1 Personal Accident Insurance Plan ACCIDENTAL DEATH and DISMEMBERMENT COMA BENEFITS COMMON DISASTER BENEFIT PERMANENT TOTAL DISABILITY DAY CARE BENEFIT EDUCATION BENEFITS REHABILITATION BENEFIT REPATRIATION BENEFIT SEAT BELT/AIR BAG PROVISION CHILDREN S ADDITIONAL BENEFIT For Eligible Employees of University of California and their Families IMPORTANT NOTICE: The Program provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical, major medical or sickness coverage.
2 The University establishes its own AD&D plan eligibility, enrollment and termination criteria based on the University of California Group Insurance Regulations and any corresponding Administrative Supplements. ELIGIBILITY The following individuals are eligible to enroll in this Plan. Employee: Information pertaining to your eligibility, enrollment, cancellation or termination of coverage and conversion options can be found in the Group Insurance Eligibility Factsheet for Employees and Eligible Family Members A copy of this factsheet is available in the Health and Welfare section of the At Your Service website (atyourservice.ucop.edu). Additional resources are also available in the Health and Welfare section of At Your Service to help you with your health and welfare plan decisions. Eligible Family Members: When you enroll any individual(s) in the Plan as a Family Member, you must provide documentation specified by the University verifying the individual(s) you have enrolled meet(s) the eligibility requirements outlined below. The Plan may also require documentation verifying eligibility status. In addition, the University and/or the Plan reserves the right to periodically request documentation to verify the eligibility of enrolled Family Members. Eligible Adult: You may enroll one eligible adult Family Member, in addition to yourself: Spouse: Your legal spouse. Domestic Partner: You may enroll your same-sex domestic partner if your partnership is registered with the State of California or otherwise meets criteria as a domestic partnership as set forth in the University of California Group Insurance Regulations. Same-sex domestic partners from jurisdictions other than California will be covered to the extent required by law. You may enroll your opposite-sex domestic partner only if either you or your domestic partner is age 62 or older and eligible to receive Social Security benefits based on age. Note: An adult dependent relative is not eligible for coverage in UC plans unless enrolled prior to December 31, 2003 and continuously eligible and enrolled since that date. To review the ongoing eligibility requirements for enrolled adult dependent relatives, see the Group Insurance Eligibility Factsheet for Employees and Eligible Family Members. Also, remember: If your adult dependent relative is still enrolled in the Plan, you cannot also enroll your spouse or domestic partner.
3 Child: All eligible children must be under the limiting age of 26 (18 for legal wards) except for a child who is incapable of self-support due to a mental or physical disability. The following categories are eligible: (a) your natural or legally adopted children; (b) your spouse s natural or legally adopted children (your stepchildren); (c) your eligible domestic partner s natural or legally adopted children; (d) grandchildren of you, your spouse or your eligible domestic partner if unmarried, living with you, dependent on you, your spouse or your eligible domestic partner for at least 50% of their support and are your, your spouse's, or your eligible domestic partner s dependents for income tax purposes; (e) children for whom you are the legal guardian if unmarried, living with you, dependent on you for at least 50% of their support and are your dependents for income tax purposes. (f) children for whom you are legally required to provide group health insurance pursuant to an administrative or court order. (Child must also meet UC eligibility requirements.) Any child described above (except a legal ward) who is incapable of self-support due to a physical or mental disability may continue to be covered past age 26 provided: - the plan-certified disability began before age 26, the child was enrolled in a UC group medical plan before age 26 and coverage is continuous; - the child is chiefly dependent upon you, your spouse, or your eligible Domestic partner for support and maintenance (50% or more); and - the child is claimed as your, your spouse s or your eligible domestic partner s dependent for income tax purposes, or if not claimed as such dependent for income tax purposes, is eligible for Social Security Income or Supplemental Security Income as a disabled person, or working in supported employment which may offset the Social Security or Supplemental Security Income.
