SUMMARY PLAN DESCRIPTION FOR UNITED BENEFIT FUND. Plan Benefits as of January 1, 2011

Transcription

1 SUMMARY PLAN DESCRIPTION FOR UNITED BENEFIT FUND Plan Benefts as of January 1, Metropoltan Ave. Mddle Vllage, New York Phone (718)

2 UNITED BENEFIT FUND Metropoltan Ave. Mddle Vllage, New York Phone (718) EMPLOYER TRUSTEES Thomas D Ambroso UNION TRUSTEES Andrew Talamo COUNSEL Gorlck, Kravtz & Lsthaus, P.C. AUDITOR Lberta & Mlo, C.P.A. FUND MANAGER Davd DeLuca CONSULTANT Dcknson Group, Inc. PLAN ADMINISTRATOR Omn Admnstrators Inc Broadway, 13th Floor New York, NY (718)

3 Dear Partcpant: We are pleased to be able to provde health care benefts for elgble partcpants of the UNITED BENEFIT FUND and ther dependents. Ths booklet, known as the Summary Plan Descrpton ( SPD ) descrbes n detal the benefts avalable to you and your elgble dependents as of January 1, Ths booklet s also the Plan of Benefts for the Unted Beneft Fund. Ths booklet sets forth the rules of elgblty governng your enttlement to benefts and represents the procedures to be followed when flng a clam or appealng any denal of benefts. Ths booklet also explans your rght to contnue coverage f you cease employment or exhaust your elgblty under the rules for actve partcpants. Ths booklet contans a summary n Englsh of the rghts and benefts that pertan to you under the Plan. If you have trouble understandng any part of ths booklet, get n touch wth the Fund Offce by wrtng to the Fund at Metropoltan Ave. Mddle Vllage, NY Also, you may call the Fund Offce at (718) Please carefully read ths booklet so that you understand what benefts are avalable under the Plan, when you are elgble to receve them, how to submt clams for benefts, and how they are pad. There have been mportant changes to the SPD snce the last prntng of ths booklet. Ths SPD replaces any pror SPDs you may have receved. Also, please remember to put ths booklet n a safe place n order to assure ts avalablty for future reference. The UNITED BENEFIT FUND s funded by monthly Employer contrbutons negotated on your behalf by the Unon and pad pursuant to a wrtten agreement. A Board of Trustees s responsble for the operaton of the Fund and for the Plan of benefts. The Board s comprsed of an equal number of Employer and Unon Trustees, each of whom serves the Fund as a fducary wthout pay. Our schedule of benefts has been establshed by the Trustees of the Plan, wth the Fund's Plan Admnstrator and professonal consultants assstng the Trustees to make the best use of the Fund s avalable assets. The benefts wll cover a sgnfcant part of your medcal expenses; however, they may not cover your entre medcal blls. Before havng any medcal treatment performed, you should frst dscuss the charges wth your doctor so that you wll know exactly what porton of the bll you wll be responsble for after the Fund and/or other nsurance rembursements. We encourage you to contact the Fund Offce pror to agreeng to out of pocket charges. The coverage schedules are structured to meet the most common needs of all partcpants and to take nto account condtons prevalent at ths tme. You should read ths booklet and share t wth your famly snce many of the benefts apply to them as well. The provsons of the Plan are subject to the rules, regulatons or procedures of the Plan n effect at the tme of a clam. The Plan Admnstrator has the power to nterpret, apply, construe, and amend the provsons of the Plan and make factual determnatons regardng ts constructon, nterpretaton and applcaton, and any decson made by the Plan Admnstrator n good fath s bndng upon Employers, Employees, Partcpants, Benefcares, and all other persons who may be nvolved or affected by the Plan.

4 We apprecate your understandng of our efforts to provde health care benefts to you and all your covered famly members, and to preserve the Plan for the collectve good of all ts partcpants. Please read ths booklet carefully so that you wll be famlar wth your Plan benefts and use the Plan wsely. Sncerely yours, BOARD OF TRUSTEES

5 TABLE OF CONTENTS UNLIMITED LIFETIME BENEFITS... 1 SECTION 1 DEFINITIONS... 2 SECTION 2 ELIGIBILITY... 7 SECTION 3 TERMINATION OF BENEFITS SECTION 4 MEDICAL BENEFITS SECTION 5 OPTICAL BENEFITS FROM UNITED HEALTH CARE VISION SECTION 6 PRESCRIPTION BENEFITS SECTION 7 COORDINATION OF BENEFITS SECTION 8 SUBROGATION SECTION 9 WORKER S COMPENSATION CASES SECTION 10 EXCLUSIONS SECTION 11 HOW TO CLAIM YOUR BENEFITS SECTION 12 CLAIM APPEAL PROCEDURE SECTION 13 GRIEVANCE PROCEDURE SECTION 14 CONTINUATION OF COVERAGE (COBRA) SECTION 15 SHORT TERM DISABILITY BENEFITS SECTION 16 IMPORTANT INFORMATION ABOUT THE PLAN SECTION 17 ERISA RIGHTS SECTION 18 ANCILLARY BENEFITS... 79

6 UNLIMITED LIFETIME BENEFITS In-Network Benefts Usng the Preferred Provder Organzaton ( PPO ) Unted Healthcare Prmary Care Physcan Vsts Specalty Care Physcan Vsts Chropractors and Podatrsts Routne Radology and Dagnostc Testng Clncal Laboratory MRI, MRA, CAT Scan, PET Scan, Mammogram In Patent Hosptalzaton and Surgery Notfcaton requred for electve admsson Notfcaton wthn 2 busness days requred after emergency admsson Out Patent Surgery... Notfcaton requred Emergency Room Anesthesa Durable Medcal Equpment Notfcaton requred Home Health Care Notfcaton requred Prescrpton Drugs Prescrpton Eyewear va Optcal Network Provder Program (Where applcable) Lfe Insurance Short - Term Dsablty Dental (Where applcable) 1

