Travel Accident Insurance Summary Plan

Transcription

1 TRAVEL ACCIDENT INSURANCE SUMMARY PLAN DESCRIPTION February 2014

2 Travel Accident Insurance Summary Plan Description for Oak Ridge Associated Universities Principle Address: P.O. Box 117 Oak Ridge, TN ORAU Telephone Number: (865) Employer Identification Number: Plan Number: 501 Insurance Carrier: Plan Administrator: Life Insurance Company of North America 1601 Chestnut Street Philadelphia, PA Director, Compensation and Benefits ORAU MS-32 P. O. Box 117 Oak Ridge, TN This SPD is a summary of the policy provisions and is presented as a matter of general information only. The contents are not to be accepted or construed as a substitute for the provisions of the policy itself. A specimen copy of the policy will be furnished on request. 2

3 TABLE OF CONTENTS DEFINITIONS/ACRONYMS... 4 Information About the Travel Accident Insurance Plan... 5 What is travel accident insurance?... 5 What is the policy year?... 5 Where are records maintained?... 5 How is the travel accident insurance plan funded?... 5 Are there eligibility restrictions?... 5 When does enrollment in the plan occur?... 5 When does the travel accident insurance coverage begin?... 5 When does the travel accident insurance coverage end?... 5 What amount of coverage is there if an accident occurs?... 6 Are additional benefits available for seat belt and air bag usage?... 6 Are there benefit payment restrictions if an accident occurs while traveling on an aircraft?... 6 What are the exclusions for benefit payments?... 7 How and when are claims to be filed?... 7 To whom will benefits be paid if an accident occurs?... 7 Can a change be made in beneficiary designation?

4 DEFINITIONS/ACRONYMS Automobile A self-propelled private passenger motor vehicle with four or more wheels which is of a type both designed and required to be licensed for use on the highways of any state or country. Automobile includes, but is not limited to, a sedan, station wagon, or jeeptype vehicle, or a motor vehicle of the pickup, van, camper, or motor home type. Automobile does not include a mobile home or any motor vehicle which is used in mass or public transit. HR Human Resources ERISA Employee Retirement Income Security Act of 1974 IRS Loss of Body Member Internal Revenue Service Hand or Foot complete severance through or above the wrist or ankle joint. Eye total and irrecoverable loss of sight. Speech complete inability to communicate audibly in any degree. Hearing irrecoverable loss of hearing, which cannot be corrected by any hearing aid or device. Thumb and index finger severance of each through or above the joint closest to the wrist. Paralysis Loss of use, without severance, of a limb. This loss must be determined by a physician to be complete and not reversible. Principal Three times basic annual earnings to a maximum of $500,000, minimum of $50,000. Sum Maximum amount payable to more than one person as a result of one single accident is $500,000. Severance SPD Complete separation and dismemberment of the limb from the body. Summary Plan Description Supplemental An airbag which inflates for added protection to the head and chest areas. Restraint System 4

5 INFORMATION ABOUT THE TRAVEL ACCIDENT INSURANCE PLAN What is travel accident insurance? Travel accident insurance is insurance that is provided by ORAU to all employees who travel on authorized ORAU business. It is an accident policy only. It does not pay benefits for loss caused by, or resulting from, illness, disease, or bodily infirmity. What is the policy year? The plan year is November 1 through October 31 of the next year. Where are records maintained? Records are maintained in Human Resources (HR). The policy may be reviewed in HR during ORAU business hours. How is the travel accident insurance plan funded? The total cost of the plan is paid by ORAU. Are there eligibility restrictions? All employees assigned to a work location in the Continental United States (CONUS) who are on official business travel for ORAU in or out of assigned work location. Employees assigned to a work location Outside the Continental United States (OCONUS) are not eligible. When does enrollment in the plan occur? All employees are enrolled in the plan at the time of employment sign-up. When does the travel accident insurance coverage begin? Coverage begins at the beginning of an authorized business trip for ORAU. The trip may start at the traveler s home, place of work, or some other authorized place. Accidents occurring during normal commuting to and from work or during personal deviations are not covered under this plan. When does the travel accident insurance coverage end? Coverage ends when the traveler arrives at his/her place of work, home, or other authorized place, whichever happens first; when a personal deviation is made while on authorized travel for ORAU; or on the date of separation. 5

6 What amount of coverage is there if an accident occurs? Within one year from the date of an accident that is covered by the policy and bodily injuries result in: (1) the death of the insured; or (2) dismemberment, loss of sight, speech, hearing, or paralysis, the carrier will pay the following for the loss: Loss of Life Loss of two or more members (hand, foot, eye) Loss of Speech and Hearing (both ears) Quadriplegia (total paralysis of both upper and lower limbs) Loss of one member Paraplegia (total paralysis of both lower limbs) Loss of speech Loss of hearing (both ears) Hemiplegia (total paralysis of upper and lower limbs on one side of the body) Loss of thumb and index finger of the same hand One-quarter the principal sum However, if the insured sustains more than one loss as the result of one accident, only one payment will be made for the largest amount to which the insured is entitled. This amount will not exceed the principal amount. The amount of coverage payable for a covered accident for employees age 70 and older is as follows: Age at Date of Loss Benefit Amount as % of Principal Sum % % % % Are additional benefits available for seat belt and air bag usage? Yes. When an employee dies in a covered accident while operating or riding as a passenger in an Automobile and wearing a properly fastened, original, factory-installed seatbelt, an additional 10% of the Principal Sum up to $10,000 will be payable. If the seat belt benefit is payable and the employee is positioned in a seat protected by a properly functioning, original, factory-installed Supplemental Restraint System that inflates on impact, an additional benefit of 5% of the Principal Sum up to $5,000 will be payable. Are there benefit payment restrictions if an accident occurs while traveling on an aircraft? If an accident occurs while the employee is riding in, getting on, or getting off, of an aircraft benefits will be paid only if: The employee is riding as a passenger, not as a pilot or member of the crew. The aircraft has a valid certificate of airworthiness. The pilot has a valid license. 6

7 The aircraft is not being used for stunt or acrobatic flying, skydiving, hang gliding, etc. The aircraft is not owned, leased, or controlled by the employee or ORAU. What are the exclusions for benefit payments? Benefits will not be paid for loss caused by or resulting from: Suicide, attempted suicide, or whenever a covered person injures himself on purpose, while sane or insane. War or acts of war, whether or not declared. An injury that occurred while on full-time active duty in any of the armed forces. Taking part in a felony. Travel or flight in any spacecraft, or flight in any aircraft, except as provided for in the contract. A bacterial infection that was not caused by an accidental cut, wound, or food poisoning. How and when are claims to be filed? Written notice must be sent to the insurance company within 30 days of the accident or as soon after that as is reasonably possible. The insurance company will send claim forms to be completed. These claim forms, with proof of loss, must be returned to the insurance company no more than 90 days after the accident or as soon after that as is reasonably possible. To whom will benefits be paid if an accident occurs? Benefits will be paid to the covered employee if living. Otherwise, benefits will be paid to the beneficiary that he/she chose. The choice of beneficiary must be in writing and filed in HR. If no beneficiary had been chosen, or if no beneficiary is alive when death of the employee occurs, benefits will be paid to: The spouse of the employee, if living. If the spouse is not living, in equal shares to the living children. If there are no children, in equal shares to his/her parents. If there are no parents, in equal shares to the living brothers and sisters. If there are no brothers and sisters, to the estate. Can a change be made in beneficiary designation? Employees have the right to select or change their beneficiary at any time. Consent of the new beneficiary is not necessary. Forms for changing the beneficiary can be obtained from an HR staff member. 7