4 Except as provided below, application for coverage beyond age 26 due to disability must be made to the Plan 60 days prior to the date coverage is to end due to reaching limiting age. If application is received timely but Plan does not complete determination of the child s continuing eligibility by the date the child reaches the Plan s upper age limit, the child will remain covered pending Plan s determination. The Plan may periodically request proof of continued disability, but not more than once a year after the initial certification. Disabled children approved for continued coverage under a University-sponsored medical plan are eligible for continued coverage under any other University-sponsored health and welfare plan; if enrollment is transferred from one plan to another, a new application for continued coverage is not required; however, the new Plan may require proof of continued disability, but not more than once a year. If you are a newly hired Employee with a disabled child over age 26 or if you newly acquire a disabled child over age 26 (through marriage, adoption or domestic partnership), you may also apply for coverage for that child. The child s disability must have begun prior to the child turning age 26. Additionally, the child must have had continuous group health and welfare coverage since age 26, and you must apply for University coverage during your Period of Initial Eligibility. The Plan will ask for proof of continued disability, but not more than once a year after the initial certification. Important Note: The University complies with federal and state law in administering its group insurance programs. Health and welfare benefits and eligibility requirements, including dependent eligibility requirements are subject to change (e.g., for compliance with applicable laws and regulations). The University also complies with federal and state income tax laws which are subject to change. Requirements may include laws mandating that the employer contribution for coverage provided to certain Family Members be treated as imputed income to the Employee. See At Your Service online for related information. Contact your tax advisor for additional information. No Dual Coverage Eligible individuals may be covered under only one of the following categories: as an Employee, a Retiree, a Disabled Member, a Survivor or a Family Member. If an Employee and the Employee s spouse or domestic partner are both eligible for coverage, each may enroll separately or one may enroll and cover the other as a Family Member. If they enroll separately, neither may enroll the other as a Family Member. Eligible children may be enrolled under either parent's or eligible domestic partner s coverage but not under both. Additionally, a child who is also eligible as an Employee may not have dual coverage through two University-sponsored health and welfare plans. More Information For information on who qualifies and how to enroll, contact the person who handles benefits for your location or the University of California's (UC) Customer Service Center at (800) You may also access eligibility factsheets on UC s At Your Service web site:
5 ENROLLMENT Information pertaining to enrollment can be found in the Group Insurance Eligibility Factsheet for Employees and Eligible Family Members A copy of this factsheet is available in the Health and Welfare section of the At Your Service website (atyourservice.ucop.edu). During a Period of Initial Eligibility (PIE) You may enroll in this plan at any time as there is no Period of Initial Eligibility associated with this coverage. Effective Date Coverage begins on the date the appropriate enrollment transaction (paper form or electronic) is processed or the first day of eligibility, whichever is later, provided the Employee is on Pay Status as an eligible Employee. Coverage cannot begin before the first day of eligibility for the plan. Once the Employee is enrolled in the family plan, new Family Members are covered automatically on the date they become eligible. If the Employee is enrolled in the modified Family Plan, newly eligible children are covered on the date they become eligible; the Employee must transfer to the family plan to cover a spouse or domestic partner. Change in Coverage In order to make any of the changes described above, contact the person who handles benefits at your location. What is The Coverage? 24-hour, 365-days-a-year insurance is provided for covered accidents in the course of business or pleasure. Coverage includes accidents (except as limited by Exclusions) whether on or off the job, occurring in the home, traveling by train, airplane, automobile, or other public and private conveyance. The benefits provided under this Plan are payable in addition to any other insurance which may be in effect at the time of the accident. There are no geographical limits; it is worldwide accident protection. Injury means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that is external to the body and that occurs while the injured person s coverage under the Policy is in force, and (2) which directly (independent of sickness, disease, mental incapacity, bodily infirmity or any other cause) causes a covered loss.