7 SECTION 1 DEFINITIONS The followng defntons are used throughout ths booklet. The defntons wll help you understand your benefts. In all cases, the Board of Trustees has sole dscreton to determne whether a defnton apples or s satsfed. Wherever the followng terms are used, they are captalzed and have the followng meanngs: Allowable Charge for servces or supples s the lowest of: 1. The usual charge by the Health Care Provder for the same or smlar servce or supply; or 2. The maxmum amount that the Plan has determned s payable for the servce or supply; or 3. Wth respect to a Health Care Provder that s party to an agreement to provde servces to Covered Persons, the charge agreed to by the Provder under such agreement; or 4. The Health Care Provder s actual charge. Clncal Elgblty for Coverage Servces requred to dagnose or treat an njury or sckness. Servces must be known to be safe, effectve and approprate by most qualfed practtoners who are lcensed to treat that njury or sckness. Servces must be performed safely at the approprate level of care or servces, and n the least costly settng requred by the njury or sckness. Servces must not be provded prmarly for the convenence of: the patent; the patent's famly; or the qualfed practtoner. Any servce or supply that does not meet the plan s gudelnes for clncal elgblty for coverage s excluded from coverage Co-Payment s that porton of elgble medcal and prescrpton drug expenses for whch you are fnancally responsble. Covered Person ncludes any Partcpant and hs or her elgble Dependents when properly enrolled n the Plan as a new hre or enrolled durng the open enrollment perod as defned n Secton 2, or followng a qualfyng event such a brth, marrage or adopton. Customary, Usual and Reasonable For Non-PPO Provders, the Customary, Usual and Reasonable ( CU&R ) fee s the lesser of the fee most often charged by the provder or the maxmum allowable fee as determned by the plan. The maxmum allowable fee s set by comparng the servce to a natonal database of fees. The database s adjusted to the localty where the servce was performed. 1. If more than one surgery s performed durng an operatve sesson, the covered expense wll be lmted. The CU&R fee for the prmary surgcal procedure wll be payable. 50% of 2

8 the CU&R fee for the secondary procedure wll be payable. 50% of the CU&R fee for the thrd and followng procedures wll be payable. 2. The CU&R fee for an assstant surgeon or physcan's assstant s based on the CU&R fee for the prmary surgeon as follows: 16% for an assstant surgeon; and 14% for a physcan's assstant. In the case of a PPO Provder, t wll mean the negotated PPO dscount rate for the servce or procedure. Deductble s the amount of elgble medcal or prescrpton drug expenses that you are responsble for payng each calendar year before the Plan begns to pay benefts. Dependent under ths Plan s: Your legal Spouse when resdng n the Unted States, other than a legally separated spouse, who s lsted on your enrollment card or Your unmarred or marred bologcal chldren, legally adopted chldren, and stepchldren up to age 26. Coverage wll be termnated at the end of the month n whch the chld turns 26 years old. Untl 2014, for UBF Plans whch are grandfathered, ths coverage s only avalable to those chldren who do not have employer-sponsored health coverage through ether ther employer or, f marred, ther spouse s employer. Grandchldren are not elgble for coverage. Emergency Care s medcal or dental care and treatment provded for: A medcal condton that comes on suddenly and s manfested by symptoms of such severty, ncludng severe pan, that a prudent person wth average knowledge of medcne could reasonably expect that the absence of mmedate medcal attenton could result n: - Placng the health of the afflcted person n serous jeopardy; or - Causng serous dysfuncton of any bodly organ or part; or - Causng serous dsfgurement of the afflcted person. Treatment and servces due to a non work related accdent and rendered wthn 48 hours of such accdent; Treatment and servces due to a sudden onset of serous llness and rendered wthn 24 hours of such llness; and Emergency stuatons such as uncontrolled bleedng, sezures or loss of conscousness, shortness of breath, chest pans or severe squeezng sensatons n the chest, suspected overdose of medcaton or posonng, sudden paralyss or slurred speech, serous burns or cuts, and broken bones. Employee means: (1) an Employee covered by a collectve barganng agreement between an Employer and a partcpatng Unon and who s n a poston for whch contrbutons for whch 3

9 contrbutons are requred to be remtted by the Employer to the Plan; or (2) an Employee n a poston wth an Employer for whch contrbutons are requred to the Fund under a wrtten agreement wth the Fund. Employer means an employer that s party to a collectve barganng agreement wth a partcpatng Unon or has executed a wrtten agreement wth the Fund, oblgatng the Employer to make payments to the Fund for coverage of ts Employees. Ths Fund and the Unon are Employers only to the extent that they make contrbutons to the Fund for coverage of ther Employees. Employment means a poston wth an Employer for whch contrbutons are requred to be made to the Fund. Essental Health Benefts shall mean, under secton 1302(b) of the Patent Protecton and Affordable Care Act, those health benefts to nclude at least the followng general categores and the tems and servces covered wthn the categores: ambulatory patent servces; emergency servces; hosptalzaton; maternty and newborn care; mental health and substance abuse dsorder servces, ncludng behavoral health treatment; prescrpton drugs; rehabltatve and rehabltatve servces and devces; laboratory servces; preventve and wellness servces and chronc dsease management; and pedatrc servces, ncludng oral and vson care. Please note that the Fund does not cover all of these servces. Expermental or Unproven Servces 1. Expermental, nvestgatonal or unproven servces, whch means any drug, servce, supply, care and/or treatment that, at the tme provded or sought to be provded, s not recognzed as conformng to accepted medcal practce or to be a safe, effectve standard of medcal practce for a partcular condton. Ths ncludes, but s not lmted to: a. Items wthn the research, nvestgatonal or expermental stage of development or performed wthn or restrcted to use n Phase I, II, or III clncal trals (unless dentfed as a covered servce elsewhere); b. Items that do not have strong research-based evdence to permt conclusons and/or clearly defne long-term effects and mpact on health outcomes (have not yet shown to be consstently effectve for the dagnoss or treatment of the specfc condton for whch t s sought). Strong research-based evdence s dentfed as peer-revewed publshed data derved from multple, large, human randomzed controlled clncal trals OR at least one or more large controlled natonal mult-center populaton-based studes; c. Items based on anecdotal and unproven evdence (lterature conssts only of case studes or uncontrolled trals),.e., lacks scentfc valdty, but may be common practce wthn select practtoner groups even though safety and effcacy s not clearly establshed; or 4

