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

27 arses from the actve duty or call to actve duty status of a covered mltary member 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; o o To enroll n or transfer to a new school or daycare faclty, a bologcal, adopted, or foster chld, a stepchld, or a legal ward of the covered mltary member, or a chld for whom the 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, when enrollment or transfer s necesstated by the actve duty or call to actve duty status of a covered mltary member; and To attend meetngs wth staff at a school or a daycare faclty, such as meetngs wth school offcals regardng dscplnary measures, parentteacher conferences, or meetngs wth school counselors, for a bologcal, adopted, or foster chld, a stepchld, or a legal ward of the covered mltary member, or a chld for whom the 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, when such meetngs are necessary due to crcumstances arsng from the actve duty or call to actve duty status of a covered mltary member; Fnancal and legal arrangements. o o To make or update fnancal or legal arrangements to address the covered mltary member s absence whle on actve duty or call to actve duty status, such as preparng and executng fnancal and healthcare powers of attorney, transferrng bank account sgnature authorty, enrollng n the Defense Enrollment Elgblty Reportng System (DEERS), obtanng mltary dentfcaton cards, or preparng or updatng a wll or lvng trust; and To act as the covered mltary member s representatve before a federal, state, or local agency for purposes of obtanng, arrangng, or appealng mltary servce benefts whle the covered mltary member s on actve duty or call to actve duty status, and for a perod of 90 days followng the termnaton of the covered mltary member s actve duty status; Counselng. To attend counselng provded by someone other than a health care provder for oneself, for the covered mltary member, or for the bologcal, adopted, or foster chld, a stepchld, or a legal ward of the covered mltary 22

28 member, or a chld for whom the 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, provded that the need for counselng arses from the actve duty or call to actve duty status of a covered mltary member; Rest and recuperaton. To spend tme wth a covered mltary member who s on short-term, temporary, rest and recuperaton leave durng the perod of deployment. Elgble employees may take up to fve days of leave for each nstance of rest and recuperaton; Post-deployment actvtes. o o To attend arrval ceremones, rentegraton brefngs and events, and any other offcal ceremony or program sponsored by the mltary for a perod of 90 days followng the termnaton of the covered mltary member s actve duty status; and To address ssues that arse from the death of a covered mltary member whle on actve duty status, such as meetng and recoverng the body of the covered mltary member and makng funeral arrangements; and Addtonal actvtes. To address other events whch arse out of the covered mltary member s actve duty or call to actve duty status provded that the partcpatng employer and employee agree that such leave shall qualfy as an exgency, and agree to both the tmng and duraton of such leave. Serous health condton s an llness, njury, mparment, or physcal or mental condton that nvolves: Inpatent care n a hosptal, hospce, or resdental medcal faclty; or Contnung treatment by a health care provder (a doctor of medcne or osteopathy who s authorzed to practce medcne or surgery, as approprate, by the state n whch the doctor practces, or any other person determned by the Secretary of Labor to be capable of provdng health care servces). Serous llness or njury s defned as an llness or njury ncurred n the lne of duty that may render the servce member medcally unft to perform hs or her mltary dutes. Son or Daughter s your bologcal, chld, adopted chld, stepchld, foster chld, a chld placed n your legal custody, or a chld for whch you are actng as the parent n place of the chld s natural blood related parent. Spouse s your husband or wfe. 23

29 NOTE: For complete nformaton regardng your rghts under FMLA, contact your partcpatng employer. Renstatement of Coverage After FMLA or USERRA Leaves of Absence If your coverage ends whle you are on an approved leave of absence under the FMLA or USERRA, your coverage wll be renstated on the day you return to Employment, f you return mmedately after your leave of absence ends, subject to all accumulated overall and annual maxmum benefts that were ncurred pror to the leave of absence. Certfcate of Credtable Coverage A Certfcate of Credtable Coverage (as descrbed n the Preexstng Excluson secton) wll be sent to you (or to any of your Dependents) by frst class mal wthn a reasonable tme after your or ther coverage under ths Plan ends. If you (or any of your Dependents) elect COBRA Coverage, another certfcate wll be sent to you (or them f COBRA Coverage s provded only to them) by frst class mal shortly after the COBRA Coverage ends for any reason. Extensons If you are lad off, granted a leave of absence or dsabled, coverage for you and your Dependents who were elgble at the tme of termnaton may contnue, provded monthly contrbutons are contnued by your Employer. After ths extenson perod s up, you and your Dependents are stll enttled to full COBRA rghts. The full descrpton of your COBRA benefts are descrbed n Secton 14 of ths Summary Plan Descrpton. To be elgble for extended benefts, you must apply to the Fund Offce at the tme your full tme employment ceases. All benefts coverage ends mmedately f the Plan s termnated or f your Employer ceases to be a contrbutng Employer to the Fund. 24

30 SECTION 4 MEDICAL BENEFITS If a beneft s covered under ths Plan and you are elgble for ths beneft, the Fund wll pay no more than the Allowable Charge. The Allowable Charge for a servce or supply 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. The Plan uses certan gudelnes to determne Allowable Charges. Some doctor or hosptal charges may request more than the Allowable Charge whch s permssble under our Plan. In that case, you are responsble for the addtonal amount over what the Plan pays. Whenever possble, dscuss the stuaton wth the doctor or surgeon n advance so that you wll have an dea what you mght have to pay. NOTIFICATION PROVISION Notfcaton s necessary for the Fund to evaluate the proposed treatments or servces for clncal elgblty for coverage before they are rendered. Hosptal servces, medcal servces, second surgcal opnons, and pre determnaton of benefts, as explaned below, all requre notfcaton. In general, your Provder needs to ntate the approval process by callng the Fund Offce before servces are rendered. You wll receve notfcaton by telephone or n wrtng no more than three (3) busness days after the Fund Offce receves all necessary medcal nformaton. To notfy the Fund of an admsson to a Hosptal, the Provder must contact the Fund Offce as follows: At least ten (10) days pror to the date of admsson for electve procedures; and Wthn two (2) busness days after an emergency admsson; Other procedures that must be notfed before benefts wll be pad are: 25

31 Chemotherapy treatment, whch s restrcted to non-hosptal, outpatent facltes only, unless the partcpant s clncal elgble for coverage n a hosptal. All drugs must be suppled by the Plan s contracted provder; MRIs; CAT scans; and Outpatent surgery. The followng nformaton must always be provded to the Fund to satsfy the notfcaton requrement. The Fund may also requre addtonal nformaton. Partcpant s & patent s nformaton: Name, Relatonshp to the Partcpant, Date of Brth and Address. Provder s nformaton: Provder ID number, Tax ID number, Dagnoss code and Procedure code. Falure to notfy for all servces that requre notfcaton wll cause the Fund to deny your request for benefts. In Network Benefts Medcal benefts are provded n two ways under the Plan: The Fund has made medcal, hosptal, optcal, prescrpton and dental benefts avalable to you and your Dependents through several preferred provder organzatons ( PPO ). Each Secton of ths SPD wll descrbe the PPO arrangement and the rules that you must follow to receve benefts under the Plan. If you choose to use a PPO provder, you generally wll pay only a Co Payment to the Physcan or Hosptal and the Deductble wll be waved, up to the maxmum beneft lmts and any exclusons. If you use a provder that s not part of the PPO, PPO benefts wll be payable for Non PPO provder servces ONLY f you receve treatment that would be a covered expense from a PPO provder and, as a result of that treatment, a covered expense s ncurred from a Non PPO provder pathologst; anesthesologst; cardologst; radologst; or emergency room physcan. Remember, the Plan covers the same servces whether you use a PPO provder or not, so servces that are not covered by the Plan wll not be covered just because you used a PPO provder. However, usng a PPO provder for covered servces saves you and the Fund money. Newborn and Mothers Health Protecton Act Under the Newborns and Mothers Health Protecton Act of 1996, group health plans and health nsurance ssuers generally may not restrct benefts for any hosptal length of stay n connecton 26