6 YOUR BENEFITS Accidental Death and Dismemberment Including Paralysis When Injury results in any of the following losses within 365 days of the date of the accident the Plan will pay as follows: Loss of Life... Full Principal Sum Loss of two or more members... Full Principal Sum Loss of speech and hearing in both ears... Full Principal Sum Quadriplegia... Full Principal Sum Paraplegia Three Quarters of Principal Sum Loss of one member....one-half of Principal Sum Loss of speech or hearing in both ears.....one-half of Principal Sum Loss of four fingers on the same hand.. One-Half of Principal Sum Loss of four toes of the same foot..one-half of Principal Sum Hemiplegia.One-Half of Principal Sum Loss of thumb and index finger of the same hand..one-quarter of Principal Sum Member means hand, foot or eye. Loss as used with reference to hand or foot means actual severance through or above the wrist or ankle joint; as used with reference to eye means irrecoverable loss of the entire sight thereof; with reference to loss of digits of the same hand means loss by actual severance through or above the metacarpophalangeal joints; as used with reference to speech means irrecoverable loss of speech which does not allow audible communication in any degree; as used with respect to hearing means irrecoverable loss of hearing which cannot be corrected by a hearing aid or device; as used with reference to quadriplegia means the complete and irreversible paralysis of both upper and lower limbs; as used with reference to paraplegia means the complete and irreversible paralysis of both lower limbs; as used with reference with hemiplegia means the complete and irreversible paralysis of upper and lower limbs of one side of the body. Indemnity provided hereunder will not be paid, under any circumstances, for more than one of the losses, the greatest, sustained by any one covered person as the result of any one accident. Children s Additional Indemnity Dismemberment/Paralysis Pays double the Child s Principal Sum when an insured dependent child suffers a covered Accidental Dismemberment or Accidental Paralysis. The amount payable is an amount equal to the amount payable under the Accidental Dismemberment or Paralysis benefit (specified above), subject to a maximum of $100,000. Day Care Benefit Pays the lesser of: Actual cost of day care for the year, following date of covered accident causing the employee s death 5% of Employee s Principal Sum $5,000 ($20,000 maximum for four years) Benefit Payable each year for maximum of 4 years for Children under age 13 on the date of the accident causing the employee s death who are enrolled in a Day Care Center or enroll within 365 days of the accident. No benefit will be payable after 4 years or beyond age 13.
7 Rehabilitation Benefit Pays up to $10,000 for all covered Rehabilitation Expenses (as defined in the Policy) within 2 years of a covered accident that result in an Accidental Dismemberment or Paralysis of an Insured Person. Excludes work-related injuries payable under Workers Compensation or other similar law. Coma Benefit When a covered accident renders the Insured Person Comatose within 30 days of the covered accident and Coma continues for a period of 30 days, the plan pays a monthly benefit of 1% of the Insured Person s Principal Sum as long as the Insured Person remains Comatose to a maximum of 100% of the Principal Sum. If an Insured Person suffers one or more losses from the same accident for which amounts are payable under more than one Benefit provided, the maximum amount payable will not exceed the amount payable for one of those losses, the largest. Common Disaster Benefit (only available if you elect to cover your spouse) If you and your covered spouse both suffer a covered accidental death in the same accident within 90 days of the covered accident, your spouse s principal sum amount will be increased to equal yours to a maximum of $500,000. Education Benefit If you have elected Family Plan or Modified Family Plan coverage and suffer loss of life in a covered accident while insured under this Plan, the Plan will pay, in addition to all other benefits payable, an amount equal to the least of the following amounts: (1) the actual annual tuition, exclusive of room and board, charged by an institution of higher learning per school year, or; (2) 5% of your Principal Sum, or; (C) $1,500.00, to or on behalf of any dependent child * who, at the date of the accident: (a) was enrolled as a full-time student in an institution of higher learning or (b) was enrolled as a full-time high school student (beyond the 8 th grade level) and subsequently enrolls in an institution of higher learning within 365 days of high school graduation. This benefit is payable annually for a maximum of four consecutive annual payments but only if the dependent child continues his or her education as a full-time student in an institution of higher learning. This Plan will also pay, in addition to all other benefits payable, the actual cost incurred within 30 months from the date of death (subject to a maximum of $10,000) to or on behalf of your surviving spouse/ domestic partner who has enrolled in any professional or trades training program for the purpose of obtaining an independent source of support and maintenance. Institute of Higher Learning as used herein includes, but is not limited to any state university, private college or trade school. * Dependent Child, as respect to this benefit provision only shall mean any unmarried child under 23 years of age who is dependent upon you for at least 50% of his maintenance and support. Seat Belt/Air Bag Provision An additional 10% of the applicable Principal Sum amount will be paid if you or a covered family member suffers loss of life despite restraint by a seat belt or air bag in an automobile accident.
