Life Insurance Plan. St. Mary s Health System Evansville, IN. Summary Plan Description. Effective January 1, January 2012 Life Insurance SPD i

Transcription

1 St. Mary s Health System Evansville, IN Life Insurance Plan Summary Plan Description Effective January 1, 2012 January 2012 Life Insurance SPD i ENABLING STRENGTHS INSPIRED PEOPLE My Life. Even Better.

2 Your Plan Outline St. Mary s Health System Basic Life Insurance Plan Evansville, IN Effective date: January 1, 2014 Who Is Eligible Eligibility Date Benefit Amount Active full time and part time associates reguarly authorized to work at least 40 hours per pay period First of the month coincident with or following one month of service Basic Life One time (1x) Basic Annual Earnings to a maximum of $1,000,000 and a minimum of $20,000 Benefit amount can be capped at $50,000 to avoid imputed income Your Cost for Coverage Your Employer provides this coverage at no cost to you. January 2012 Life Insurance SPD i

3 Your Plan Outline Effective date: January 1, 2014 St. Mary s Health System Supplemental Term Life Insurance Plan Evansville, IN Who Is Eligible Eligibility Date Dependent Age Limit Active full time and part time associates regularly authorized to work at least 40 hours per pay period First of the month coincident with or following one month of service Eligibility continues to child s 26 th birthday (coverage ends on 26 th birthday) Employee-Only Coverage Options 1X Basic Annual Earnings 2X Basic Annual Earnings 3X Basic Annual Earnings 4X Basic Annual Earnings 5X Basic Annual Earnings 6X Basic Annual Earnings 7X Basic Annual Earnings Maximum $5,000,000 Minimum $20,000 Spouse- Only Coverage Options $10,000 $25,000 $50,000 $75,000 $100,000 Children-Only Coverage Options $5,000 $10,000 Your Cost for Coverage $125,000 $150,000 $175,000 $200,000 $250,000 You pay the full cost of coverage. See your enrollment materials for the current rates. January 2012 Life Insurance SPD i

4 Your Plan Outline St. Mary s Health System Voluntary AD&D Insurance Plan Evansville, IN Who Is Eligible Eligibility Date Dependent Age Limit Coverage Options Benefit Amount Effective date: January 1, 2014 Active full time and part time associates regularly authorized to work at least 40 hours per pay period First of the month coincident with or following one month of service Eligibility continues to child s 26 th birthday (coverage ends on 26 th birthday) You have two choices for coverage: Employee Only: The Plan pays benefits to you if you suffer an Injury or to your beneficiary(ies) if you die in an accident. Family: The Plan pays benefits if a Covered Dependent suffers an Injury or dies in an accident. You are the beneficiary. No Coverage 1X (One times) Basic Annual Earnings 2X (Two times) Basic Annual Earnings 3X (Three times)basic Annual Earnings 4X (Four times) Basic Annual Earnings 5X (Five times) Basic Annual Earnings 6X (Six times) Basic Annual Earnings 7X (Seven times) Basic Annual Earnings 8X (Eight times) Basic Annual Earnings 9X (Nine times) Basic Annual Earnings 10X (Ten times) Basic Annual Earnings 1 million maximum $20,000 minimum Your Cost for Coverage You pay the cost of coverage. See your enrollment materials for the current rates. January 2012 Life Insurance SPD i

5 Your Contact Information For Questions About Eligibility Your local Human Resources Department For Questions about Benefits and How the Plan Works Prudential To File a Claim Your local Human Resources Department To Appeal a Claim If You Have a Dispute that Can t be Resolved by Prudential Prudential Group Life Claim Division The Prudential Insurance Company of America P.O. Box 8517 Philadelphia, PA Depending on the state in which you reside, there may be a state or government agency you can contact. To obtain contact information for these additional resources, contact Prudential Customer Service at Monday - Friday 8:00 a.m. 8:00 pm EST; 7:00 a.m. 7 pm CST You can also contact the Employee Benefits Security Administration at January 2012 Life Insurance SPD ii

6 Contents Plan Outline... i Your Contact Information...ii Introduction... 1 Glossary... 2 Section 1: Eligibility and Participation... 6 Eligibility... 6 Enrollment... 6 Change Events... 8 Participant Contributions... 8 When Coverage Begins... 9 When Coverage Ends... 9 Continuing Your Coverage Taking Your Coverage With You; The Portability Plan Right to Amend or Discontinue the Plan Section 2: Life Insurance Benefits Basic Life Coverage Supplemental Associate Life Coverage Supplemental Dependent Life Coverage Section 3: AD&D Insurance Benefits Basic AD&D Coverage Supplemental Associate AD&D Coverage Supplemental Dependent AD&D Coverage How AD&D Coverage Works Additional AD&D Benefits Section 4: What s Not Covered Section 5: Other Plan Provisions Payment of Your Death Benefit Benefits During a Terminal Illness Coverage Reduction at Age Limits on Assignments Limits on Life Insurance Coverage Due to Death Prior to Enrollment Section 6: Claims Procedures Filing a Claim Timing of Claims Review If Your Claim Is Denied Appealing a Denied Claim Overpayment of Claims January 2012 Life Insurance SPD iii