32 wth chldbrth for the mother or newborn chld to less than 48 hours followng a vagnal delvery, or less than 96 hours followng a cesarean secton. However, the mother s or newborn s attendng provder may, after consultng wth the mother, dscharge the mother or her newborn earler than 48 hours (or 96 hours as applcable). In any case, plans and ssuers may not, under federal law, requre that a provder obtan authorzaton from the plan or the ssuer for prescrbng a length of stay not n excess of 48 hours (or 96 hours). In no event wll an attendng provder nclude a plan, hosptal, managed care organzaton, or other ssuer. Benefts are payable n the same manner as for medcal or surgcal care of an llness, shown n the Schedule of Benefts and ths secton, and subject to the same maxmums. Women s Health and Cancer Rghts Act The federal Women s Health and Cancer Rghts Act contans coverage requrements for breast cancer patents who elect reconstructon n connecton wth a mastectomy. The law requres group health plans that provde mastectomy coverage to also cover breast reconstructon surgery and prostheses followng mastectomy. As requred by law, you are beng provded ths notce to nform you about these provsons. The law mandates that ndvduals recevng benefts for a medcally necessary mastectomy wll also receve coverage for: Reconstructon of the breast on whch the mastectomy has been performed; Surgery and reconstructon of the other breast to produce a symmetrcal appearance; and Prostheses and physcal complcatons from all stages of mastectomy, ncludng lymphedemas; n a manner determned n consultaton wth the attendng physcan and the patent. Ths coverage wll be subject to the same annual deductble and consurance provsons that currently apply to mastectomy coverage, and wll be provded n consultaton wth you and your attendng physcan. The Genetc Informaton Nondscrmnaton Act of 2008 The Genetc Informaton Nondscrmnaton Act of 2008 ( GINA ) and ERISA prohbt group health plans, ssuers of ndvdual health care polces, and employers from dscrmnatng on the bass of genetc nformaton. Accordngly, the Fund does not dscrmnate on the bass of genetc nformaton. In partcular, the Fund does not consder genetc nformaton to be a pre-exstng condton unless the genetc condton has already caused a dsease. The term genetc nformaton means, wth respect to any ndvdual, nformaton about: 27

33 An ndvdual s genetc tests; The genetc tests of famly members of an ndvdual; and An ndvdual s famly members manfested dseases or dsorders. A genetc test s an analyss of human chromosomes, DNA, RNA or protens that detects genotypes, mutatons, or chromosomal changes. For example, a genetc test ncludes a test to determne whether someone has the BRCA1 or BRAC2 varant ndcatng a predsposton to breast cancer, a test to determne whether someone has a genetc varant assocated wth heredtary nonpolyposs colon cancer and a test for a genetc varant for Huntngton s dsease. The Fund wll not requre that a partcpant undergo a genetc test. GINA also prohbts the Fund from requestng or requrng dsclosure of genetc nformaton of an ndvdual or a famly member of the ndvdual, except as specfcally allowed by GINA. To comply wth ths law, the Fund asks that you do not provde any genetc nformaton when respondng to any Fund request for medcal nformaton. 28

34 SECTION 5 OPTICAL BENEFITS FROM UNITED HEALTH CARE VISION SPECIAL NOTE: NOT ALL PLANS CONTAIN A VISION BENEFIT PLEASE CHECK THE APPENDIX Your vson s mportant to your health. Whether your vson s 20/20 or less than perfect, everyone should receve regular vson care. The UntedHealthcare Vson beneft s beng offered as a part of our commtment to your well-beng. UntedHealthcare Vson provdes affordable, qualty vson care, natonwde. Through our natonal provder network, you wll receve a comprehensve vson examnaton, as well as eyeglasses (lenses and frames), or contact lenses n leu of eyeglasses. Carefully revew the summary of your vson beneft. If you have any questons or concerns about your vson optons, please call UntedHealthcare Vson s Customer Servce Center. (1-800) or TDD (1-800) for the hearng mpared Monday - Frday 8:00 a.m. to 11:00 p.m. EST Saturday 9:00 a.m. to 6:30 p.m. EST. Schedule of Benefts Exam once every 12 months Lenses once every 12 months Frames once every 24 months Contacts* once every 12 months *(n leu of lenses & frames) Exam Co-pay $10 Materals Co-pay $0 Wth UntedHealthcare Vson, you are able to vst any provder you choose, but you maxmze your savngs when you vst a network provder. How to locate a network provder: Clck on Provder Locator on the top left porton of the screen. Clck on whether you are a Current Member or a Future Member. Then enter your search optons, and select a provder near you. The onlne Provder Locator offers door-to-door drectons to your selected network provder s offce. Other servces, such as clam status trackng, order trackng, and answers to frequently asked questons, are also avalable onlne. You may also fnd a network provder through UntedHealthcare s Interactve Voce Response (IVR) system at (1-800) Smply follow the voce prompts. Once you ve chosen a network provder, call them to schedule your appontment. Let your provder know you have UntedHealthcare Vson coverage, and gve your prmary nsured s unque dentfcaton number and the patent s name and date of brth. 29

35 Network Benefts Examnaton ($10 co-pay, once every 12 months): Receve a comprehensve eye examnaton from a state-lcensed optometrst or ophthalmologst, covered-n-full, after exam co pay. Materals ($0 co pay): The materals co pay s a sngle payment that apples to the entre purchase of eyeglasses (lenses and frames), or contacts n leu of eyeglasses. Par of Lenses (once every 12 months) Lens Optons Frames (once every 12 months) Contact Lenses n Leu of Eyeglasses (once every 12 months) Out-of-Network Beneft If you choose an out-of-network provder, you wll be rembursed up to: Exam $40 Lenses: Sngle vson $40 Bfocal $60 Trfocal $80 Lentcular $80 Frames $45 Contact Lenses n Leu of Eyeglasses (lenses & frame) Electve $105* Necessary** $210 * Less any network fttng/evaluaton fee. ** Necessary contact lenses are determned at the provder s dscreton for one or more of the followng condtons: followng cataract surgery wthout ntraocular lens mplant; to correct extreme vson problems that cannot be corrected wth spectacle lenses; wth certan condtons of ansometropa; wth certan condtons of keratoconus. If your provder consders your contacts necessary, you should ask your provder to contact UntedHealthcare Vson concernng the rembursement that UntedHealthcare Vson would make before you purchase such contacts. If you vst an out-of-network provder, you wll need to send your temzed recepts, wth the prmary-nsured s unque dentfcaton number and the patent s name and date of brth, to: UntedHealthcare Vson Clams Department P.O. Box Salt Lake Cty, UT FAX: (248) Recepts for servces and materals purchased on dfferent dates must be submtted at the same tme to receve rembursement. Recepts must be submtted wthn 12 months of the date of servce. 30

36 Laser Vson Correcton You may receve access to dscounted laser vson correcton procedures from numerous provder locatons throughout the Unted States. To fnd a partcpatng laser vson correcton surgeon n your area, vst our Web ste at or call (1-888) Your $105 contact lens allowance s appled to the fttng/evaluaton fee and the purchase of contact lenses. For example, f the fttng/evaluaton fee s $30, you wll have $75 towards the purchase of contact lenses. The allowance may be separated at some retal chan locatons between the examnng physcan and the optcal store. Benefts are avalable every 12 months (dependng on the beneft frequency), based on last date of servce. UntedHealthcare Vson now offers an Addtonal Materals Dscount Program. At a partcpatng network provder you wll receve a 20% dscount on an addtonal par of eyeglasses or contact lenses. 31

37 SECTION 6 PRESCRIPTION BENEFITS Servces and Supples Provded to Covered Persons By 4D Pharmacy Management Admnstrators. Prescrpton drug benefts are provded to partcpants through 4D Pharmacy Management Admnstrators. To use ths beneft, smply present your UNITED BENEFIT FUND/Medcal Card at any 4D partcpatng pharmacy. Partcpatng pharmaces wll dsplay a green and whte 4D decal n the store wndow or near the pharmacy areas. If you have any questons regardng whether your pharmacy or any other pharmacy n your area partcpates, please feel free to call Express Scrpts toll free Customer Servce Department at (877) Your pharmacst wll dspense your medcaton, submt the clam through the 4D system, and notfy you of the amount that you are requred to pay. There s no guarantee that the Fund wll cover the whole amount of the pharmacy charge and you are responsble for the balance, f any. Whenever possble, you should dscuss prescrpton drug charges wth your doctor or pharmacsts n advance so that you are aware of any porton that wll be your responsblty to pay. Schedule of Benefts and Prescrpton Co-payments. Covered Persons must pay for a part of ther prescrpton drug benefts. For each prescrpton at a partcpatng pharmacy or by mal order, you must pay the Co-Payment lsted below. The Co- Payment s dfferent for generc or brand name prescrpton drugs. The Plan allows for the dspensng of up to a 30-day supply as prescrbed by the Physcan. The mal order program was desgned to allow Covered Persons to receve large quanttes of mantenance medcaton (e.g., heart medcaton, blood pressure medcaton, dabetc medcaton, etc.). Covered Persons may obtan up to a 90-day supply of ther prescrpton. The maxmum beneft for covered prescrpton drug expenses ncurred by a Covered Person s entre famly durng each Plan Year s descrbed n the Appendx of Benefts to ths Summary Plan Descrpton. Call the Fund Offce for advce on how to preserve and maxmze your annual drug beneft. COVERED ITEMS Federal legend (prescrpton) drugs State restrcted (prescrpton) drugs Anabolc sterods Bee stng kts Cholesterol lowerng drugs Compounded prescrptons Cough and cold preparatons Dexedrne/Rtaln under age Dabetc drugs (oral) 32