8 Natural Disaster Benefit An additional 10% of the applicable Principal Sum amount will be paid if you or a covered family member suffers loss of life or sustains a covered loss as a result of a Natural Disaster. Natural Disaster means a storm (wind, rain, snow, sleet, hail, lightning, dust or sand), earthquake, flood, volcanic eruption, wildfire or other similar event that is due to natural causes and results in such severe and widespread damage that the area of damage is officially declared a disaster area by a state or federal government if the event occurs in the United States of America, or by a corresponding authority if the event occurs outside the United States of America. Permanent and Total Disability (not applicable to spouse/ domestic partner or eligible dependent children or to you if you are age 70 or older on the date of the accident) When Injury causes you to be permanently and totally disabled within 120 days of a covered accident, and you are unable to perform the material and substantial duties of any occupation for which you are qualified by reason of your education, training or experience and such disability lasts for 12 consecutive months and you are then judged to be permanently and totally disabled, the Plan will pay the Principal Sum less any amount paid or payable under the policy as a result of the same accident, at the rate of one percent per month for 100 months. Repatriation of Remains Benefit (Also available to covered spouses and/or covered dependent child (ren), if enrolled) If you suffer a covered accidental death while at least 100 miles from home, the benefits pay for covered expenses to return your body to home to a maximum of $50,000. What Are The Exclusions? No coverage shall be provided under the Policy and no payment shall be made for any losses resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks even if the proximate or precipitating cause of the loss is an accidental bodily Injury: suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury or auto-eroticism; sickness, disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly form any of these; travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is (a) riding as a passenger in any aircraft not intended or licensed for the transportation or passengers (b) performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or (c) riding as a passenger in an aircraft owned, leased or operated by the University of California; declared or undeclared war, or any act of declared or undeclared war; infections of any kind regardless of how contracted, except bacterial infections that are directly by botulism, ptomaine poisoning or an accidental cut or wound independent an d in the absence of any underlying sickness, disease or condition; full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured Person is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded.).
9 What Is The Schedule of Monthly Costs? Here is a chart summarizing the monthly cost for you and your family which will be paid by monthly payroll deductions. This chart should be used when filling out the Enrollment Form. PRINCIPAL SUM EMPLOYEE ONLY FAMILY PLAN MODIFIED FAMILY PLAN $10,000 $0.12 $0.21 $0.15 $20,000 $0.24 $0.42 $0.30 $30,000 $0.36 $0.63 $0.45 $40,000 $0.48 $0.84 $0.60 $50,000 $0.60 $1.05 $0.75 $60,000 $0.72 $1.26 $0.90 $70,000 $0.84 $1.47 $1.05 $80,000 $0.96 $1.68 $1.20 $90,000 $1.08 $1.89 $1.35 $100,000 $1.20 $2.10 $1.50 $125,000 $1.50 $2.63 $1.88 $150,000 $1.80 $3.15 $2.25 $175,000 $2.10 $3.68 $2.63 $200,000 $2.40 $4.20 $3.00 $300,000 $3.60 $6.30 $4.50 $400,000 $4.80 $8.40 $6.00 $500,000 $6.00 $10.50 $7.50
10 Each employee enrolling in the Plan will receive a certificate of insurance. How Much Coverage May I Obtain for My Family? Under the Family Plan your spouse/domestic partner and eligible children are automatically covered as follows: your spouse/domestic partner is insured for a Principal Sum equal to 50% of your Principal Sum and each eligible child is insured for 20% of your Principal Sum. If you have no eligible children, your spouse/domestic partner s Principal Sum is 60% of yours. What Is The Modified Family Plan? The Modified Family Plan covers one parent and all eligible children, at a modified premium rate. If both husband and wife/domestic partner are eligible employees of the University, only one may elect to cover their eligible children. Single parents may elect to cover themselves and their eligible children. Under the Modified Family Plan each of your eligible children is insured for an amount equal to 20% of your Principal Sum. To Whom Are My Benefits Paid? Benefits for loss of your life will be payable in accordance with the beneficiary designation