7 Misrepresentations Section 7: Your ERISA Rights Receiving Information About Your Plan and Benefits Prudent Actions by Plan Fiduciaries Enforcing Your Rights Assistance with Your Questions Section 8: Plan Information January 2012 Life Insurance SPD iv

8 Introduction Ascension Health and your Participating Employer offer life insurance and accidental death and dismemberment (AD&D) insurance benefits to you and your Eligible Dependents. The Ascension Health Life Insurance Plan provides financial protection to you and your family in the event of death or serious accidental injury. This Information Is a Summary The information in this summary plan description (SPD) is intended to serve as a summary of the Ascension Health Life Insurance Plan (Plan), effective January 1, You should refer to the official Plan document for details. You or your refers to the Eligible Associate and any Eligible Dependents covered under the Plan. Days refers to calendar days. If there are any discrepancies between the information in this SPD and the official Plan document, the terms of the Plan document will prevail. This SPD does not constitute a contract of employment or a guarantee of benefits or future employment. In addition, your eligibility for and participation in the Plan as described in this SPD should not be construed as an employment contract. Certain words in this SPD are capitalized. These words are defined in the Glossary section. You may find it helpful to consult the Glossary section as you read this SPD. The following pages of this SPD explain provisions that generally apply to Eligible Associates of all Participating Employers that offer life insurance and AD&D benefits under this Plan. The Plan Outline section of this SPD contains specific requirements and provisions that apply to Eligible Associates of your Participating Employer. January 2012 Life Insurance SPD 1

9 Glossary The following terms may help you in reading and understanding this SPD. Active Employment/Actively Employed Working part- or full-time at the Participating Employer s place of business or at any other place that the Participating Employer s business requires you to go. Normal vacation is considered Active Employment if the Associate was actively at work on his or her last regularly scheduled workday. Air Bag An inflatable safety device that meets published federal safety standards, is installed by the Automobile s manufacturer, and is not altered after that installation. Associate Any individual who is classified by a Participating Employer as an employee. Automobile A validly registered vehicle that may be legally driven with the standard issue class of motor vehicle driver s license and no additional class of license is necessary to operate this vehicle; or a four-wheel, two-axle private passenger motor vehicle. It does not include a motor vehicle intended for off-road use or a motor vehicle being used without the owner s permission. Beneficiary Any person or legal entity chosen on a form approved by The Prudential Insurance Company of America (Prudential) to receive insurance benefits under the Plan. Change Event A change in status or change in family status event that is described in the Internal Revenue Code Section 125 cafeteria plan adopted by the Participating Employer of the Eligible Associate. Change of Benefits Date The effective date of a mid-year election change due to a Change Event. The Change of Benefits Date for a Change Event related to birth, adoption or placement for adoption is the date of the birth, adoption or placement for adoption. The Change of Benefits Date for all other Change Events is as soon as administratively possible after the requested change is filed. Child The Eligible Associate s natural child, legally adopted child, child placed with Eligible Associate for adoption, foster child, or stepchild. Child shall also include any child for whom the Eligible Associate has been granted court-appointed full legal custody or guardianship. Child Care Center A facility or individual operating pursuant to law, if locally required, who is not a family member, and who primarily provides care and supervision for children in a group setting on a regular, daily basis. Coma A profound state of unconsciousness from which the person cannot be aroused, even January 2012 Life Insurance SPD 2

10 by powerful stimulation, as determined by the person s Doctor. Doctor A licensed practitioner of the healing arts, acting within the scope of a license. Earnings Your hourly rate multiplied by the number of hours you are authorized or scheduled to work during a regular pay period, multiplied by the number of pay periods in a calendar year or your annual base benefit rate, as calculated by your Participating Employer. Eligible Associate An Associate who is in the class of Associates eligible to participate in the Plan, as specified in the Addendum/Joinder Agreement of the Plan applicable to the Participating Employer and the Plan Outline section of this SPD. Eligible Associate does not include a leased employee or independent contractor, regardless of any retroactive reclassification as a common law employee. Eligible Dependent An Eligible Associate s Spouse or Child who is either less than age 26, or a Child who is age 26 or older if: Unmarried, Permanently and totally disabled prior to the attainment of age limits under the Plan, Receiving over half his or her support from the Eligible Associate or Eligible Associate s Spouse, and Eligible to be claimed as a dependent on the Eligible Associate s or Eligible Associate s Spouse s federal income tax return. A Child is permanently and totally disabled if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. ERISA The Employee Retirement Income Security Act of 1974, as amended. Health Ministry A legal entity related to Ascension Health. Felonious Assault A Physical Attack by another person resulting in bodily harm to you. But a Felonious Assault is not a moving violation as defined under the applicable state motor vehicle laws. Hemiplegia The total and permanent paralysis of the upper and lower limbs on one side of the body. Injury Injury to the body of a Participant. Paraplegia The total and permanent paralysis of both lower limbs. January 2012 Life Insurance SPD 3