38 Dabetc lancets Dabetc test strps Immune alterng drugs Insuln on prescrpton Non-sterodal ant-nflammatory drugs Pre-natal vtamns Retn-A under age 25 Syrnges and needles EXCLUSIONS In addton to the Exclusons and Lmtatons applcable to all benefts under the Plan (see Secton 10), Prescrpton Benefts do not cover: Drugs or medcatons avalable over-the-counter for whch state or federal laws do not requre a prescrpton. Any drugs that are labeled as expermental or nvestgatonal. Unted States Food and Drug Admnstraton (FDA) approved prescrptons drugs used for purposes other than those approved by the FDA unless the drug s recognzed for the treatment of the partcular ndcaton n one of the standard reference compenda, such as The Unted States Pharmacopoea (USP) Drug Informaton, the Amercan Medcal Assocaton Drug Evaluatons, The Amercan Hosptal Formulary Servce Drug Informaton, the Physcan Drug Reference (PDR)) or n current medcal lterature. Medcal lterature means scentfc studes publshed n peer-revewed natonal professonal medcal journals. Drugs newly approved by the FDA, pror to ther revew by the Fund s Pharmacy and Therapeutcs Commttee. Prescrpton and nonprescrpton supples (such as ostomy supples), devces and applances other than syrnges used n conjuncton wth njectable medcatons. Allergy serums Anorexants Dagnostc drugs Federal legend oral contraceptves (except f clncal elgblty for coverage) Federal legend smokng cessaton products Federal legend vtamns (adult) Fertlty drugs (njectables) Fertlty drugs (oral) Genetcally engneered drugs Imtrex (refll vals) Imtrex auto njector Injectables Injectable contraceptves Lupron Male sexual dysfuncton drugs 33

39 Rhogam Rogane and smlar drugs Serums Yohmbne and smlar drugs Prescrptons covered wthout charge under federal, state or local programs, ncludng Worker s Compensaton Any charge for the admnstraton of a drug or nsuln Unauthorzed reflls Immunzaton agents, bologcal serums, blood or plasma Medcaton for a Covered Person confned to a rest home, nursng home, santarum, extended care faclty, hosptal or smlar entty Any charge where the usual and customary charge s less than the Covered Person s co-payment Any charge above the usual and customary, advertsed, or posted prce, whchever s less than the Allowable Charge. Any mental health drug whch s prescrbed for to treat any mental or psychologcal health condton. 34

40 SECTION 7 COORDINATION OF BENEFITS Members of a famly may be covered under more than one health program or nsurance contract. Ths Coordnaton of Benefts provson covers all benefts except Death Benefts and s ncluded n ths Summary Plan Descrpton to ensure that the Fund does not make duplcate payments, whch can ncrease the cost of your health coverage. Ths Coordnaton of Benefts apples to smlar medcal benefts payable under other health programs or nsurance contracts, ncludng: (a) any group nsurance coverage, (b) an Employer-sponsored Blue Cross Blue Sheld, or other pre-payment coverage, (c) any coverage under labor-management trusteed Plans or Employee benefts organzaton Plans, ncludng ths Plan, (d) any coverage under government programs, (e) any coverage requred or provded by statute (except Medcad), (f) any mandatory "no-fault" coverage, and (g) student coverage obtaned or offered by an educatonal nsttuton. One of the two or more Plans s consdered the Prmary Plan and the others are the Secondary Plan(s). The Prmary Plan pays benefts frst, wthout consderaton of the other Plans. The Secondary Plans then make up the dfference up to 100% of the Allowable Charges for each procedure. Ths Plan wll never pay more than t would have pad wthout ths provson. You must provde the Fund Offce wth any nformaton necessary for admnsterng ths provson. To determne whch coverage s prmary and whch s secondary, the followng rules apply: The plan wthout a coordnaton of benefts provson smlar to ths one wll be the prmary plan. The plan n whch the patent s the partcpant (rather than a dependent) wll be the prmary plan. If your dependent chld s covered under both your spouses and your health plans, the prmary coverage wll be determned by the followng factors: The plan of the parent whose brthday falls frst durng the year (regardless of year of brth) wll pay frst. If you and your spouse share the same brthday, the plan coverng the parent longer wll be prmary. If the other plan does not have a brthday provson and uses gender to determne prmary responsblty, the father s plan wll be prmary. If you and your spouse are dvorced or separated, and there s no court decree gvng fnancal responsblty for your chld s health care expenses to one parent, your dependent chld wll receve prmary coverage under the custodal parent s health coverage program. The plan of the 35

41 parent that was gven fnancal responsblty for the chld s health care by decree of the court s the Prmary Plan. If you a n d / or your spouse remarres, the followng order s used to determne prmary responsblty for your dependent chld s health coverage program: The parent wth legal custody The spouse of the parent wth legal custody The parent wthout legal custody The spouse of the parent wthout legal custody A patent s health coverage as an actvely-employed partcpant or as a dependent of an actvely employed partcpant s Prmary over other health care programs that they may have as ether a lad-off employee, a retred employee, or a dependent of a lad-off employee or a retred employee. If the other health care coverage s prmary, then ths rule wll not apply. If none of the prevous rules apply, the plan that has covered the patent the longest wll be the Prmary Plan. If both a husband and wfe are partcpants of ths Plan, the beneft s calculated frst as f ths Plan was the Prmary Plan and then as f ths Plan was secondary. Ths wll allow the same coverage as f the husband and wfe were covered as Employees n two dfferent plans. If ths Plan s the Secondary Plan and the Prmary Plan s a health mantenance organzaton or preferred provder organzaton, then ths Plan assumes that the Prmary Plan pays the full value of the servces and ths Plan s the Secondary Plan only for any Deductble or Co- Payment under the Prmary Plan. If you have coverage through your work under an HMO and ths Plan s the Secondary Plan for you as a Dependent, you must follow the rules of the HMO n order to have remanng balances consdered for payment by the Plan as the Secondary Plan. If you go outsde of your HMO for servces (or otherwse fal to follow the rules of the HMO), and then submt the bll to ths Plan for payment, t wll be dened. For purposes of coordnatng benefts, an HMO s treated the same as any other plan. If you fal to follow the rules of any Prmary Plan, ths Plan wll not pay benefts as ether prmary or secondary. The Fund also has the rght to collect any excess payment drectly from the partes nvolved, from the other plan, or by an offset aganst any future beneft payment from the Fund on the Partcpant or Dependent s behalf, f he or she faled to notfy the Fund Offce of the avalablty of other Partcpant s or health coverage. Ths rght of offset does not keep the Fund from recoverng erroneous payments n any other manner. To ensure that the Plan coordnates benefts wth any other health plan coverage you have, you must keep the Plan nformed of any and all coverage for you and your Dependents. 36

42 If the Fund has made payment of any amount that s n excess of that permtted by these Coordnatng of Benefts rules, the Fund Admnstrator s Offce has the rght to recover such amount from any party who has receved such overpayment by requestng a refund from such party, credtng other clams aganst the amount owed to the Fund, or takng legal acton. COORDINATION WITH MEDICARE: Generally, anyone age 65 or older s enttled to Medcare coverage. Anyone under age 65 who s enttled to Socal Securty Dsablty Income Benefts s also enttled to Medcare coverage after a watng perod. Medcare ncludes hosptal nsurance benefts (Part A) as well as supplementary medcal nsurance (Part B). In general, f you or a dependent are enrolled n the Fund and n Medcare, the Fund wll provde all benefts due under the partcpant s Plan. Medcare may then pay any remanng charges, f such charges are covered under Medcare. In techncal terms, the Fund s prmary (pays frst) for your covered medcal and hosptal expenses, whle Medcare s secondary (pays second). Rule for Small Employers of Partcpants Age 65 and Over and Ther Dependents: If you work for an Employer wth fewer than 20 Employees for each workng day n each of 20 or more calendar weeks n the current or precedng calendar year and the Fund has obtaned an excepton for your Employer, then Medcare wll be prmary for you and your Dependents. The Fund wll notfy you f Medcare s prmary because your employer has obtaned ths excepton. Dsabled Employees or Dsabled Dependents Under 65: Ths Plan s prmary for Employees or ther Dependents who are under age 65 and for Employees or ther Dependents who have a Socal Securty Dsablty Award and are enttled to Medcare benefts due to Total Dsablty (other than End Stage Renal Dsease). End Stage Renal Dsease: If, whle you are n Employment, you or any of your Dependents become enttled to Medcare because of End Stage Renal Dsease (ESRD), ths Plan pays prmary and Medcare pays secondary for 30 months startng wth the earler of (1) the month n whch Medcare ESRD coverage begns; or (2) the frst month n whch the ndvdual receves a kdney transplant. Then, startng wth the 31st month after the start of Medcare coverage, Medcare pays prmary and ths Plan pays secondary. Medcad: If you are covered by both ths Plan and Medcad, ths Plan s prmary and Medcad pays secondary. CHAMPUS (Cvlan Health and Medcal Program of the Unformed Servces): If you are covered by both ths Plan and CHAMPUS, ths Plan pays as prmary and CHAMPUS pays secondary. 37