10 d. Items whch have been dentfed through research-based evdence to not be effectve for a medcal condton and/or to not have a benefcal effect on health outcomes. Note: FDA and/or Medcare approval does not guarantee that a drug, supply, care and/or treatment s accepted medcal practce, however, lack of such approval wll be a consderaton n determnng whether a drug, servce, supply, care and/or treatment s consdered expermental, nvestgatonal or unproven. In assessng cancer care clams, sources such as the Natonal Comprehensve Cancer Network (NCCN) Compendum, Clncal Practce Gudelnes n Oncology TM or Natonal Cancer Insttute (NCI) standard of care compendum gudelnes, or smlar materal from other or successor organzatons wll be consdered along wth benefts provded under the Plan and any benefts requred by law. Furthermore, off-label drug or devce use (sought for outsde FDA-approved ndcatons) s subject to medcal revew for approprateness based on prevalng peer-revewed medcal lterature, publshed opnons and evaluatons by natonal medcal assocatons, consensus panels, technology evaluaton bodes, and/or ndependent revew organzatons to evaluate the scentfc qualty of supportng evdence. Fund or Welfare Fund means the UNITED BENEFIT FUND. Health Care Provder means an ndvdual traned to provde the servces rendered to the patent and lcensed under laws of the jursdcton where the servces are rendered who acts wthn the scope of hs or her lcense. Hosptal means an accredted general or specalty hosptal that has full dagnostc surgcal and therapeutc facltes under the supervson of a staff of Physcans, and whch regularly provdes 24 hour nursng servces by regstered, graduate nurses or lcensed practcal nurses. Care n nsttutons or parts of nsttutons prncpally used as clncs or mantaned for care of the aged or chroncally ll, rest or nursng homes, or other extended care facltes (such as acute and sub-acute rehabltaton) are not consdered Hosptals wthn the meanng of the Plan. Illness s any bodly sckness or dsease, ncludng any congental abnormalty of a newborn chld, as dagnosed by a Physcan and as compared to the person s prevous condton. Expenses ncurred because of pregnancy, chldbrth and related medcal condtons are covered under the Plan to the same extent as any other Illness. Incurred s any charge submtted to the fund for medcal servces. The ncomng retal charge wll always be calculated pror to adjudcaton and or re prcng. Payment amounts after adjudcaton are known as Net Payouts/Payments. Injury s any damage to a body part resultng from trauma from an external source. Morbd Obesty Surgcal and non surgcal treatment of morbd obesty. Coverage for nonexpermental and scentfcally proven, surgcal treatment by a qualfed practtoner. Morbd obesty s defned as a Body Mass Index (BMI) equal to or greater than 40. BMI s your weght n klograms dvded by the square of your heght n meters. Pre authorzaton s requred or benefts wll not be payable under the plan. The plan reserves the rght to determne whether the treatment s 5

11 elgble for coverage. Benefts do not nclude nutrtonal supplements, body composton or underwater weghng procedures, exercse therapy, weght control or reducton programs. Medcare s the Health Insurance for the Aged and Dsabled provsons n Ttle XVIII of the U.S. Socal Securty Act as amended. Net Payout/Payment s the fnal, adjudcated prce after network re prcng, co pays, deductbles, out of network penaltes, f any, and any audt reductons, f any. The Fund wll never pay out more than the Net Payout Maxmums as defned n each plan Appendx. Partcpant s an Employee who meets the elgblty requrements of Secton 2 of ths Plan. A former Employee who contnues to be elgble for coverage under COBRA Coverage wll be a Partcpant untl that coverage ends. Physcan s a person lcensed as a Medcal Doctor (MD) or Doctor of Osteopathy (DO) and authorzed to practce medcne, to perform surgery, and to admnster drugs under laws of the jursdcton where the servces are rendered and who acts wthn the scope of hs or her lcense. Plan Document means the benefts and provsons descrbed n ths booklet. Polcy s a set of coverage rules as explaned n ths SPD whch apples to partcpant, and any elgble dependents. At no tme wll the Fund ever pay more than the establshed lmts as lsted n a polcy s applcable Beneft Appendx. Qualfed Medcal Chld Support Order (QMCSO) s a court or state admnstratve agency order that comples wth requrements of federal law as descrbed n Secton 2. Surgery s any operatve or dagnostc procedure performed n the treatment of an Injury or llness by nstrument or cuttng procedure through an ncson or any natural body openng. Total Dsablty or Totally Dsabled means a dsablty that result from a bodly Injury or dsease that wholly prevents the person from engagng n any ganful work. Work Related means an Injury or Illness arsng out of or n the course of one s employment, whether or not the person properly asserts hs or her rghts and whether or not any recovery s receved. If, except for your falure to follow the approprate procedural requrements for flng a clam or to otherwse smlarly act, your clam could have been compassable by, for example, the relevant Workers Compensaton law; t wll be treated as Work Related by the Fund and excluded from coverage under the Plan. You or Your refers to the Partcpant, unless the context clearly ndcates otherwse. Ths booklet descrbes the Plan as t apples to most members. It s subject to admnstratve modfcatons, rules, regulatons and procedures of the Plan n effect at tme of servce. In dealng wth stuatons not specfcally covered by general terms of the Plan, the rules and regulatons are nterpreted by the Trustees n a manner consstent wth the ntent and lmts of the Plan descrpton. 6