11 Participant Any Eligible Associate, Eligible Dependent or other individual who is covered in accordance with the Plan and the Eligibility and Participation and Plan Outline sections of this SPD. Participant Contribution Any amount the Plan Administrator may require you to contribute for coverage under the Plan (see the Plan Outline section of this SPD). Participating Employer The Plan Sponsor or any Health Ministry that adopts the Plan. Physical Attack Any willful or unlawful use of force or violence upon you with the intent to cause bodily Injury to you. The Physical Attack must be considered a felony or misdemeanor in the jurisdiction in which it occurs. Plan The Ascension Health Life Insurance Plan, as amended from time to time. Plan Administrator Ascension Health, or such other person or committee that Ascension Health may appoint to administer the Plan. Plan Outline A brief description of some of the key features of the Plan as offered by your Participating Employer. Plan Sponsor Ascension Health. Plan Year The calendar year. Prudential The claims administrator for the Plan. Quadriplegia The total and permanent paralysis of both upper and lower limbs. School An institution of higher learning. The term includes a university, college or trade school. Seat Belt Any passive restraint device for an adult that meets published federal safety standards, is installed by the Automobile s manufacturer and is not altered after that installation, or a federally approved, properly installed child safety seat. Sickness A disorder of the body or mind of a Participant. Sickness does not include Injury, pregnancy, abortion, miscarriage or childbirth. Spouse An individual legally married to an Eligible Associate (even if legally separated), including an individual who is the common-law spouse, in states that recognize common-law marriage, of an Eligible Associate, if such individual and the Eligible Associate are of opposite sex. Uniplegia The total and permanent paralysis of one limb. January 2012 Life Insurance SPD 4

12 January 2012 Life Insurance SPD 5

13 Section 1: Eligibility and Participation If you are an Eligible Associate, you automatically receive basic life insurance at no cost to you. You may also receive basic AD&D insurance at no cost to you, if your Participating Employer offers such coverage. In addition, you and your Eligible Dependents may also be eligible for supplemental life and supplemental AD&D coverage, if your Participating Employer offers such coverage, but you pay the full cost of such coverage. Eligibility All Associates in your Participating Employer s class of Eligible Associates may enroll in the Plan. Your Eligible Dependents are also eligible to enroll under any supplemental dependent coverage options. Please see the Plan Outline section of this SPD for your Participating Employer s eligibility requirements and coverage offerings. Enrollment This section describes the enrollment process for life and AD&D insurance benefits. Basic Coverage You are automatically enrolled in basic life insurance and basic AD&D insurance, if offered by your Participating Employer; no action is required by you. Supplemental Coverage Your Participating Employer may also offer optional supplemental life and supplemental AD&D coverage for yourself and supplemental dependent life and supplemental dependent AD&D insurance for your Eligible Dependents. If these optional benefits are available, your local Human Resources Department will provide an enrollment package that explains the enrollment process and deadline, as well as the cost of coverage. The Plan doesn t allow for double coverage, which means individuals can t be covered as both an Eligible Dependent and Eligible Associate. Therefore: If your Spouse also works for Ascension Health or a Participating Employer, he or she can t be covered under the Plan as your Eligible Dependent or vice versa, and Your Child cannot be covered under the Plan as an Eligible Dependent of both you and your Spouse. January 2012 Life Insurance SPD 6

14 Evidence of Insurabiilty If you do not enroll when you are first eligible, or lose coverage because you do not pay a required contribution, you must provide evidence of insurability upon any subsequent enrollment. Exception: You will not need to provide evidence of insurability for most coverage if you: To enroll for supplemental coverage without needing evidence of insurability, you must complete your enrollment form and submit it to your local Human Resources Department during the initial enrollment period. Experience a Change Event (see the Change Event section of this SPD for more information on Change Events and status changes), Are terminated and rehired within 31 days and your and/or your Spouse s amount of insurance in effect on the day before your termination date is reinstated, or Are returning from an approved leave and your amount, and/or your Spouse s amount, of insurance in effect on the day prior to the date your leave began is reinstated. Evidence of insurability is not required for your Child. Once your enrollment is accepted, you will receive a confirmation statement indicating your effective date of coverage and your amount of insurance under the Plan. You must notify your local Human Resources Department of any Change Event, such as if you gain a new dependent or if any of your dependents are no longer eligible under the Plan, within 31 days of the event. Naming a Beneficiary It is important to select one or more benficiaries at the time your coverage begins. Your beneficiary(ies) will receive all death benefits payable from the Plan. You may choose a different beneficiary for each type of coverage under the Plan (i.e., supplemental life, dependent life, basic AD&D, etc.). In lieu of a beneficiary, you may assign coverage to a legal entity, such as a trust. You may change your beneficiary selection at any time by filing a Beneficiary Designation Form with your local Human Resources Department. Beneficiary elections are effective when forms are signed. Beneficiary Designation Forms are available from and should be returned to your local Human Resources Department. If you do not select a beneficiary or make an assignment of coverage, in the event of your death, payments will be distributed in the order listed under the Payment of Your Death Benefit section of this SPD. January 2012 Life Insurance SPD 7