43 Other Coverage Provded by State or Federal Law: If you are covered by both ths Plan and any other coverage provded by any other state or federal law, the coverage provded by any other state or federal law pays frst and ths Plan pays second. 38

44 SECTION 8 SUBROGATION Were you or your Dependent njured n an accdent for whch someone else s lable? If so, that person or hs/her nsurance may be responsble for payng your or your Dependent s related medcal and dsablty expenses and these expenses would not be covered under the Plan. However, watng for a thrd party to pay for these njures may be dffcult; recovery from a thrd party may take a long tme (you may have to go to court) and your credtors may not wat patently. Because of ths, as a servce to you, the Fund wll advance you or your Dependent beneft payments related to such an accdent based on the Fund s rghts of rembursement and subrogaton. In order for you to be enttled to ths beneft, you and/or the Dependent are requred to notfy the Fund wthn ten (10) days of any accdent or Injury for whch someone else may be lable. Ths deadlne s mportant, and your falure to comply wth t wll result n a denal of any clam for benefts for an njury that someone else may be lable. Further, the Fund must be notfed wthn ten (10) days of the ntaton of any lawsut arsng out of the accdent and of the concluson of any settlement, judgment or payment relatng to the accdent n any lawsut ntated to protect the Fund s clams. If you or your Dependent receve any beneft payments from the Fund for an Injury or Illness and you or your Dependent recover any amount from any thrd party or partes n connecton wth such Injury or Illness, you or your Dependent must remburse the Fund from that recovery the total amount of all beneft payments the Fund made or wll make on your or your Dependent s behalf n connecton wth such Injury or Illness. Ths s referred to as the Fund s rght of rembursement. In addton, f you or your Dependent receve any beneft payments from the Fund for any Injury or Illness, the Fund s subrogated to all rghts of recovery avalable to you or your Dependent arsng out of any clam, demand, cause of acton or rght of recovery whch has accrued, may accrue or whch s asserted n connecton wth such Injury or Illness, to the extent of any and all related beneft payments made or to be made by the Fund on your or your Dependent s behalf. Ths means that the Fund has an ndependent rght to brng an acton n connecton wth such Injury or Illness n your or your Dependent's name and also has a rght to ntervene n any such acton brought by you or your Dependent, ncludng any acton aganst an nsurance carrer under any unnsured or under-nsured motor vehcle polcy. Ths s referred to as the Fund s rght of subrogaton. The Fund's rghts of rembursement and subrogaton apply regardless of the terms of the clam, demand, rght of recovery, cause of acton, judgment, award, settlement, compromse, nsurance or order, regardless of whether the thrd party s found responsble or lable for the Injury or Illness, and regardless of whether you or your Dependent actually obtan the full amount of such judgment, 39

45 award, settlement, compromse, nsurance or order. The Fund's rghts of rembursement and subrogaton provde the Fund wth frst prorty to any and all recovery n connecton wth the Injury and Illness, whether such recovery s full or partal and no matter how such recovery s characterzed, why or by whom t s pad, or the type of expense for whch t s specfed. Such recovery ncludes amounts payable under your or your Dependent s own unnsured motorst nsurance, under-nsured motorst nsurance, or any medcal pay or no-fault benefts payable. The "make-whole" doctrne does not apply to the Fund's rght of rembursement and subrogaton. The Fund s rghts of rembursement and subrogaton are for the full amount of all related benefts payments; ths amount s not offset by legal costs, attorneys' fees or other expenses ncurred by you or your Dependent n obtanng recovery. Consstent wth the Fund s rghts set forth n ths secton, f you or your Dependent submt clams for or receve any beneft payments from the Fund for an Injury or Illness that may gve rse to any clam aganst any thrd-party, you and/or your Dependent wll be requred to execute a Subrogaton, Assgnment of Rghts, and Rembursement Agreement affrmng the Fund s rghts of rembursement and subrogaton wth respect to such beneft payments and clams. Your falure to execute ths agreement wll result n a denal of ths beneft. Ths Agreement must also be executed by you or your Dependent's attorney, f applcable. Payments are not payable unless you sgn a Subrogaton Agreement, you or your Dependent s clams wll not be consdered fled and wll not be pad untl the fully sgned Agreement s receved by the Fund. Ths means that, f you fle a clam and your Subrogaton Agreement s not receved promptly, the clam wll be untmely and wll not be pad f the sxty day perod for flng clams passes (see Secton 11) before your Subrogaton Agreement s receved. Under ths provson, you and/or your Dependent are oblgated to take all necessary acton and cooperate fully wth the Fund n ts exercse of ts rghts of rembursement and subrogaton, ncludng notfyng the Fund of the status of any clam or legal acton asserted aganst any party or nsurance carrer and of you or your Dependent s recept of any recovery. You or your Dependent also must do nothng to mpar or prejudce the Fund s rghts. For example, f you or your Dependent chooses not to pursue the lablty of a thrd party, you or your Dependent may not wave any rghts coverng any condtons under whch any recovery could be receved. If you are asked to do so, you must contact the Fund Offce mmedately. If you or your Dependent refuse to remburse the Fund from any recovery or refuse to cooperate wth the Fund regardng ts subrogaton or rembursement rghts, the Fund has the rght to recover the full amount of all benefts pad by methods whch nclude, but are not necessarly lmted to, offsettng the amounts pad aganst your future beneft payments under the Plan. Non-cooperaton ncludes the falure of any party to execute a Subrogaton, Assgnment of Rghts, and Rembursement Agreement and the falure of any party to respond to the Fund s nqures concernng the status of any clam or any other nqury relatng to the Fund s rghts of rembursement and subrogaton. 40

46 SECTION 9 WORKER S COMPENSATION CASES No benefts wll be pad by ths Fund for an accdent or Illness n any way connected wth Employment. If you have a Work-Related accdent or Illness, notfy your Employer mmedately and fle a Worker s Compensaton clam wth your Employer. Certan Illnesses lke hernas, varcose vens, allergy to chemcals or materals may occur due to the nature of the work n the ndustry. Snce Worker s Compensaton offers certan protectons f you have such an Illness, dscuss your job actvtes wth the doctor to determne f t could be Work-Related. Falure to fle a Worker s Compensaton clam could mean the loss of benefts whch mght otherwse protect you aganst medcal costs or loss of earnngs resultng from a Work-Related accdent or Illness. 41

47 SECTION 10 EXCLUSIONS DENIAL OR LOSS OF BENEFITS In addton to the exclusons and lmtatons set forth n the varous beneft sectons of ths booklet, the followng crcumstances may cause loss of benefts and/or charges and expenses whch are not payable from the Fund. Benefts are dened when t s determned that, at the tme the clam was ncurred, you or your Dependent, as the case may be: Were not elgble for benefts clamed. Faled to submt requred evdence to substantate the clam. Faled to apply or make tmely applcaton for benefts. Made ntentonal materal msstatements n connecton wth elgblty or any payments made n relance on such msstatement. Omtted facts or materal statements as to other nsurance avalable to you and your Dependents. Each beneft secton of ths SPD may contan lmtatons and exclusons that apply to that partcular beneft. The followng exclusons and lmtatons apply to all benefts under the Plan except as otherwse specfcally ndcated n ths Plan. Benefts under the Plan do not nclude: Any servce or supply that does not meet the plan s gudelne for clncal elgblty for Coverage. Genetc testng or counselng, unless used to treat the sckness or njury of a covered person or used n the treatment of a hgh rsk pregnancy. Servces that are not Clncal elgblty for coverage: All servces, ncludng physcal examnatons, unrelated to an Illness or Injury are excluded; as s all or any part of a hosptal stay related to an unnecessary servce ncludng any servces provded durng that perod (except where otherwse provded). Hosptalzaton furnshed under federal, state and other laws for whch the government program s prmary. Care n a veteran s faclty or a Hosptal operated by federal or state government, to the extent permtted by law. Hosptalzaton for whch no charge s made. Confnement prmarly for custodal or for rest cures or, for long-term care. Admssons due to llegal Surgery or for dentstry (except as the result of an accdent subject to the preexstng condton exclusons above). Servces of prvate or specal nurses or servces generally provded on an outpatent bass. In the event that the Plans beneft lmt s reached. 42