12 SECTION 2 ELIGIBILITY You become elgble when you work n full tme Employment as an Employee wth an Employer. INITIAL ENROLLMENT Once you become elgble you must enroll n the plan f you want to receve benefts. You must enroll n the Plan wthn thrty (30) days of when you frst become elgble. If you wat beyond ths thrty (30) day perod you wll consdered a late enrollee and may be subject to extended restrctons on coverage for any pre-exstng condton(s). Obtan an Enrollment Card from the Fund Offce and return the completed card mmedately. If you do not, the start of your coverage wll be delayed and you may lose some benefts. The Enrollment Card s a permanent record of mportant dates for you and your elgble Dependents. For famly benefts, you must lst your elgble Dependents wth ther dates of brth and submt legal marrage, brth, or adopton certfcates. The Funds wll deny clams for benefts ncurred before your Enrollment Card was receved by the Fund Offce, or for a Dependent not lsted on the card. It s your oblgaton to keep the Fund Offce nformed and to fle for a new enrollment card wthn 30 days of any changes n your: Address Dependent Status (Brth/Adopton of a Chld) Martal Status LATE ENROLLMENT If you and/or your elgble dependents dd not enroll durng your orgnal 30 day elgblty perod or any specal enrollment perods descrbed n ths Secton and have now decded to apply for coverage, you may enroll by makng wrtten applcaton to the Plan Admnstrator. In these crcumstances, you and/or your elgble dependents wll be consdered late enrollees. Coverage wll become effectve at 12:01 A.M. on the frst day of the month followng enrollment. Late enrollees are subject to the Plan s pre exstng condton lmtaton restrctons on coverage for pre-exstng condtons whch may extend coverage for up to eghteen (18) months, except where prohbted by law. Please refer to the secton enttled, Pre exstng Condton Lmtaton for more nformaton. 7

13 Specal Enrollment Perods Ths Plan provdes specal enrollment perods that allow you to enroll n the Plan wthout any extended restrctons that mght otherwse lmt coverage of preexstng condtons, even f you declned enrollment durng an ntal or subsequent elgblty perod. If you declned enrollment for yourself or your dependents (ncludng your spouse) because you had other health coverage, you may enroll for coverage for yourself and/or your dependents f the other health coverage s lost. You must make wrtten applcaton for specal enrollment wthn thrty (30) days of the date the other health coverage was lost. For example, f you lose your other health coverage on September 15, you must notfy the Plan Admnstrator and apply for coverage by close of busness on October 16. If You are an elgble employee or dependent and you lose your Medcad or state Chldren s Health Insurance Program coverage, also called CHIP, you have sxty (60) days to elect coverage under the Plan. You or your elgble dependents may enroll durng ths specal enrollment perod f the person who wshes to enroll, called the enrollee, meets all of the followng condtons: The enrollee s elgble for coverage under the terms of ths Plan; The enrollee s not currently enrolled under the Plan; When enrollment was prevously offered, the enrollee declned because of coverage under another group health plan or health nsurance coverage. You or the enrollee must have provded a wrtten statement that other health coverage was the reason for declnng enrollment under ths Plan; and The other coverage was termnated due to loss of elgblty for the coverage (ncludng due to legal separaton, dvorce, death, termnaton of employment, or reducton n the number of hours), or because employer contrbutons for the coverage were termnated. The enrollee s not elgble for ths specal enrollment rght f: The other coverage was COBRA contnuaton coverage and the enrollee dd not exhaust the maxmum tme avalable to you for that COBRA coverage; or The other coverage was lost due to non payment of premum or for cause (such as makng a fraudulent clam or an ntentonal msrepresentaton of a materal fact n connecton wth the other plan). If the condtons for specal enrollment are satsfed, coverage for the enrollee wll be effectve at 12:01 A.M. on the frst day of the frst calendar month begnnng after the date the wrtten request s receved by the Plan. 8

14 Specal Enrollment for New Dependents If you acqure a new dependent as a result of marrage, brth, adopton, or placement for adopton, you may be able to enroll yourself and your dependents durng a specal enrollment perod. You must make wrtten applcaton for specal enrollment no later than thrty (30) days after you acqure the new Dependent, excludng the day of the acquston. For example, f you are marred on September 15, you must notfy the Plan Admnstrator and apply for coverage by close of busness on October 16. You may enroll yourself and/or your elgble dependents durng ths specal enrollment perod f: You are elgble for coverage under the terms of ths Plan, and You have acqured a new dependent through marrage, brth, adopton or placement for adopton. If the condtons for specal enrollment are satsfed, coverage for you and your dependent(s) wll be effectve at 12:01 a.m.: For a marrage, on the frst day of the calendar month followng recept of your ntal employer contrbuton. For a brth, on the date of brth. For an adopton or placement for adopton, on the date of the adopton or placement for adopton. Qualfed Medcal Chld Support Orders (QMCSOs) The Fund wll provde coverage to your chld f requred to do so under the terms of a qualfed medcal chld support order (referred to as a "QMCSO"). The Fund wll provde coverage to a chld under a QMCSO even f you do not have legal custody of the chld, the chld s not dependent on you for support, the chld does not resde wth you, and regardless of any watng perod that otherwse may exst for Dependent coverage. If the Fund receves a QMCSO and f you do not enroll the affected chld, the Fund wll allow the custodal parent or state agency to complete the necessary enrollment forms on behalf of the chld. A copy of the Fund's procedures for determnng whether an order s a QMCSO can be obtaned from the Fund. OPEN ENROLLMENT Open Enrollment gves you the opportunty to make changes to your beneft electons for the comng year. Open Enrollment s usually held every year for an entre month, from January 1 through January 31. Some employers may have open enrollment durng a dfferent tme of year and/or a dfferent length, dependng on ther contract wth the Unon and agreements wth UBF. Please make sure to check wth your employer and unon rep to verfy when your open enrollment perod begns and ends, and for the proper procedures n makng changes to your coverage durng your open enrollment perod. 9