15 Change Events This section only applies to supplemental AD&D coverage because the cost of this coverage is deducted on a pre-tax basis. Because your supplemental AD&D benefit elections are part of a Section 125 plan, tax laws prevent you from changing your benefit elections during the Plan Year, except in the case of a life event change, or Change Event. You may change your supplemental AD&D benefit elections during the year only if: You have a qualifying change in status, You report the change within 31 days of the event, The change affects your eligibility under the supplemental AD&D coverage, and The election you make is consistent with your change in status. Examples of qualifying changes in status are: You get married or divorced A change in dependent Children through birth, adoption, custody, court order, or death Your Spouse becomes employed or unemployed Your Child no longer meets the eligibility requirements You become disabled Your Spouse becomes disabled or dies You change from full-time to part-time, or part-time to full-time employment You, your Spouse, or your dependent has a change in residence To change your supplemental AD&D benefit elections, you must request the change in writing within 31 days after the Change Event and identify the event that resulted in the change you are requesting. The requested change must be consistent with the Change Event. Election changes will be effective on your Change of Benefits Date. If you file the request later than 31 days after the Change Event, no changes will be made to your elections or Participant Contributions, but you may make the necessary change during the next Open Enrollment Period for the following Plan Year. Participant Contributions Ascension Health and your Participating Employer pay the full cost of Basic Life and Basic AD&D coverage, if applicable. You pay the full cost of any supplemental coverage you choose. Rates for supplemental coverage for you and your Eligible Dependents are included in the enrollment materials provided to you by your local Human Resources Department. January 2012 Life Insurance SPD 8

16 When Coverage Begins Basic Life and Basic AD&D Your coverage begins on the date indicated by your Participating Employer in the Plan Outline section of this SPD. You must be Actively Employed for coverage to begin. If you are absent from work due to an Injury, Sickness, layoff or leave of absence, your coverage will begin on the date you return to Active Employment. Supplemental Coverage If you enroll during the annual Open Enrollment period, coverage is effective on January 1 of the following year. Otherwise, your and/or your Eligible Dependents coverage begins on the date indicated by your Participating Employer in the Plan Outline section of this SPD. However, coverage will only be effective as of the dates above if: You have enrolled, You and/or your Eligible Dependents have satisfied any evidence of insurability requirements, You have paid any required contributions, and You are Actively Employed. If you are absent from work due to an Injury, Sickness, layoff or leave of absence, your coverage will not begin until the date you return to Active Employment. This applies to your initial coverage as well as any subsequent increases in coverage. If your Eligible Dependent is confined for medical care treatment, at home or elsewhere, on the day coverage is to begin, the start of his or her coverage will be delayed until final medical release from such confinement is granted by a Doctor. When Coverage Ends Newborn and Adopted Child Exception If a Child is born to you and you elect Supplemental Dependent Life or AD&D coverage for that Child, his or her coverage is effective immediately; there is no delay in coverage. If you adopt a Child, coverage for that Child is effective on the date of adoption. Eligible Associates Your coverage for all insurance under the Plan ends at 11:59 p.m. on the earliest of the date: You no longer meet the definition of Eligible Associate, The Plan ends, or You fail to pay the required contributions, if the coverage requires contributions. If you are no longer eligible, you may be able to change your Plan coverage to an individual January 2012 Life Insurance SPD 9

17 conversion or ported group policy. Eligible Dependents Your dependents coverage for all insurance under the Plan ends at 11:59 p.m. on the earlier of: The date coverage ends under your Participating Employer, The date in which you no longer meet the definition of Eligible Associate, or The date in which your dependent no longer meets the definition of Eligible Dependent. Continuing Your Coverage Conversion Privilege When your basic or supplemental life insurance coverage under the Plan ends, you may convert all or part of that coverage to an individual life insurance contract without providing proof of good health if: For more information on continuing your coverage, contact Prudential at You are no longer eligible for coverage under the Plan, or The Participating Employer no longer provides coverage under the Plan and you have been insured for at least five years under the Plan. To receive individual coverage, you must apply for coverage and pay the first premium by the later of 31 days after your coverage ends or the 15 th day after you have been given a written notice of your conversion privilege. In no event can you elect conversion beyond 92 days from the date coverage ended. The amount of coverage you can convert when your insurance under this Plan ends cannot exceed the amount of your life insurance under this Plan. Also, the amount of your coverage may be limited if your insurance under this Plan ends because all life insurance under the Plan for the Participant s class of Eligible Associates ends. In this case, the total amount of individual insurance you may receive in place of all your life insurance then ending under the Plan will not exceed the lesser of the following: The total amount of your life insurance coverage under the Plan minus any new group life insurance for which you are or will become eligible for within 31 days from the end of Plan coverage, or $10,000. January 2012 Life Insurance SPD 10