48 For any servces receved by you or your dependent(s) wthout fllng out the health questonnare upon new membershp (Obtanable at the Fund Offce). If a partcpant ntentonally omts or msrepresents health nformaton n ther enrollment applcaton. If such ntentonal omsson or msrepresentaton s dscovered after the partcpant enrolls, such partcpant wll be classfed as a non-qualfyng partcpant and the Fund wll not pay any of that partcpant s clams. In connecton wth an Injury or Illness arsng out of a procedure, surgery or treatment performed by a Doctor/Faclty/Provder that causes harm to a partcpant. In connecton wth an njury or Illness arsng out of or n the course of Employment for whch benefts are payable under Worker s Compensaton Laws (benefts may be dened f you or your Dependent fal to prosecute a Worker s Compensaton clam). Whch are not consstent wth the dagnoss and treatment of a condton. For servces, supples and treatment unless performed or prescrbed as necessary by a legally lcensed Physcan. For whch Medcare benefts are payable (or would be payable f the patent had enrolled n Medcare when frst elgble). See Secton 7. For Injures or Illnesses arsng from an automoble, motorcycle or related accdent f personal njury protecton coverage or no-fault benefts are recoverable under state law, even f coverage s dened by the carrer for any reason such as, for example, because you or your Dependent are njured whle n an ntoxcated condton, or there s a no-fault nsurance Deductble. No Fault Insurance: No Fault s prmary. If a case s dened because of llegal substance use or DUI, then fund wll also not cover any deductble or dollar amount over the nsured s lmt. No coverage f No nsurance n place as requred by New York or other state laws. In connecton wth plastc Surgery for cosmetc purposes (except as a result of accdent subject to the preexstng condton excluson above) or psychologcal reasons. In connecton wth dental work or treatment (except as a result of accdent or njury subject to the preexstng condton excluson above) other than the dental benefts n effect. Charges that the member s not legally requred to pay. For any Expermental procedures, servces, or drugs. For example, Hosptal stays for any procedure that s no longer generally regarded as effectve or t s Expermental n the sense that ts effectveness s not generally recognzed. For any servces rendered by the clamant s Famly Member. Injury arsng out of or n the course of any employment for wage or proft. In connecton wth an Illness or Injury that was self-nflcted or resulted from the person partcpatng n an llegal act, such as crme, rot or nsurrecton or care or treatment whle n prson. In connecton wth or resultng from alcohol abuse or llegal use of drugs. In connecton wth an Illness or Injury that s ncurred or s a result of a declared or undeclared war or mltary servces. 43

49 Any medcal procedure, surgery, or treatment whch was requred as a result of the medcal provder s malpractce, neglgence, or malfeasance. For prescrpton drugs or vtamns other than those admnstered durng a Hosptal stay (Except where otherwse provded). No benefts wll be pad n connecton wth any Illness that may be caused by a partcpant s voluntary nvolvement n the physcal practce of ngestng non prescrbed drugs and/or foods known to be dangerous to humans and/or deleterous to one s physcal well- beng and/or the contnual practce of placng oneself n an unhealthy envronmental surroundng. Recreatonal or lesure travel, even f recommended by a doctor. Expenses for the treatment of nfertlty and ts complcatons, ncludng drugs, procedures or devces to acheve fertlty, n vtro fertlzaton, low tubal transfer, artfcal nsemnaton, embryo transfer, gamete transfer, zygote transfer, surrogate parentng, donor semen, adopton, and reversal of sterlzaton procedures. Transportaton charges to and from health care provders except as specfed n ths Plan booklet. Servces related to gender change. Care for surrogate mothers. Coverage for any weght loss or control. Coverage for Gastrc Bypass or any other surgcal procedure unless clncal elgblty for coverage. Coverage for har loss. Coverage for marrage or famly counselng. Except as otherwse specfcally covered, expenses related to preventon of pregnancy, ncludng, but not lmted to, condoms and daphragms, and expenses furnshed n connecton wth the pregnancy of a Dependent chld, ncludng termnaton of pregnancy. Membershp fees, dues or any other charges n connecton wth recreatonal facltes, ftness centers, det, stress management centers or nutrtonal centers, even f prescrbed or recommended by a Physcan. Preparaton of medcal reports or clam forms, malng or handlng expenses, charges for broken appontments, photocopyng fees and any and all telephone calls between a Physcan or other Health Care Provder and any patent, other Health Care Provder, or any representatve of the Plan for any purpose whatsoever. Educatonal servces, supples or equpment, ncludng, but not lmted to computers, software, prnters, books, tutorng, vsual ads, audtory ads, speech ads, etc., even f they are requred because of an Injury or Illness. For physcal examnatons and testng requred for employment, government or regulatory purposes, nsurance, school, camp, recreaton, sports, or by any thrd party. For prayer, relgous healng, sprtual healng, naturopathc, naprapathc, homeopathc servces or supples, hypnoss, hypnotherapy, bofeedback, Massage therapy, Rolfng and related servces. 44

50 Expenses for ncotne gum or patches, or other products, servces or programs ntended to assst an ndvdual to stop smokng. Coverage for mental health and psychologcal servces and/or the treatment of mental health or psychologcal condtons. Wth respect to any njury whch s otherwse covered by the Plan, the Plan wll not deny benefts provded for treatment of the njury f the njury results from an act of domestc volence or a medcal condton caused by domestc volence (ncludng both physcal and mental health condtons). Any partcpant who mproperly collects benefts from the Fund, based on msstatement or msrepresentaton, wll be legally lable for the return to the Fund any mproper Fund payments. In addton the partcpant wll be subject to suspenson of all benefts. The Mental Health Party Act Ths Plan does not cover Mental health and substance abuse dsorder benefts. 45

51 SECTION 11 HOW TO CLAIM YOUR BENEFITS Flng Medcal Clams All clams must be fled at the Fund Offce on the approprate form. A Partcpant may obtan the necessary forms for flng a clam by telephone or wrtng to the Fund Offce at Metropoltan Ave. Mddle Vllage, New York The telephone number s (718) All necessary nformaton must accompany your clam n order for the Fund to process the clam effectvely ncludng all medcal notes whch were generated as a result of the medcal treatment and/or care. There s a sxty (60) day tme lmt from the date servces were receved for flng medcal clams. Any clam receved after ths tme lmt wll be dened. IMPORTANT NOTE: You and your Dependents should be aware that you or your medcal provder s falure to fle the clam for benefts wthn the sxty (60) day deadlne wll mean that your clam s late and cannot be pad by the Fund. Consequently, the medcal provder may seek to collect any money t s owed drectly from you. It s therefore very mportant that you make sure that you or your provder submt your medcal clams on tme. Addtonally, f the Fund denes or partally denes any clam for benefts that you do make, you or your provder must appeal the denal wthn the one hundred and eghty (180) days as explaned n Secton 12 f you wsh to contest the Fund s decson. A falure to request ths revew bnds you and your provder to accept the amount, f any, that the Fund has already pad regardng the clam. The Fund cannot pay any clams after the tme to appeal a denal has elapsed and the medcal provder may then seek to collect any money t s owed drectly from you. You must fle a completed clam form each tme a bll s submtted. If you wsh us to pay the provder of servces drectly, you must provde us wth your orgnal sgnature (not a photocopy) authorzng us to do so. Please be sure to ndcate on the clam form f there s an Injury nvolved, a lawsut or thrd party recovery, or any change n your martal status, you or your spouse s employment status or elgblty for other medcal coverage. You wll receve a Plan dentfcaton (ID) card whch wll contan mportant nformaton, ncludng clam flng drectons and contact nformaton. Your ID card wll show your PPO network, and your Cost Contanment Program admnstrator. At the tme you receve treatment, show your ID card to your provder of servce. In most cases, your provder wll fle your clam for you. You may fle the clam yourself by submttng the requred nformaton to: UMR, Inc. 333 West Vne Street Sute 500 Lexngton, KY (877)

