Extension of 18-Month Period of Continuation Coverage If the Social Security Administration (SSA) determines that you or anyone in your family covered under the Plan is disabled and the COBRA Administrator receives timely notice of that determination, you and/or your other family members may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months of COBRA coverage. The disability must have started at some time before the 60 th day of COBRA continuation coverage and must last at least until the end of the initial 18- month period of COBRA continuation coverage. For the extension to be available, you must notify the COBRA Administrator in writing of the disability determination during the first 18 months of COBRA continuation coverage and no more than 60 days after the latest of: (i) the date of the SSA determination, (ii) the date of the qualifying event or (iii) the date coverage would end on account of the qualifying event. The notice must include your name, the name of the disabled individual and a copy of the Social Security Administration disability determination. A notice mailed to the COBRA Administrator is considered provided on the date of mailing. If notice is not provided within the above timeframes, the 18-month maximum coverage period will not be extended. The disability extension is available only for as long as the family member remains disabled. You must notify the COBRA Administrator if the Social Security Administration makes a final determination that the individual is no longer disabled. Continuation coverage ends on the first day of the month that begins more than 30 days after the date of the determination. 19