18 When your AD&D coverage under the Plan ends, you may NOT convert it to an individual policy. However, you can continue your coverage as an accidental death benefit rider if you convert your coverage to a whole life policy. The amount of the accidental death benefit rider must be at least $25,000, but cannot exceed $500,000. Taking Your Coverage With You; The Portability Plan If your life insurance coverage under the Plan ends and you do not wish to convert your coverage, you can instead take your current life insurance coverage with you in the form of a ported group term life insurance policy without providing proof of good health as long as: Your coverage did not end due to your failure to pay required contributions or because this Plan was replaced within 31 days with other similar group coverage for which you are eligible. These age requirements are met: If you are a Participant and have Associate life coverage, you are less than age 80, If you are a Spouse and have dependent life coverage, you are less than age 80, and If you are an Eligible Dependent other than a Spouse and have dependent life coverage, you are less than age 26. The amount of your insurance under the Plan is at least $20,000 on the day your insurance ends. If you choose to port your life insurance coverage under the Plan, you may also port the amount of your AD&D coverage for which you were insured under the Plan as of the date your coverage ended. To change your Plan coverage to a ported group term policy you must meet the following requirements: You must apply within 31 days after your coverage under the Plan ends (or, if later, the number of days during which you have a conversion privilege). Coverage will be effective at the end of the 31-day period. If you are an Eligible Dependent, you can only be enrolled in coverage under the portability plan if you are covered under dependent life coverage on the day coverage ends. You will have to pay premiums for your coverage (the first premium is due within 31 days of the date your first bill is issued). Your ported group policy will be limited to the amount of coverage you had under the Plan as of the last day it was in effect. Your total maximum coverage under the portability plan must be the lesser of five times your annual earnings or $1,000,000. Your coverage, however, cannot be less than $20,000. If the Participant dies, an Eligible Dependent can apply for coverage under the portability plan if the eligibility requirements described above are satisfied. January 2012 Life Insurance SPD 11

19 Right to Amend or Discontinue the Plan Ascension Health and your Participating Employer are committed to maintaining the Plan. However, Ascension Health (the Plan Sponsor) reserves the right to amend or terminate the Plan in whole or in part, at any time, and for any reason, without advance notice. Amendment or termination of the Plan shall be effective if it is approved in writing by a duly authorized officer of Ascension Health, or if it is adopted pursuant to Ascension Health s procedures allocating or delegating authority to act on behalf of Ascension Health, as such procedures exist from time to time. Any Participating Employer will be permitted to discontinue or revoke its participation in the Plan. January 2012 Life Insurance SPD 12

20 Section 2: Life Insurance Benefits The Plan provides financial security in the event of death. Basic Life Coverage You automatically receive basic life insurance at no cost to you. Amount of Coverage Eligible Associates will receive basic life insurance coverage as indicated in the Plan Outline section of this SPD. If your insurance coverage is a multiple of Earnings and your annual base pay is not a multiple of $1000, for purposes of determining your coverage amount, it will be rounded up to the next $1,000. Minimum coverage is $20,000; maximum is $1,000,000. The value of life insurance over $50,000 is taxable and is reported on your W-2 form each year. Value means what the Internal Revenue Service determines to be the premium cost. If you do not wish to be taxed on amounts in excess of $50,000, you may limit your coverage to $50,000 by submitting a written request to your local Human Resources Department. Supplemental Associate Life Coverage For extra protection, you may also choose to enroll in optional supplemental Associate life insurance coverage on an after-tax basis, if your Participating Employer offers such coverage. Amount of Coverage Eligible Associates have the choice of seven coverage levels, up to a Plan maximum of $5,000, times your annual Earnings 2 times your annual Earnings 3 times your annual Earnings 4 times your annual Earnings 5 times your annual Earnings 6 times your annual Earnings 7 times your annual Earnings January 2012 Life Insurance SPD 13

21 For purposes of determining your coverage amount, each multiple of your Earnings will be rounded to the next highest $1,000, if it is not already a multiple of $1,000. The minimum amount of coverage you can elect is $20,000. In no event can your amount of supplemental Associate life insurance under the Plan exceed $5,000,000. You will be required to provide evidence of insurability for this coverage if: You are newly eligible and you wish to enroll at a level of more than two times your annual Earnings, You are enrolling for the first time and waived coverage when it was first available to you (unless your change is due to a Change Event), or You have a Change Event and you wish to enroll at a level of more than one times your annual Earnings, or increase your current coverage by more than one times your annual Earnings. Increases and Decreases in Coverage You may change the amount of your coverage during the annual Open Enrollment Period or following a Change Event. Change in coverage forms are available from and must be returned to your local Human Resources Department. If you wish to increase your level of coverage due to a Change Event, you must submit your change in coverage form within 31 days of the Change Event, or evidence of insurability will be required. If you are Actively Employed, your change in coverage will be effective the later of: The date selected by your Participating Employer, or The date Prudential approves your evidence of insurability, if applicable. Supplemental Dependent Life Coverage You may enroll your Eligible Dependent in supplemental dependent life coverage on an aftertax basis. January 2012 Life Insurance SPD 14

22 Amount of Coverage Coverage amounts are as follows: Supplemental Dependent Life Coverage Spouse Coverage Levels Child Coverage Levels $10,000 $5,000 $25,000 $10,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $250,000 For Spouse coverage, you will be required to provide evidence of insurability if: Your Spouse is newly eligible and you wish to enroll in more than $25,000 of coverage, You are enrolling your Spouse for the first time and waived coverage when it was first available to you (unless your change is due to a Change Event), or You have a Change Event and you wish to enroll in more than $25,000 of spouse coverage, or increase your current Spouse coverage by more than one level. Coverage will not go into effect for a Participant s Eligible Dependent if he or she is confined at home or in a hospital for medical care or treatment. If this is the case, the start of his or her coverage will be delayed until final medical release from such confinement is granted by a Doctor. Evidence of insurability is not required for Child coverage. Increases and Decreases in Coverage You may change the amount of your coverage during the annual Open Enrollment Period or following a Change Event. If you wish to increase your level of coverage due to a Change Event, you must submit your change in coverage form within 31 days of the Change Event, or evidence of insurability will be required. If your change is due to a Change Event related to birth, adoption or placement for adoption, the effective date of coverage is the date of the birth, adoption or placement for January 2012 Life Insurance SPD 15