15 WAITING PERIOD On the frst day of the month n whch the ntal (frst) Employer contrbuton to the Fund s receved on your behalf, you wll become elgble for the followng benefts: Medcal Benefts Major Medcal Benefts Surgcal Benefts Lfe Insurance Optcal Benefts Dental Benefts Hosptal Benefts Prescrptons Benefts If you are not actvely employed by an Employer n Employment when your benefts are frst scheduled to be n force, then coverage for you wll be delayed untl you return to actve, fulltme employment. However, f you are not actvely at work due to Illness or Injury, you wll be treated as beng actvely at work for purposes of elgblty under the Fund, provded that you actually began work covered by the Fund. PRE EXISTING EXCLUSION Notwthstandng any other clause n the Plan, the followng rules apply to pre exstng medcal condtons: Coverage under the Plan s excluded for a pre exstng condton, subject to the excluson parameters set forth below. For the purposes of elgblty for benefts under ths Plan, a preexstng condton s defned as a condton other than pregnancy for whch an ndvdual receved or was recommended medcal advce, dagnoss, care or treatment wthn the sx month perod endng on the date you enroll n the plan. Ths s your Enrollment Date. For purposes of ths paragraph, the 6-month perod endng on the Enrollment Date begns on the 6-month annversary date precedng the Enrollment Date. For example, for an Enrollment Date of August 1, the 6-month perod precedng the Employment Date s the perod commencng on February 1 and contnung through July 31. Ths pre exstng excluson does not apply to genetc nformaton n the absence of a dagnoss of the condton related to such nformaton or to Dependent chldren under the age of 19. The rules of ths paragraph are llustrated by the followng examples: 10

16 Example 1 Indvdual A s treated for a medcal condton 7 months before the Enrollment Date under the Plan. As part of such treatment, A s Physcan recommends that a follow up examnaton be gven 2 months later. Despte the recommendaton, A does not receve a follow up examnaton and no other medcal advce, dagnoss, care, or treatment for that condton s recommended to A or receved by A durng the 6 month perod endng on A s Enrollment Date n the Plan. In ths Example 1, the Plan wll not mpose a pre exstng condton excluson perod wth respect to the condton for whch A receved treatment 7 months pror to the Enrollment Date. Example 2 Indvdual B has asthma and s treated for that condton several tmes durng the 6 month perod before B s Enrollment Date n the Plan. The Plan mposes 12 month pre exstng condton excluson. B has no pror credtable coverage to reduce the excluson perod. Three months after the Enrollment Date, B begns coverage under the Plan. Two months later, B s hosptalzed for asthma. In ths Example 2, the Plan wll exclude payment for the hosptal stay and the Physcan servces assocated wth ths llness because the care s related to a medcal condton for whch treatment was recommended or receved by B durng the 6 month perod precedng the Enrollment Date. Ths Plan excludes coverage for an ndvdual s pre exstng condton for 12 months (18 months for a late enrollee). Ths excluson perod s reduced by the ndvdual s Credtable Coverage, whch s health coverage the ndvdual had before ths Plan s Enrollment Date (such as COBRA coverage, coverage under another employer s health plan or ndvdual health nsurance coverage) so long as the ndvdual dd not go 63 days or longer wthout coverage. Credtable Coverage means coverage for the cost of medcal care whether provded drectly, through nsurance, rembursement or otherwse and as otherwse requred by federal law. Perods of coverage precedng a break n coverage of 63 days or more do not count as Credtable Coverage. Watng Perods do not count as Credtable Coverage but do count as a break n coverage. Credtable Coverage s determned wthout regard to the partcular benefts offered under the pror coverage, except that coverage solely of excepted Benefts s not Credtable Coverage. Excepted Benefts s defned as coverage solely for one or more of the followng: accdent, accdental death and dsmemberment, dsablty, workers compensaton, lmted dental benefts, lmted vson benefts, long term care benefts, coverage for only a specfed dsease or llness, supplemental benefts such as Medcare Supplemental nsurance, and as otherwse defned n Secton 706(c) of ERISA. Employees must enroll n the Plan at the frst opportunty to take advantage of the shorter 12 month pre exstng condton excluson perod. Otherwse, the longer 18 month pre exstng condton perod for late enrollees wll apply. 11

17 Notwthstandng the above language, ths Plan wll not apply the above pre exstng condton exclusons for pregnancy or for newborn/adopted chldren who are covered under any Credtable Coverage wthn 30 days of brth or adopton so long as the chld does not ncur a break n coverage of 63 days or more. Example 1 Seven months after enrollment n the Plan, Indvdual E has a chld born wth a brth defect and enrolls the chld wthn 30 days of brth. Because the chld s enrolled n the Plan wthn 30 days of brth, no pre-exstng condton excluson wll be mposed wth respect to the chld under the Plan. Example 2 Employee F s enrolled n another health plan wth Employer W. Seven months after enrollment n that plan the Partcpant has a chld born wth a brth defect. Three months after the chld s brth, the Partcpant commences employment wth Employer X and enrolls wth ths Plan 45 days after leavng Employer W s plan. Ths Plan mposes a 12 month excluson for any preexstng condton. In ths Example, the Plan may not mpose any pre exstng condton excluson wth respect to the Partcpant s chld because the chld was covered wthn 30 days of brth and had no sgnfcant break n coverage (a break of 63 days or more). Ths result apples regardless of whether the Partcpant s chld s ncluded n the certfcate of credtable coverage provded to the Plan by Employer W ndcatng 300 days of dependent coverage or receves a separate certfcate ndcatng 90 days of coverage. The Plan may mpose pre exstng condton excluson wth respect to the Partcpant for up to 65 days for any pre exstng condton of the Partcpant for whch medcal advce, dagnoss, care, or treatment was recommended or receved by the Partcpant wthn the 6 month perod endng on the Partcpant s Enrollment Date n the Plan. If the Pre Exstng Excluson apples, you or your Dependent must provde the Fund Offce wth evdence of your Credtable Coverage n order to reduce the 12 month (or 18 month) Pre Exstng Excluson perod. Any ndvdual has a rght to request a Certfcate of Credtable Coverage from a pror plan or nsurer. The Fund Offce can assst you n obtanng that certfcate f necessary. The certfcaton must be dated and should generally provde the followng nformaton for all coverage for twenty four (24) months pror to the date of the request: (1) the name of the group health plan; (2) the full legal name of the partcpant of dependent and a form of dentfcaton, such as date of brth or SSN; (3) the name, address and telephone number of the Plan Admnstrator or the name, address and telephone number of the nsurer; (4) the date any watng or afflaton perod began; (5) the date coverage began; (6) the date coverage ended or that coverage s contnung; and a telephone number and address for further nformaton. In the alternatve, f you had 18 months of credtable coverage, the certfcate wll smply state that fact. 12