on your enrollment form. If no such designation has been made, such indemnity shall be payable to the person or persons (in equal shares) in the first of the following categories in which there is a survivor: 1. Your spouse or domestic partner 2. Child or children of deceased child shall take the share of such child by representation; 3. Your parent or parents; 4. Your surviving brothers and sisters; 5. Your executors and administrators. If you select either of the Family Plans, you will be the beneficiary of your covered dependents for loss of life. If you are not living at the date of death of your covered dependent, payment will be made (a) in the case of the death of your spouse/ domestic partner, to the spouse/domestic partner s executors or administrator; (b) in the case of the death of your child, to the first surviving class of the following classes of successive preference beneficiaries; the child s (1) surviving parent; (2) surviving brothers and sisters; (3) executors or administrators. All other indemnities are payable to the person suffering the loss. When Will Coverage Be Effective? Your insurance will become effective as of the date the electronic enrollment is completed or the application is received in your local Benefits or Accounting Office or your first day of eligibility, whichever is later. Insurance of an employee who is not actively at work on the normal effective date will become effective the day after the employee s first full day actively at work, unless the employee is on an approved leave with pay for non-health reasons. Your newborn natural child is covered from the date of birth and any minor child placed with you for adoption is covered when the child is placed in your physical custody; provided you are enrolled in one of the family plans and the child s effective date of coverage is not earlier than your coverage effective date. New or increased coverage for any other family member who is hospitalized on the normal effective date begins on the day after the family member is discharged from the hospital.
11 When Does My Coverage Terminate? Your coverage will terminate immediately on the earliest of the following dates: a) On the date the Master Policy is terminated. b) On the premium due date if the University fails to pay the required premium for you except as the result of an inadvertent error. c) On the premium due date next following the date you cease to be an eligible employee of the University for this insurance. d) With respect to an Insured Person who is insured under the Master Policy as a dependent, on the premium due date next following the date he or she ceases to be an eligible dependent TERMINATION OF COVERAGE The termination of coverage provisions that are established by the University of California in accordance with its Regulations are described below. Additional Plan provisions apply and are described elsewhere in the document. Deenrollment Due to Loss of Eligible Status If you are an Employee and lose eligibility, your coverage and that of any enrolled Family Member stops at the end of the month in which eligibility status is lost. Also, if you are enrolled in a health and welfare plan that requires premium payments (in addition to amounts subtracted from your monthly retirement payments), and you do not continue payment, your coverage will be terminated at the end of the month for which you paid. If your Family Member loses eligibility, you must complete the appropriate transaction to delete him or her within 60 days of the date the Family Member is no longer eligible. Coverage stops at the end of the month in which he or she no longer meets all the eligibility requirements. For information on deenrollment procedures, contact the person who handles benefits at your location. Other Deenrollments Coverage for you and/or your Family Members may be suspended for up to 12 months if you and/or a Family Member misuse the Plan, as described in the Group Insurance Regulations. Misuse includes, but is not limited to, actions such as falsifying enrollment or claims information, allowing others to use the Plan identification card, intentionally enrolling, or failing to deenroll, individuals who are not/no longer eligible Family Members, threats or abusive behavior toward Plan providers or representatives. You may also be deenrolled for up to 12 months if you fail to provide upon request documentation specified by the University or the Plan verifying that the individual(s) you have enrolled are eligible Family Members. Individuals whose eligibility has not been verified will be deenrolled until verification is provided. Individuals who are not eligible Family Members will be permanently deenrolled.