23 adoption. If you are Actively Employed, your change in coverage will be effective the later of: The date selected by your Participating Employer, or The date Prudential approves your evidence of insurability, if applicable. January 2012 Life Insurance SPD 16

24 Section 3: AD&D Insurance Benefits The Plan provides financial protection in addition to your life insurance coverage if death or dismemberment occurs as a result of an accident. Basic AD&D Coverage If your Participating Employer offers this coverage, you automatically receive basic AD&D coverage equal to the amount of your basic life insurance coverage at no cost to you. Supplemental Associate AD&D Coverage For extra protection, you may also choose to enroll in optional supplemental Associate AD&D insurance coverage on a pre-tax basis. Amount of Coverage Eligible Associates have the choice of 10 coverage levels, up to a maximum of $4,000, times your annual Earnings 2 times your annual Earnings 3 times your annual Earnings 4 times your annual Earnings 5 times your annual Earnings 6 times your annual Earnings 7 times your annual Earnings 8 times your annual Earnings 9 times your annual Earnings 10 times your annual Earnings For purposes of determining your coverage amount, each multiple of your Earnings will be rounded to the next highest $1,000, if it is not already a multiple of $1,000. The minimum amount of coverage you can elect is $20,000. In no event can your amount of supplemental Associate AD&D insurance under the Plan exceed $4,000,000. Supplemental Dependent AD&D Coverage If you elect supplemental AD&D insurance for yourself, you may also enroll your Spouse and/or your Child in supplemental AD&D coverage on a pre-tax basis. Amount of Coverage The coverage amount for your Eligible Dependents will be a percentage of your AD&D coverage amount. However, the maximum amount of coverage for your Spouse is $1,000,000 and the maximum amount for each Child is $75,000. Coverage amounts are as follows: January 2012 Life Insurance SPD 17

25 Supplemental Dependent AD&D Coverage Options Coverage Spouse Coverage 65% Child Coverage 25% Spouse and Child Coverage Percent of Associate s Coverage 55% for your Spouse and 20% for each Child How AD&D Coverage Works If death or Injury is caused by an accident within 365 days of the date of that accident, the Plan pays a percentage of the affected Participant s coverage amount. The percentage received depends upon the nature of the loss as follows: Loss Determining Your Benefit Percentage of AD&D Benefit Life 100% Both hands or both feet, or one hand and one foot 100% Sight of both eyes 100% One hand or foot, and the sight of one eye 100% Speech and hearing in both ears 100% Quadriplegia 100% Paraplegia 75% Hemiplegia 66.67% Uniplegia 50% One hand or one foot 50% Sight of one eye 50% Thumb and index finger of the same hand 25% Speech or hearing in both ears 25% Coma (if the loss is continuous for 31 days and is determined to be total and permanent at the end of those 31 days) 1% per month, up to 100 months, beginning at the end of the initial 31 days of a continuous Coma If more than one loss is experienced as a result of the same accident, you will not receive more than the amount of your coverage in force at the time of the accident. January 2012 Life Insurance SPD 18

26 Exposure and Disappearance Coverage If you experience an Injury or death as the result of exposure to the elements, it is considered an accidental Injury. Also, it will be presumed that a Participant has died if his or her body has not been found within one year of a disappearance, stranding, sinking or wrecking of any vehicle in which he or she was an occupant. Additional AD&D Benefits In addition to your basic and supplemental AD&D coverage amounts, additional benefits will be paid under certain circumstances. Unless specified otherwise below, these benefits are paid to either: You, Your beneficiary, if you are no longer living, or A participating dependent who suffers a loss if you are no longer living. (However, if that dependent is not living, the benefits will be paid to that dependent s estate). Seat Belt Benefit If an Injury results in death due to an accident while driving or riding in an Automobile, your beneficiary will be paid the lesser of 10% of the coverage amount of the person who sustains the loss and $25,000 if the following criteria are met: The seatbelt(s) were in actual use and worn in the manner prescribed by the vehicle s manufacturer at the time of the covered accident, and The actual use of the seatbelt(s) at the time of the Injury is verified in an official report of the covered accident or is certified in writing by the investigating official(s). Exception: A benefit will not be paid if your Injury or death occurred while driving or riding in an Automobile used in a race or a speed or endurance test for acrobatic or stunt driving, or for any illegal purpose. Air Bag Benefit If Injury causes death while driving or riding in an Automobile, the beneficiary of the Participant who sustains the loss will be paid the lesser of 15% of the Participant s coverage amount and $15,000 if the following criteria are met: The seatbelt(s) were in actual use and worn in the manner prescribed by the vehicle s manufacturer at the time of the covered accident, The actual use of the seatbelt(s) at the time of the Injury is verified in an official report of the covered accident or is certified in writing by the investigating official(s), The Automobile is equipped with a factory-installed Air Bag, and A properly functioning Air Bag was deployed for the seat the Participant occupied. January 2012 Life Insurance SPD 19