18 Certfcatons must be provded automatcally (and as soon as admnstratvely feasble) when a partcpant loses coverage; when a partcpant becomes elgble for COBRA coverage; and when COBRA coverage ends. In addton, certfcatons must be provded upon the wrtten request of a partcpant or benefcary wthn twenty four (24) months followng the termnaton of the ndvdual s coverage. Ths apples to coverage under ths Fund and to most pror coverage you may have had. You receve credt for your prevous coverage that occurred wthout a break n coverage of 63 days of more. It s credted aganst the pre exstng condton excluson perod. If you do not have a certfcate and cannot obtan one when t s needed, you may establsh Credtable Coverage by presentng other documentaton to the Fund Offce. Ths may be accomplshed by (1) presentng evdence of some Credtable Coverage durng the perod; and (2) statng n wrtng the perod of Credtable Coverage and cooperate wth the Fund s efforts to verfy the pror coverage. You can show Credtable Coverage for your Dependent by statng n wrtng the perod of Dependent coverage and cooperatng wth the Fund s efforts to verfy Dependent status. Contact the Fund Offce f you need assstance. If an ndvdual s dened coverage for a pre exstng condton, the Fund wll provde that ndvdual wth a wrtten explanaton detalng the reason for the denal. Any ndvdual has the rght to appeal a denal of coverage relatng to a pre exstng condton or any other denal of coverage. See secton 12 of the SPD for appeal procedures. Ths Plan does not dscrmnate among Partcpants on any mpermssble bass and does not requre late enrollees to pass a physcal exam. 13

19 SECTION 3 TERMINATION OF BENEFITS All beneft coverage for both you and your Dependents termnates as of the last day of the month your Employer makes contrbutons on your behalf. Other reasons for termnaton are descrbed n Secton 14 of ths Summary Plan Descrpton. The Plan wll be permtted to retroactvely rescnd an ndvdual's coverage only for fraud or ntentonal msrepresentaton of materal facts or, n the case of COBRA, for non-payment of premums. Leave for Mltary Servce under the Unformed Servces Employment and Reemployment Rghts Act of 1994 ("USERRA") If you are nducted nto the Mltary Servce of the Armed Forces of the Unted States of Amerca, or f you enlst n the Mltary Servce, ncludng part-tme Natonal Guard Servce, or f, because of membershp n a reserve component of the Armed Forces, you are called nto actve federal servce, your health coverage wll be contnued by the Fund durng your frst thrty-one (31) days of mltary servce n accordance wth the Unformed Servces Employment and Reemployment Rghts Act ( USERRA ) of After thrty-one (31) days, your elgblty for health care coverage under ths Plan wll be suspended durng the perod of your mltary servce. You should receve mltary health care coverage at no cost. You may choose to contnue coverage under ths Plan, at your own expense up to a maxmum of 24 months. You and your Dependents covered under the Plan may also be elgble to contnue coverage under the COBRA provsons by makng the requred self- payments. The Fund does not voluntarly mantan your coverage; you and your elgble dependents wll be gven the opportunty to elect contnung coverage at your own expense. If you are n the reserves and return from actve duty you wll be enttled to resume elgblty under ths Plan f you return to actve covered employment wthn nnety (90) days from the date of dscharge, orgnally left the employer for mltary servce from other than a temporary poston, and was released from actve duty under honorable condtons. The veterans rghts law requres ths nnety (90) day grace perod as a type of protecton for partcpants, for the duraton of the reserve call-up or any other type of mltary servce up to fve (5) years. The Fund s not oblgated to offer ths nnety (90) day perod to partcpants servng n the mltary for fve (5) or more years. Essentally, the Fund wll suspend your elgblty n the Plan untl you are dscharged. Your elgblty wll be based on your hours worked n covered employment pror to enterng the mltary. If you do not return to actve covered employment wthn nnety (90) days (or any tme otherwse specfed), you wll be consdered a new employee, subject to the ntal elgblty provsons. Questons regardng your enttlement to ths leave should be referred to your Employer. Questons about the USERRA contnuaton of coverage should be referred to the Fund Offce 14