52 Most clams under the Plan wll be post servce clams. A post servce clam s a clam for a beneft under the Plan after the servces have been rendered. Post servce clams must nclude the followng nformaton n order to be consdered fled wth the Plan: A Form HCFA or Form UB92 completed by the provder of servce, ncludng: The date of servce; The name, address, telephone number and tax dentfcaton number of the provder of the servces or supples; The place where the servces were rendered; The dagnoss and procedure codes; The amount of charges (ncludng PPO network reprcng nformaton); The name of the Plan; The name of the covered employee; and The name of the patent. A call from a provder who wants to know f an ndvdual s covered under the Plan, or f a certan procedure or treatment s a covered expense before the treatment s rendered, s not a clam snce an actual clam for benefts s not beng fled wth the Plan. Lkewse, presentaton of a prescrpton to a pharmacy does not consttute a clam. Procedures for All Clams The procedures outlned below must be followed by covered persons to obtan payment of health benefts under ths Plan. Health Clams All clams and questons regardng health clams should be drected to the thrd party admnstrator. The Plan Admnstrator shall be ultmately and fnally responsble for adjudcatng such clams and for provdng full and far revew of the decson on such clams n accordance wth the followng provsons and wth ERISA. Benefts under the Plan wll be pad only f the Plan Admnstrator decdes n ts dscreton that the covered person s enttled to them. The responsblty to process clams n accordance wth the summary plan descrpton has been delegated to the thrd party admnstrator. Each covered person clamng benefts under the Plan shall be responsble for supplyng, at such tmes and n such manner as the Plan Admnstrator n ts sole dscreton may requre, wrtten 47

53 proof that the expenses were ncurred or that the beneft s covered under the Plan. If the Plan Admnstrator n ts sole dscreton determnes that the covered person has not ncurred a covered expense or that the beneft s not covered under the Plan, or f the covered person fals to furnsh such proof as s requested, no benefts are payable under the Plan. Under the Plan, there are three types of clams: Pre-servce (Non-urgent), Concurrent Care and Post-servce. Pre-servce Clams A pre-servce clam s a clam for a beneft under the Plan where the Plan condtons recept of the beneft, n whole or n part, on approval of the beneft n advance of obtanng medcal care. A pre-servce urgent care clam s any clam for medcal care or treatment wth respect to whch the applcaton of the tme perods for makng non-urgent care determnatons could serously jeopardze the lfe or health of the covered person or the covered person s ablty to regan maxmum functon, or, n the opnon of a physcan wth knowledge of the covered person s medcal condton, would subject the covered person to severe pan that cannot be adequately managed wthout the care or treatment that s the subject of the clam. It s mportant to remember that, f a covered person needs medcal care for a condton whch could serously jeopardze hs lfe, there s no need to contact the Plan for pror approval. The covered person should obtan such care wthout delay and then later fle the clam as a Post-Servce clam. Further, f the Plan does not requre the covered person to obtan approval of a specfc medcal servce pror to gettng treatment, then there s no pre-servce clam. The covered person smply follows the Plan s procedures wth respect to any notce whch may be requred after recept of treatment, and fles the clam as a post-servce clam. Concurrent Clams. A concurrent clam arses when the Plan has approved an on-gong course of treatment to be provded over a perod of tme or number of treatments, and ether: The Plan Admnstrator determnes that the course of treatment should be reduced or termnated; or The covered person requests extenson of the course of treatment beyond that whch the Plan Admnstrator has approved. Snce the Plan does not requre that the covered person obtan approval of a medcal servce n an urgent care stuaton pror to gettng treatment, there s no need to contact the Plan Admnstrator to request an extenson of a course of treatment n an urgent care stuaton. The covered person should smply follow the Plan s procedures wth respect to any notce whch may be requred after recept of treatment, and fle the clam as a post-servce clam. 48

54 Post-Servce Clams. A post-servce clam s a clam for a beneft under the Plan after the servces have been rendered. When Health Clams Must Be Fled Post-servce health clams must be fled wth the clams admnstrator wthn sxty 60 days of the date charges for the servce were ncurred. In no event wll the tme lmt be extended beyond sxty (60) days from the date the charges were ncurred except n the case of legal ncapacty of the covered person. Benefts are based upon the Plan s provsons at the tme the charges were ncurred. Late Clams wll be dened. A pre-servce clam (ncludng a concurrent clam that also s a pre-servce clam) s consdered to be fled when the request for approval of treatment or servces s made and receved by the thrd party admnstrator n accordance wth the Plan s procedures. Upon recept of the requred nformaton, the clam wll be deemed to be fled wth the Plan. The thrd party admnstrator wll determne f enough nformaton has been submtted to enable proper consderaton of the clam. If not, more nformaton may be requested as provded heren. Ths addtonal nformaton must be receved by the thrd party admnstrator wthn 45 days from recept by the covered person of the request for addtonal nformaton. Falure to do so may result n clams beng declned or reduced. Tmng of the Fund s Clam Decsons The Plan Admnstrator shall notfy the covered person, n accordance wth the provsons set forth below, of any adverse beneft determnaton (and, n the case of pre-servce clams and concurrent clams, of decsons that a clam s payable n full) wthn the followng tmeframes: Pre-servce Non-urgent Care Clams: o o If the covered person has provded all of the nformaton needed to process the clam, the Fund shall notfy the partcpant of the Fund s decson wthn a reasonable perod of tme approprate to the medcal crcumstances, but not later than 15 days after recept of the clam, unless an extenson has been requested, then pror to the end of the 15-day extenson perod. If the covered person has not provded all of the nformaton needed to process the clam, then the covered person wll be notfed as to what specfc nformaton s needed as soon as possble, but not later than 5 days after recept of the clam. The covered person wll be notfed of a determnaton of benefts n a reasonable perod of tme approprate to the medcal crcumstances, ether pror to the end of the extenson perod (f addtonal nformaton was requested durng the ntal processng perod), 49

55 or by the date agreed to by the Plan Admnstrator and the covered person (f addtonal nformaton was requested durng the extenson perod). Concurrent Clams: o Plan Notce of Reducton or Termnaton. If the Plan Admnstrator s notfyng the covered person of a reducton or termnaton of a course of treatment (other than by Plan amendment or termnaton), the Fund shall make the notfcaton before the end of such perod of tme or number of treatments. The covered person wll be notfed suffcently n advance of the reducton or termnaton to allow the covered person to appeal and obtan a determnaton on revew of that adverse beneft determnaton before the beneft s reduced or termnated. o Request by Covered Person Involvng Non-urgent Care. If the Plan Admnstrator receves a request from the covered person to extend the course of treatment beyond the perod of tme or number of treatments that s a clam not nvolvng urgent care, the request wll be treated as a new beneft clam and decded wthn the tmeframe approprate to the type of clam (ether as a pre-servce non-urgent clam or a post-servce clam). Post-servce Clams. o o If the covered person has provded all of the nformaton needed to process the clam, the Fund shall notfy the partcpant wthn a reasonable perod of tme, but not later than 30 days after recept of the clam, unless an extenson has been requested, then pror to the end of the 15-day extenson perod. If the covered person has not provded all of the nformaton needed to process the clam and addtonal nformaton s requested durng the ntal processng perod, then the covered person wll be notfed of a determnaton of benefts pror to the end of the extenson perod, unless addtonal nformaton s requested durng the extenson perod, then the covered person wll be notfed of the determnaton by a date agreed to by the Plan Admnstrator and the covered person. Extensons Pre-servce Non-urgent Care Clams. Ths perod may be extended by the Plan for up to 15 days, provded that the Plan Admnstrator both determnes that such an extenson s necessary due to matters beyond the control of the Plan and notfes the covered person, pror to the expraton of the ntal 15-day processng perod, of the crcumstances requrng the extenson of tme and the date by whch the Plan expects to render a decson. 50

56 Extensons Post-servce Clams. Ths perod may be extended by the Plan for up to 15 days, provded that the Plan Admnstrator both determnes that such an extenson s necessary due to matters beyond the control of the Plan and notfes the covered person, pror to the expraton of the ntal 30-day processng perod, of the crcumstances requrng the extenson of tme and the date by whch the Plan expects to render a decson. Calculatng Tme Perods. The perod of tme wthn whch a beneft determnaton s requred to be made shall begn at the tme a clam s deemed to be fled n accordance wth the procedures of the Plan. Notfcaton of an Adverse Beneft Determnaton The Plan Admnstrator may provde notfcatons of adverse beneft determnatons ether by letter or electroncally. Every notce of an adverse beneft determnaton shall nclude: Informaton suffcent to dentfy the clam nvolved, ncludng the date of the servce, the name of the health care provder, the clam amount (f applcable), the dagnoss code and ts correspondng meanng, and the treatment code and ts correspondng meanng. A reference to the specfc porton(s) of the summary plan descrpton upon whch a denal s based; Specfc reason(s) for a denal; A descrpton of any addtonal nformaton necessary for the covered person to perfect the clam and an explanaton of why such nformaton s necessary; A descrpton of the Plan s revew procedures and the tme lmts applcable to the procedures, ncludng a statement of the covered person s rght to brng a cvl acton under secton 502(a) of ERISA followng an adverse beneft determnaton on fnal revew; A statement that the covered person s enttled to receve, upon request and free of charge, reasonable access to, and copes of, all documents, records and other nformaton relevant to the covered person s clam for benefts; The dentty of any medcal or vocatonal experts consulted n connecton wth a clam, even f the Plan dd not rely upon ther advce (or a statement that the dentty of the expert wll be provded, upon request); Any rule, gudelne, protocol or smlar crteron that was reled upon n makng the determnaton (or a statement that t was reled upon and that a copy wll be provded to the covered person, free of charge, upon request); and 51