12 Leave of Absence, Layoff, Change in Employment Status or Retirement Contact the person who handles benefits for your location for information about continuing your coverage in the event of an authorized leave of absence, layoff, change of employment status, or retirement. When You Retire You and your family members may not continue the UC-sponsored Employee AD&D coverage when you retire. You and your spouse/domestic partner, however, may purchase AD&D coverage through the UC-sponsored Voluntary Accident Insurance Program available to UC retirees. Contact the insurance carrier for more information. May I Convert My Insurance? If you leave your employment with the University of California for any reason you may convert within 31 days of termination to an individual form of Accidental Death & Dismemberment coverage at the individual premium rate in use at time of the conversion. No medical certification will be required to obtain the conversion policy. Coverage cannot exceed the amount purchased under the Group Plan (not less than $10,000 nor more than $500,000). Covered dependents can also convert with the same restrictions as above. Coverage will be effective either the date the application for the converted policy is received or the date coverage under the group contract ends, whichever is later. Action Which May Affect Coverage The following provisions apply unless the employee or family member converts to an individual plan. Leave Without Pay. You may continue coverage for up to 2 years of an approved leave without pay or during an approved military leave of up to 31 days by making direct payment of premiums to your local benefits or accounting office. If you do not continue coverage during a leave without pay, you must re-enroll by the end of the month following your return to work in order to renew your coverage. Leave with Pay. You may continue coverage for up to 2 years as long as earnings cover required deductions. Furlough/Layoff. You may continue coverage for up to 4 calendar months by making direct payment of premium. Insufficient Earnings. If premium cannot be taken from the first check following two consecutive months of missed premiums, coverage lapses retroactively to the first day of the first month for which a premium was missed. Contract Termination Coverage under the Plan is terminated when the group contract between the University and the Plan Vendor is terminated. Benefits will cease to be provided as specified in the contract and you may have to pay for the cost of those benefits incurred after the contract terminates. You may be entitled to continued benefits under terms which are specified elsewhere in this document. (If you apply for an individual HIPAA or conversion plan, the benefits may not be the same as you had under this Plan.)
13 University of California Group Accidental Death & Dismemberment Insurance Active Employees PLAN SPONSORSHIP AND PLAN AND CLAIMS ADMINISRATION PLAN ADMINISTRATION This Plan is administered in accordance with the University of California Group Insurance Regulations, applicable contracts/service agreements, evidence of coverage booklets, and applicable state and federal laws. No person is authorized to provide benefits information not contained in these source documents, and information not contained in these source documents cannot be relied upon as having been authorized by the Plan Administrator or Claims Administrator, as applicable. The terms of those documents apply if information in this document is not the same. The University of California Group Insurance Regulations will take precedence if there is a difference between its provisions and those of this document and/or the group insurance contracts. What is written in this document does not constitute a guarantee of plan coverage or benefits--particular rules and eligibility requirements must be met before benefits can be received. This section describes how this Plan is administered and what your rights are. PLAN SPONSHORSHIP AND PLAN AND CLAIMS ADMINISTRATION. Plan Sponsor and Plan Administrator The University of California is the Plan sponsor and the President of the University (or his/her delegates) is the Plan Administrator for the Plan eligibility and enrollment provisions described in this insert to the Plan Evidence of Coverage booklet. If you have a question about eligibility or enrollment, you may direct it to: University of California Human Resources 300 Lakeside Drive Oakland, CA Any appeals regarding coverage denials that relate to eligibility or enrollment requirements are subject to the University of California Group Insurance Regulations. To obtain a copy of the Eligibility Claims Appeal Process, please contact the person who handles benefits for your location (or the UC Customer Service Center if you are a Retiree or Survivor). Claims and appeals for benefits under the Plan are processed by National Union Fire Insurance Company of Pittsburgh, PA and National Union Fire Insurance Company has full and final discretion and authority to determine whether and to what extent enrollees are entitled to benefits under the Plan. If you have a question about benefits under the Plan or about a specific claim, please refer to the appeal section found later in this document and/or contact National Union Fire Insurance Company at the following address and phone number.