20 May I contnue to partcpate whle I am absent under USERRA? You may elect to contnue coverage under the Plan for yourself and your dependents, when: You and your dependents were covered persons n the Plan mmedately pror to your leave of absence for unformed servce; and The reason for your leave of absence s due to actve servce n the unformed servces. In addton, you must meet the followng requrements: You (or an approprate offcer of the unformed servce) must gve advance wrtten or verbal notce of your servce to your partcpatng employer. Ths notce wll not be requred f gvng t s precluded by mltary necessty or s otherwse mpossble or unreasonable; The cumulatve length of ths absence and all prevous absences wth your partcpatng employer by reason of your servce n the unformed servce does not exceed fve years (although certan exceptons apply to ths fve-year maxmum requrement); and You comply wth the notce requrements set forth n "When wll coverage contnued through USERRA termnate?" The law requres your partcpatng employer to allow you to elect coverage whch s dentcal to smlarly stuated employees who are not on USERRA leave. Ths means that f the coverage for smlarly stuated employees and dependents s modfed, coverage for the ndvdual on USERRA leave wll be modfed. What s the cost of contnung coverage under USERRA? The cost of contnung your coverage wll be: For leaves of 30 days or less, the same as the contrbuton requred from smlarly stuated employees; For leaves of 31 days or more, up to 102% of the contrbuton requred from smlarly stuated employees and your partcpatng employer. Contnuaton apples to all coverage provded under ths Plan, except for short and long-term dsablty, and lfe nsurance, coverage. 15

21 When wll coverage contnued through USERRA termnate? Contnued coverage under ths provson wll termnate on the earlest of the followng events: The date you fal to apply for or fal to return to work for your partcpatng employer followng completon of your leave. You must notfy your partcpatng employer of your ntent to return to employment wthn: For leaves of 30 days or less, or f you are absent from employment for a perod of any length for the purposes of an examnaton to determne your ftness to perform servce n the unformed servce, by reportng to the partcpatng employer: o o Not later than the begnnng of the frst full regularly scheduled work perod on the frst full calendar day followng the completon of your perod of servce and the expraton of eght hours after a perod allowng for your safe transportaton from the place of servce to your resdence; or If reportng wth such perod s mpossble or unreasonable through no fault of yours, then as soon as possble after the expraton of the eght-hour perod referred to above. For leaves of 30 to 180 days, by submttng an applcaton for reemployment wth your partcpatng employer: o o Not later than 14 days after completng unformed servce; or If submttng such applcaton wthn that perod s mpossble or unreasonable through no fault of your own, then the next frst full calendar day when submsson of such applcaton becomes possble. For leaves of more than 180 days, by submttng an applcaton for reemployment wth your partcpatng employer not later than 90 days after completng unformed servce. If you are hosptalzed for, or convalescng from, an llness or njury ncurred n, or aggravated durng, the performance of servce n the unformed servce, by reportng to, or submttng an applcaton for reemployment wth, your partcpatng employer (dependng upon the length of your leave as ndcated above), at the end of the perod that s necessary for you to recover from such llness or njury. Ths perod may not exceed two years, except f crcumstances beyond your control make reportng to your partcpatng employer mpossble or unreasonable, then the two-year perod may be extended by the mnmum tme requred to accommodate such crcumstances. 16

22 The date you fal to pay any requred contrbuton. 24 months from the date your leave began. How wll my coverage be renstated on return from USERRA leave? The law also requres, regardless of whether contnuaton of coverage was elected, that your coverage and your dependents coverage be renstated mmedately upon your return to employment, so long as you comply wth the requrements set forth above n "May I contnue partcpaton whle I am absent under USERRA?" and, f your absence was more than 30 days, you have furnshed any avalable documents requested by your partcpatng employer to establsh that you are enttled to the protectons offered by USERRA. Further, your separaton from servce or dscharge may not be dshonorable or based upon bad conduct, on grounds less than honorable, absent wthout leave, or endng n a convcton under court martal. Upon renstatement, an excluson or watng perod may not be mposed f that excluson or watng perod would not have been mposed had your coverage (or your dependents' coverage) not termnated as a result of your servce n the unformed servce. However, ths does not apply to coverage of any llness or njury determned by the Secretary of Veteran Affars to have been ncurred n, or aggravated durng, performance of your servce n the unformed servces. NOTE: For complete nformaton regardng your rghts under USERRA, contact your partcpatng employer. Famly and/or Medcal Leave The Famly and Medcal Leave Act ( FMLA ) s a federal law that apples, generally, to employers wth 50 or more employees, and provdes that an elgble employee may elect to contnue coverage under ths Plan durng a perod of approved FMLA leave at the same cost as f the FMLA leave not been taken. If the FMLA apples to your employer, the law requres that your Employer to gve you up to 12 weeks of job-protected, unpad leave durng any 12-month perod for one or more of the reasons descrbed below, so long as you have worked 1,250 hours durng the precedng 12 months. The FMLA also requres your Employer to mantan your coverage under the Plan durng your perod of leave under the FMLA just as f you were n Employment. Your coverage under the FMLA wll cease once the Fund s notfed or otherwse determnes that you have termnated Employment, exhausted your 12 week FMLA leave enttlement, nformed the Fund of your ntent not to return from leave, or your Employer ceases to make contrbutons to the Fund on your behalf durng the perod of FMLA leave. Once the Fund s notfed or otherwse determnes that you are not returnng to Employment followng a perod of FMLA leave, you may elect contnued coverage under the COBRA 17