27 Exception: A benefit will not be paid if your Injury or death occurred while driving or riding in an Automobile used in a race or a speed or endurance test for acrobatic or stunt driving, or for any illegal purpose. Tuition Reimbursement Benefit for Your Spouse If you die and your Spouse enrolls in any professional or trades program within 30 months after the date of your death for the purposes of obtaining an independent source of support or enriching that Spouse s ability to earn a living, your Spouse (or your Spouse s estate if your Spouse is no longer living) will receive the lesser of the actual annual tuition charged for the program or $3,000 (payable for one year). Tuition Reimbursement Benefit for Your Child If you or your participating Spouse dies, a benefit will be paid if your Child is less than age 26, wholly depends on you for support and maintenance, and is either: Enrolled as a full-time student in a School at the time of your or your Spouse s death, or In the 12 th grade on the date of your or your Spouse s death and becomes a full-time student in a School within 365 days of that date. The benefit will be equal to the least of the actual annual tuition, (excluding room and board), 5% of the coverage amount of the Participant who sustains the loss, and $5,000. This benefit is payable annually for up to four consecutive years, up to the date your Child reaches age 26. If both you and your Spouse are no longer living, benefits are paid to the person or institution who assumes the main support of the Child. Child Care Expenses Benefit If you or your participating Spouse dies, a benefit will be paid if your Child is less than age 13, wholly depends on you for support and maintenance, and is either: Enrolled at a Child Care Center on the date of your or your Spouse s death, or Becomes enrolled at a Child Care Center within 90 days after the date of your or your Spouse s death. The benefit is the least of the actual cost charged by the Child Care Center per year, 6% per year of the coverage amount of the Participant who sustains the loss, and $6,000. However, the benefit cannot exceed $24,000 per lifetime. This benefit is payable annually for up to four consecutive years, up to the date your Child reaches age 13. If both you and your Spouse are no longer living, benefits are paid to the person or institution who assumes the main support of the Child. January 2012 Life Insurance SPD 20

28 Return of Remains Benefit If a Participant dies outside a 75 mile radius of his or her home, the Plan will pay up to $2,000 to cover return of remains expenses, which include embalming, cremation, a coffin and transportation of the remains back to the Participant s home in the United States or Canada. Felonious Assault Benefit If a loss occurs as the result of a Felonious Assault, a benefit will be paid equal to the lesser of 5% of the coverage amount of the Participant who sustains the loss and $5,000. Felonious Assault While Working Benefit If a loss occurs as the result of a Felonious Assault while you are working for your Participating Employer and because of your employment, a benefit will be paid of up to $10,000. Working for your Participating Employer means performing the duties of your job with your Participating Employer either on or off your Participating Employer s premises. It does not include commuting to and from work, vacations or leaves of absence. During the Critical Period After Loss of Life If, at the time of your death, you have a surviving Spouse or Child, a benefit will be paid equal to 1% of your coverage amount for each of the six months immediately following your death. January 2012 Life Insurance SPD 21

29 Section 4: What s Not Covered The Plan will not pay benefits under circumstances listed in this section. No benefits will be paid as a result of the following: You die or sustain an Injury while: Operating or serving as a member of a crew of any aircraft Riding as a passenger in any aircraft not intended or licensed for the transportation of passengers Exclusions for aircraft and Automobiles include getting in, out, on, or off any such vehicle. Riding as a passenger in any aircraft owned, leased, controlled or operated by or on behalf of Ascension Health or any of its Participating Employers You die or sustain an Injury as a result of any of the following: Intentionally self-inflicted Injury, or attempt to inflict such Injury Suicide or any attempt at suicide while sane Sickness, whether the loss results directly or indirectly from the Sickness Medical or surgical treatment of Sickness, whether the loss results directly or indirectly from the treatment War or act of war or insurrections, whether declared or undeclared, including resistance to armed aggression Service or full-time active duty in the armed forces of any country or international authority for more than 30 days, not including Reserve or National Guard active duty for training Any bacterial or viral infection other than a pyogenic infection due to an accidental bodily Injury or a bacterial infection due to accidental ingestion of a contaminated substance Being legally intoxicated or under the influence of any narcotic, unless administered or consumed as prescribed by a Doctor An attempt to commit or commission an assault or felony Participation in scuba diving, bungee jumping, skydiving, parachuting, hang gliding, paragliding, paramotoring, parascending or ballooning January 2012 Life Insurance SPD 22

30 Section 5: Other Plan Provisions Payment of Your Death Benefit If you die while covered under the Plan, your death benefit is equal to your Plan coverage at the time of your death. It will be paid to your selected beneficiary(ies) when proof of death is received by Prudential. Benefits are payable in a single lump sum payment unless another payment arrangement is made with Prudential. If you die within 31 days after you cease to be eligible for coverage under the Plan and you were entitled to convert your coverage to an individual contract, the amount of your benefit is equal to the amount you were entitled to convert. Order of Payment Payment will be made to your selected beneficiary(ies). If you name more than one beneficiary, each beneficiary will share equally, unless you specify otherwise. If a beneficiary predeceases you, his or her share will be paid equally to the surviving beneficiaries, unless you had stipulated otherwise. Any amount for which a beneficiary is not named will be paid in the following order: 1. Your surviving Spouse 2. If you do not have a surviving Spouse, to your surviving Children, in equal shares 3. If you do not have any surviving Children, to your surviving parents, in equal shares 4. If you do not have any surviving parents, to your surviving brothers or sisters, in equal shares 5. If you do not have any surviving brothers or sisters, to the executors or administrators of your estate If contingent beneficiaries are named, the benefit amount will be paid in equal shares, unless otherwise stipulated. If you and a beneficiary die in the same event, and it cannot be determined who died first, the benefit will be payable as if that beneficiary died before you. Benefits During a Terminal Illness If you or your participating Spouse becomes terminally ill with a life expectancy of 12 months or less, you may choose the option to accelerate payment of death benefits. This option provides access a portion of the life insurance benefit prior to death. Once you exercise the accelerated payment option, you can no longer assign coverage. The amount that can be withdrawn is up to 80% of the life insurance amount, with these January 2012 Life Insurance SPD 23