57 In the case of denals based upon a medcal judgment (such as whether the treatment s medcally necessary or expermental), ether an explanaton of the scentfc or clncal judgment for the determnaton, applyng the terms of the Plan to the covered person s medcal crcumstances, or a statement that such explanaton wll be provded to the covered person, free of charge, upon request. 52

58 SECTION 12 CLAIM APPEAL PROCEDURE Appeal of Adverse Beneft Determnatons Full and Far Revew of All Clams In cases where a clam for benefts s dened, n whole or n part, and the covered person beleves the clam has been dened wrongly, the covered person may appeal the denal and revew pertnent documents. The clams procedures of ths Plan provde a covered person wth a reasonable opportunty for a full and far revew of a clam and adverse beneft determnaton. More specfcally, the Plan provdes: Covered persons 180 days followng recept of a notfcaton of an ntal adverse beneft determnaton to appeal the determnaton; Covered persons the opportunty to submt wrtten comments, documents, records, and other nformaton relatng to the clam for benefts; For a revew that does not afford deference to the prevous adverse beneft determnaton and that s conducted by an approprate named fducary of the Plan, who shall be nether the ndvdual who made the adverse beneft determnaton that s the subject of the appeal, nor the subordnate of such ndvdual; For a revew that takes nto account all comments, documents, records, and other nformaton submtted by the covered person relatng to the clam, wthout regard to whether such nformaton was submtted or consdered n any pror beneft determnaton; That, n decdng an appeal of any adverse beneft determnaton that s based n whole or n part upon a medcal judgment, the Plan fducary shall consult wth a health care professonal who has approprate tranng and experence n the feld of medcne nvolved n the medcal judgment, who s nether an ndvdual who was consulted n connecton wth the adverse beneft determnaton that s the subject of the appeal, nor the subordnate of any such ndvdual; For the dentfcaton of medcal or vocatonal experts whose advce was obtaned on behalf of the Plan n connecton wth a clam, even f the Plan dd not rely upon ther advce; and That a covered person wll be provded, upon request and free of charge, reasonable access to, and copes of, all documents, records, and other nformaton relevant to the covered person s clam for benefts n possesson of the Plan Admnstrator or the thrd party admnstrator; nformaton regardng any voluntary appeals procedures offered by the Plan; any nternal rule, 53

59 Requrements for Appeal gudelne, protocol or other smlar crteron reled upon n makng the adverse determnaton; and an explanaton of the scentfc or clncal judgment for the determnaton, applyng the terms of the Plan to the covered person s medcal crcumstances. The covered person must fle the appeal n wrtng wthn 180 days followng recept of the notce of an adverse beneft determnaton. To fle an appeal n wrtng, the covered person s appeal must be addressed as follows and maled or faxed as follows: UMR, Inc. 333 West Vne Street Sute 500 Lexngton, KY (877) It shall be the responsblty of the covered person to submt proof that the clam for benefts s covered and payable under the provsons of the Plan. Any appeal must nclude: The name of the employee/covered person; The employee/covered person s socal securty number; The group name or dentfcaton number; All facts and theores supportng the clam for benefts. Falure to nclude any theores or facts n the appeal wll result n ther beng deemed waved. In other words, the covered person wll lose the rght to rase factual arguments and theores whch support ths clam f the covered person fals to nclude them n the appeal; A statement n clear and concse terms of the reason or reasons for dsagreement wth the handlng of the clam; and Any materal or nformaton that the covered person has whch ndcates that the covered person s enttled to benefts under the Plan. If the covered person provdes all of the requred nformaton the Admnstrator wll be able to decde the appeal. Tmng of Notfcaton of Beneft Determnaton on Revew The Plan Admnstrator shall notfy the covered person of the Plan s beneft determnaton on revew wthn the followng tmeframes: 54

60 Pre-servce Non-urgent Care Clams: Wthn a reasonable perod of tme approprate to the medcal crcumstances, but not later than 30 days after recept of the appeal. Concurrent Clams: The response wll be made n the approprate tme perod based upon the type of clam pre-servce non-urgent or post-servce. Post-servce Clams: Wthn a reasonable perod of tme, but not later than 60 days after recept of the appeal. Calculatng Tme Perods The perod of tme wthn whch the Plan s determnaton s requred to be made shall begn at the tme an appeal s fled n accordance wth the procedures of ths Plan, wthout regard to whether all nformaton necessary to make the determnaton accompanes the flng. Manner and Content of Notfcaton of Adverse Beneft Determnaton on Revew If, upon appeal, The Plan Admnstrator denes a partcpant s appeal, ether n whole or n part, the Plan Admnstrator shall provde the partcpant wth notfcaton, n wrtng or electroncally, settng forth: The specfc reason or reasons for the denal; Reference to the specfc porton(s) of the summary plan descrpton on whch the denal s based; The dentty of any medcal or vocatonal experts consulted n connecton wth the clam, even f the Plan dd not rely upon ther advce; A statement that the covered person s enttled to receve, upon request and free of charge, reasonable access to, and copes of, all documents, records, and other nformaton relevant to the covered person s clam for benefts; If an nternal rule, gudelne, protocol, or other smlar crteron was reled upon n makng the adverse determnaton, a statement that such rule, gudelne, protocol, or other smlar crteron was reled upon n makng the adverse determnaton and that a copy of the rule, gudelne, protocol, or other smlar crteron wll be provded free of charge to the covered person upon request; If the adverse beneft determnaton s based upon a medcal judgment, a statement that an explanaton of the scentfc or clncal judgment for the determnaton, applyng the terms of the Plan to the covered person s medcal crcumstances, wll be provded free of charge upon request; 55

61 A statement of the covered person s rght to brng an acton under secton 502(a) of ERISA, followng an adverse beneft determnaton on fnal revew; and The followng statement: You and your Plan may have other voluntary alternatve dspute resoluton optons, such as medaton. One way to fnd out what may be avalable s to contact your local U.S. Department of Labor Offce and your state nsurance regulatory agency. Access to, and copes of, documents, records, and other nformaton descrbed n ths secton, as approprate. External Revew When a covered person has exhausted the nternal appeals process outlned above, the covered person has a rght to have that decson revewed by ndependent health care professonals who has no assocaton wth the Plan, the Plan Sponsor, or the Fund. If the adverse beneft determnaton nvolved makng a judgment as to the medcal necessty, approprateness, health care settng, level of care or effectveness of the health care servce or treatment you requested, you may submt a request for external revew wthn 4 months after recept of a denal of benefts to Dr. Sdney Jakubovcs 411 Felter Avenue Woodmere, N.Y (516) For standard external revew, a decson wll be made wthn 45 days of recevng your request. If you have a medcal condton that would serously jeopardze your lfe or health or would jeopardze your ablty to regan maxmum functon f treatment s delayed, you may be enttled to request an expedted external revew of the denal. If our denal to provde or pay for health care servce or course of treatment s based on a determnaton that the servce or treatment s expermental or nvestgaton, you also may be enttled to fle a request for external revew of our denal. Please contact your Plan Admnstrator wth any questons on your rghts to external revew. Appontment of Authorzed Representatve A covered person s permtted to appont an authorzed representatve to act on hs or her behalf wth respect to a beneft clam or appeal of a denal. An assgnment of benefts by a covered person to a provder wll not consttute appontment of that provder as an authorzed representatve. To appont such a representatve, the covered person must complete a form whch can be obtaned from the Plan Admnstrator or the thrd party admnstrator. However, n connecton wth a clam nvolvng urgent care, the Plan wll permt a health care professonal wth knowledge of the covered person s medcal condton to act as the covered person s authorzed representatve wthout completon of ths form. In the event a covered person desgnates an authorzed representatve, all future communcatons from the Plan wll be wth the representatve, rather than the covered person, unless the covered person drects the Plan Admnstrator, n wrtng, to the contrary. 56