23 contnuaton of coverage rules. The Qualfyng Event enttlng you to COBRA coverage s the last day of your FMLA leave. If you fal to return to Employment followng your leave, the Fund may recover the value of benefts t pad to mantan your health coverage durng the perod of FMLA leave, unless your falure to return was based upon the contnuaton, recurrence, or onset of a serous health condton that affects you or a Famly Member and that would normally qualfy you for leave under the FMLA. If you fal to return from FMLA leave for mpermssble reasons, the Fund may offset payment of outstandng medcal clams ncurred pror to the perod of FMLA leave aganst the value of the benefts pad on your behalf durng the perod of FMLA leave. If provsons under the Plan change whle you are on FMLA leave, the changes wll be effectve for you on the same date as they would have been had you not taken leave. FMLA leave may be pad (usng accrued vacaton tme, personal leave or famly or sck leave, as applcable) or unpad. Your partcpatng employer has the rght to requre that all pad leave be used pror to provdng any unpad leave. You must contnue to pay your porton of the Plan contrbuton, f any, durng the FMLA leave. Payment must be made wthn 30 days of the due date establshed by the Plan Admnstrator. If payment s not receved, coverage wll termnate on the last date for whch the contrbuton was receved n a tmely manner. Questons regardng your enttlement to FMLA leave should be referred to your Employer. Questons about the FMLA contnuaton coverage should be referred to the Fund Offce. Am I an elgble employee? You are an elgble employee f all of the followng condtons are met: You have been employed wth the partcpatng employer for at least 12 months; You have been employed wth the partcpatng employer at least 1,250 hours durng the 12 consecutve months pror to the request for FMLA leave; and You are employed at a workste that employs at least 50 employees wthn a 75- mle radus. What crcumstances qualfy for FMLA leave? Coverage under FMLA leave s lmted to a total of 12 workweeks durng any 12-month perod for the followng reasons: The brth of, and to care for, your newborn son or daughter; 18

24 The placement of a chld wth you for adopton or foster care; Your takng leave to care for your spouse, son or daughter, or parent who has a serous health condton; or Your decson to take leave due to a serous health condton whch makes you unable to perform the functons of your poston. A qualfyng exgency arsng out of the fact that a spouse, son or daughter, parent, or next of kn of the employee s a regular or reserve component n the Armed Forces. Mltary Caregver Leave Coverage for mltary caregver leave under FMLA s lmted to a total of 26 workweeks durng any 12-month perod for the followng stuatons: To care for a servce member followng a serous llness or njury to that servce member, when the employee s that servce member s spouse, son or daughter, parent, or next of kn. To care for a veteran who s undergong medcal treatment, recuperaton, or therapy for a serous llness or njury that occurred any tme durng the fve years precedng the date of treatment, when the employee s that veteran s spouse, son or daughter, parent, or next of kn. What are the notce requrements for FMLA leave? You must provde at least 30 days notce to your partcpatng employer pror to begnnng any leave under FMLA. If the nature of the leave does not permt such notce, you must provde notce of the leave as soon as possble. Your partcpatng employer has the rght to requre medcal certfcaton to support your request for leave due to a serous health condton for yourself or your elgble famly members. How long may I take FMLA leave? Durng any one 12-month perod, the maxmum amount of FMLA leave may not exceed 12 workweeks for most FMLA related stuatons. The maxmum perods for an employee who s the prmary care gver of a servce member wth a serous llness or njury that was ncurred n the lne of actve duty may take up to 26 weeks of FMLA leave n a sngle 12-month perod to care for that servce member. Your partcpatng employer may use any of four methods for determnng ths 12-month perod. If you and your spouse are both employed by the partcpatng employer, FMLA leave may be lmted to a combned perod of 12 workweeks, for both spouses, when FMLA leave s due to: 19

25 The brth or placement for adopton or foster care of a chld; or The need to care for a parent who has a serous health condton. Wll FMLA leave termnate before the maxmum leave perod? Coverage may end before the maxmum 12-week (or 26-week) perod under the followng crcumstances: When you nform your partcpatng employer of your ntent not to return from leave; When your employment relatonshp would have termnated but for the leave (such as durng a reducton n force); When you fal to return from the leave; or If any requred Plan contrbuton s not pad wthn 30 days of ts due date. If you do not return to work when coverage under FMLA leave ends, you wll be elgble for COBRA contnuaton of coverage at that tme. Recovery of Plan contrbutons Your partcpatng employer has the rght to recover the porton of the Plan contrbutons t pad to mantan coverage under the Plan durng an unpad FMLA leave f you do not return to work at the end of the leave. Ths rght wll not apply f falure to return s due to the contnuaton, recurrence or onset of a serous health condton that enttles you to FMLA leave (n whch case your partcpatng employer may requre medcal certfcaton) or other crcumstances beyond your control. Wll my coverage be renstated when I return to work? The law requres that coverage be renstated upon your return to work followng an FMLA leave whether or not you mantaned coverage under the Plan durng the FMLA leave. On renstatement, all provsons and lmts of the Plan wll apply as they would have appled f FMLA leave had not been taken. The watng perod and the pre-exstng condton lmtaton wll be credted as f you had been contnually covered under the Plan. 20

26 Defntons For the purpose of ths FMLA provson only, the followng terms are defned as stated. Next of kn the nearest blood relatve to the servce member. Parent s your bologcal parent or someone who has acted as your parent n place of your bologcal parent when you were a son or daughter. Qualfyng exgency ncludes the followng stuatons: Short-notce deployment. o o To address any ssue that arses from the fact that a covered mltary member s notfed seven or less calendar days pror to the date of deployment of an mpendng call or order to actve duty n support of a contngency operaton; and Leave taken for ths purpose can be used for a perod of seven calendar days begnnng on the date a covered mltary member s notfed of an mpendng call or order to actve duty n support of a contngency operaton; Mltary events and related actvtes. o o To attend any offcal ceremony, program, or event sponsored by the mltary that s related to the actve duty or call to actve duty status of a covered mltary member; and To attend famly support or assstance programs and nformatonal brefngs sponsored or promoted by the mltary, mltary servce organzatons, or the Amercan Red Cross that are related to the actve duty or call to actve duty status of a covered mltary member; Chldcare and school actvtes. o o To arrange for alternatve chldcare when the actve duty or call to actve duty status of a covered mltary member necesstates a change n the exstng chldcare arrangement for a bologcal, adopted, or foster chld, a stepchld, or a legal ward of a covered mltary member, or a chld for whom a covered mltary member stands n loco parents, who s ether under age 18, or age 18 or older and ncapable of self-care because of a mental or physcal dsablty at the tme that FMLA leave s to commence; To provde chldcare on an urgent, mmedate need bass (but not on a routne, regular, or everyday bass) when the need to provde such care 21