14 Chartis U.S. Chartis Domestic Claims Accident & Health Claims Department P.O. Box Shawnee Mission, KS (302) Employer Identification Number The employer identification number assigned to the Regents of the University of California by the Internal Revenue Service is
15 Group Contract Number The group contract number for this Plan is PAI Type of Plan This plan provides group health and welfare care benefits. This plan is one of the benefit plans offered under the University of California Health and Welfare Programs for eligible Faculty and Staff. Plan Year The plan year is January 1 through December 31. Continuation of the Plan The University of California intends to continue the plan of benefits described in this booklet indefinitely but reserves the right to terminate or amend the benefits provided under this or any University-sponsored plan at any time. Plan benefits are not accrued or vested benefit entitlements. Any such amendment or termination shall be carried out by the President or his or her delegates.. Financial Arrangement The benefits under the Plan are provided by the National Union Fire Insurance Company of Pittsburgh, PA under a Group Service Agreement.. The cost of the premiums is paid entirely by plan participants. Agent for Service or Legal Process Legal Process may be served on National Union Fire Insurance Company of Pittsburgh, PA at the address listed above. Certificate A certificate of insurance will be provided (by National Union Fire Insurance Company of Pittsburgh, PA), following enrollment in the plan, describing in detail the coverage summarized in this brochure. Your Rights Under This Plan As a participant in a University of California Plan, you are entitled to certain rights and protections. All plan participants shall be entitled to: Examine, without charge, at the Plan Administrator s office and other specified sites, all Plan documents, including the Group Services Agreement, at a time and location mutually convenient to the participant and the Plan Administrator. Obtain copies of all Plan documents and other information for a reasonable charge upon written request to the Plan Administrator. How to File a Claim You or your beneficiaries should protect your rights by filing a written notice of claim with National Union Fire Insurance Company of Pittsburgh, PA within 20 days of the loss. See Uniform Provisions Section of your certificate, paragraphs Notice of Claim, Claim Forms, Proofs of Loss Time of Payment of Claims. If a claim is denied, your beneficiary will receive a notice from National Union Fire Insurance Company of Pittsburgh, PA that states the reasons for the denial and describes any additional information needed. Your beneficiary may, within 60 days after receiving notice of the denial formally appeal the denial in writing. The appeal should state the specific reasons with reference to the Policy provisions, why the claim should not be denied.
16 National Union Fire Insurance Company of Pittsburgh, PA will reply to your beneficiary in writing. If more than 60 days from the date the formal appeal is received are needed for an evaluation, your beneficiary will be notified in writing of the reason for the extension of time. National Union Fire Insurance Company of Pittsburgh, PA decision is final. Nondiscrimination Statement In conformance with applicable law and University policy, the University of California is an affirmative action/equal opportunity employer. Please send inquiries regarding the University s affirmative action and equal opportunity policies for staff to Systemwide AA/EEO Policy Coordinator University of California, Office of the President, 1111 Franklin Street, 5 th Floor Oakland CA 94607, and for faculty to Office of Academic Personnel, University of California Office of the President, 1111 Franklin Street, Oakland, CA IMPORTANT This booklet provides you with an easy-to-understand summary of the benefits provided under the Personal Accident Insurance Plan offered by National Union Fire Insurance Company of Pittsburgh, PA. If any conflict should arise between the contents of this summary and the Master Policy PAI or the University s Group Insurance Regulations, or if any point is not covered herein the terms of the Master Policy will govern in all cases. YOU MAY DIRECT INQUIRIES ABOUT THIS PROGRAM TO: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA TWO RINCON CENTER 121 SPEAR STREET SAN FRANCISCO, CA This program is underwritten by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA Executive Offices: 175 Water Street New York, NY (Rev 10/2013)
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