31 maximums: Up to $1,000,000 for the Eligible Associate Up to $200,000 for a participating Spouse Payments will be in the form of a lump sum or in 12 equal monthly installments. If you reach age 70 during this 12-month period, the benefit payment will be reduced accordingly (see the Coverage Reduction at Age 70 section of this SPD). To apply for accelerated payment of death benefits, submit an application along with a Doctor s certification of your life expectancy. Forms are available from your local Human Resources Department. You will receive a payment once Prudential receives proof of terminal illness. If you have chosen to receive 12 monthly payments, the remaining monthly payments will subsequently be paid on the same day of each of the next 11 months. The life insurance coverage that remains in force will be reduced by the amount of accelerated death benefit received. If death occurs before all payments have been made, the remaining amount of accelerated death benefit, plus any remaining life insurance benefit, will be paid in one lump sum as follows: If the terminally ill person is the Associate, to that Associate s beneficiary If the terminally ill dependent is the Associate s participating Spouse, to the Associate You are not eligible for this benefit if you are required: By law to use the accelerated payment of death benefits to meet the claims of creditors, whether in bankruptcy or otherwise, or By a governmental agency to use this option for a government benefit or entitlement. Coverage Reduction at Age 70 At age 70, the amount of coverage is reduced to 50% of the amount for which you would otherwise be insured under the following coverage: Basic life and supplemental Associate life Supplemental dependent life Spouse coverage only Basic AD&D Supplemental AD&D Associate coverage only If you wish to maintain your level of coverage, you may convert the amount by which your coverage was reduced to an individual policy. Please see the Continuing Your Coverage section of this SPD for more information. January 2012 Life Insurance SPD 24

32 Limits on Assignments You can assign your life insurance coverage to an organization or individual as a gift. When you make this assignment, it includes all rights, benefits and privileges associated with the coverage, such as the right to change beneficiaries or convert to another policy. In the event of your death, if there is no beneficiary chosen by the assignee, the benefit will not be paid as stated in the beneficiary rules, but rather will be payable to: The assignee, if living, or The estate of the assignee, if the assignee is not living. Effect of Gift Assignment of the Rights of Group Life Insurance Under Another Group Contract If you make an irrevocable and absolute gift assignment of your group life coverage under a previous group plan, that assignment remains in effect for this coverage and any future coverage that replaces this coverage, if applicable. Limits on Life Insurance Coverage Due to Death Prior to Enrollment If Your Spouse Dies Within 30 Days of Your Marriage If a Participant has not enrolled for dependent life coverage and his or her Spouse dies within 30 days of their marriage date, the amount of dependent life coverage will be limited to $10,000 for that Spouse. If Your Child Dies Within 30 Days of Birth If a Participant has not enrolled for dependent life coverage and his or her newborn Child dies within 30 days of his or her birth, the amount of dependent life coverage will be limited to $5,000 for that Child. January 2012 Life Insurance SPD 25

33 Section 6: Claims Procedures You or your beneficiary must submit a claim form as instructed by your local Human Resources Department to receive a benefit under the Plan. Filing a Claim Claim Forms Claim forms are available from your local Human Resources Department. Medical Exam and Autopsy You may be required to undergo an exam by a Doctor at Prudential s expense to help determine benefits. Prudential also has the right to arrange for an autopsy in case of accidental death, if not forbidden by law. When Benefits are Paid Benefits are paid after Prudential receives sufficient written proof of the loss. If have questions about your rights to appeal a denied claim, contact Prudential. To appeal a claim, you will need to send notification of your desire to appeal within 180 days from receipt of your claim denial. Be sure to include the following: Your name ID and claim numbers Also, indicate whether the person requesting the appeal is the Eligible Associate, Eligible Dependent or authorized representative. Timing of Claims Review Prudential will notify you of its benefit determination within 45 days after receipt of the claim. This period may be extended for up to 30 days if an extension is necessary due to matters beyond the control of the Plan. If such an extension of time is taken, Prudential will notify you in writing, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If, prior to the end of the first 30-day extension period, Prudential determines that, due to matters beyond the control of the Plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days. If such an additional extension of time is taken, Prudential will notify you in writing, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date by which a decision is expected to be rendered. However, if a period of time is extended due to your failure to submit information necessary to decide the claim, the period for making the benefit determination by Prudential will be suspended from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information. If Your Claim Is Denied January 2012 Life Insurance SPD 26