62 Physcal Examnatons The Plan reserves the rght to have a physcan of ts own choosng examne any covered person whose llness or njury s the bass of a clam. All such examnatons shall be at the expense of the Plan. Ths rght may be exercsed when and as often as the Plan Admnstrator may reasonably requre durng the pendency of a clam. The covered person must comply wth ths requrement as a necessary condton to coverage. Autopsy The Plan reserves the rght to have an autopsy performed upon any deceased covered person whose llness or njury s the bass of a clam. Ths rght may be exercsed only where not prohbted by law. Payment of Benefts All benefts under ths Plan are payable, n U.S. Dollars, to the covered employee whose llness or njury, or whose covered dependent s llness or njury, s the bass of a clam. In the event of the death or ncapacty of a covered employee and n the absence of wrtten evdence to ths Plan of the qualfcaton of a guardan for hs or her estate, the Plan Admnstrator may, n ts sole dscreton, make any and all such payments to the ndvdual or nsttuton whch, n the opnon of the Plan Admnstrator, s or was provdng the care and support of such employee. Assgnments Benefts for medcal expenses covered under ths Plan may be assgned by a covered person to the provder; however, f those benefts are pad drectly to the employee, the Plan shall be deemed to have fulflled ts oblgatons wth respect to such benefts. The Plan wll not be responsble for determnng whether any such assgnment s vald. Payment of benefts whch have been assgned wll be made drectly to the assgnee unless a wrtten request not to honor the assgnment, sgned by the covered employee and the assgnee, has been receved before the proof of loss s submtted. Non-U.S. Provders Medcal expenses for care, supples or servces whch are rendered by a provder whose prncpal place of busness or address for payment s located outsde the Unted States (a non-u.s. provder ) are payable under the Plan, subject to all Plan exclusons, lmtatons, maxmums and other provsons, under the followng condtons: Benefts may not be assgned to a non-u.s. provder; The covered person s responsble for makng all payments to non-u.s. provders, and submttng recepts to the Plan for rembursement; 57

63 Beneft payments wll be determned by the Plan based upon the exchange rate n effect on the ncurred date; The non-u.s. provder shall be subject to, and n complance wth, all U.S. and other applcable lcensng requrements; and Clams for benefts must be submtted to the Plan n Englsh. Recovery of Payments Occasonally, benefts are pad more than once, are pad based upon mproper bllng or a msstatement n a proof of loss or enrollment nformaton, or are not pad accordng to the Plan s terms, condtons, lmtatons or exclusons. Whenever the Plan pays benefts exceedng the amount of benefts payable under the terms of the Plan, the Plan Admnstrator has the rght to recover any such erroneous payment drectly from the person or entty who receved such payment and/or from the covered person or dependent on whose behalf such payment was made. A covered person, dependent, provder, another beneft plan, nsurer, or any other person or entty who receves a payment exceedng the amount of benefts payable under the terms of the Plan or on whose behalf such payment was made, shall return the amount of such erroneous payment to the Plan wthn thrty (30) days of dscovery or demand. The Plan Admnstrator shall have no oblgaton to secure payment for the expense for whch the erroneous payment was made or to whch t was appled. The person or entty recevng an erroneous payment may not apply such payment to another expense. The Plan Admnstrator shall have the sole dscreton to choose who wll repay the Plan for an erroneous payment and whether such payment shall be rembursed n a lump sum. When a covered person or other entty does not comply wth the provsons of ths secton, the Plan Admnstrator shall have the authorty, n ts sole dscreton, to deny payment of any clams for benefts by the covered person and to deny or reduce future benefts payable (ncludng payment of future benefts for other njures or llnesses) under the Plan by the amount due as rembursement to the Plan. The Plan Admnstrator may also, n ts sole dscreton, deny or reduce future benefts (ncludng future benefts for other njures or llnesses) under any other group benefts plan mantaned by the Plan Sponsor. The reductons wll equal the amount of the requred rembursement. Provders and any other person or entty acceptng payment from the Plan, n consderaton of such payments, agree to be bound by the terms of ths Plan and agree to submt clams for rembursement n strct accordance wth ther state s health care practce acts, ICD-9 or CPT standards, Medcare gudelnes, HCPCS standards, or other standards approved by the Plan Admnstrator or nsurer. Any payments made on clams for rembursement not n accordance wth the above provsons shall be repad to the Plan wthn 30 days of dscovery or demand or ncur prejudgment nterest of 1.5% per month. If the Plan must brng an acton aganst a covered person, provder or other person or entty to enforce the provsons of ths secton, then that covered person, provder or other person or entty agrees to pay the Plan s attorneys fees and costs, regardless of the acton s outcome. 58

64 Legal Acton for Benefts If, for any reason, the covered person does not receve a wrtten response to the appeal wthn the approprate tme perod set forth above, the covered person may assume that the appeal has been dened. Note that: all clam revew procedures provded for n the Plan must be exhausted before any legal acton s brought. Any legal acton for the recovery of any benefts must be commenced wthn nnety (90) days after the Plan s clam revew procedures have been exhausted. 59

65 SECTION 13 GRIEVANCE PROCEDURE In addton to the procedure for appeals for denal of benefts set forth above, we have nsttuted the followng grevance procedure for other concerns that do not nvolve a clam for benefts under the Plan: CONCERNS - Level I If you are dssatsfed wth a person, a servce, the qualty of care, or the contractual benefts, you may express ths concern to the Fund Offce. The Fund Offce wll make an attempt to solve problems expressed orally to your satsfacton durng the ntal telephone call or ntervew. Concerns wll be acknowledged n wrtng no later than 15 workng days. Concerns of an expedted nature wll be resolved wthn 72 hours. All other concerns wll be resolved wthn 15 workng days. If you are not satsfed wth the Fund s response, you should put the concern n wrtng. Ths wll elevate the concern to the complant level, level II. COMPLAINTS - Level II If you have complant concernng a person, a servce, the qualty of care, or the contractual benefts, you may regster the complant n wrtng to the Fund Offce. For the purposes of ths secton, a complant means a wrtten dssatsfacton regardng the resoluton of a concern from you regsterng a request for revew of a pror decson regardng a concern. Wthn 15 workng days of the recept of the wrtten complant, you wll be notfed of the tme frame when the complant wll be resolved and whether any addtonal nformaton s necessary n order to make the decson. Complants of an expedted nature wll be resolved wthn 72 hours. All other complants wll be resolved wthn 30 workng days. If you stll are not satsfed wth the decson regardng the complant, you may fle a wrtten appeal for revew by the Board of Trustees wthn 60 workng days of the recept of the complant determnaton. Ths wll elevate your complant to the Grevance level III. GRIEVANCE - Level III For purposes of ths secton, grevance means a notce sent by you to regster a request for a formal revew of a complant decson. Issues categorzed as grevances are those that have proceeded through the Concern and Complant levels and you are dssatsfed wth the outcome of the ssue revewed at both levels. Wthn 15 workng days of recept of a wrtten appeal, you wll receve wrtten acknowledgment of the appeal. Ths acknowledgment wll state whether addtonal nformaton s necessary to revew the ssue. You wll be notfed of the scheduled revew. 60

66 The Board of Trustees wll render a decson wthn 3 workng days for expedted Grevances and wthn 30 days for all other Grevances. You wll be notfed n wrtng of the Board of Trustees decson, whch shall be the fnal admnstratve revew of the matter. For levels I, II, and III, revew wll be contngent on the recept of all necessary nformaton. In addton, a concern, complant or grevance s consdered to be of an expedted nature f delay would sgnfcantly ncrease rsk to your health. 61

67 SECTION 14 CONTINUATION OF COVERAGE (COBRA) The Consoldated Omnbus Budget Reconclaton Act, commonly called COBRA, generally requres that health plans offer Employees and ther Dependents the opportunty to temporarly contnue ther health care coverage at group rates when coverage under the Plan would otherwse end. Ths extended coverage s called COBRA coverage. COBRA Coverage under the Plan ncludes all benefts that the person was enttled to before the Qualfyng Event, except Lfe Insurance Benefts. If you, your spouse and/or your Dependent chld(ren) are covered under the Plan, you and/or your spouse or chldren can contnue coverage for a tme f coverage ends for one of several reasons (called Qualfyng Events ), even f you or they are already covered by another group health Plan or Medcare. Qualfyng events are certan events that would cause you or your dependent to lose health coverage. The type of qualfyng event wll determne who the qualfed benefcares are and how long the Plan must offer them COBRA coverage. Qualfyng Events for Employees: Voluntary or nvoluntary termnaton of employment for reasons other than gross msconduct; Reducton n the number of hours of employment resultng n a loss of elgblty for health benefts. Qualfyng Events for Spouses: Voluntary or nvoluntary termnaton of the Employee's employment for any reason other than gross msconduct; Reducton n the hours worked by the Employee resultng n a loss of elgblty for health benefts; Employee becomes enttled to Medcare; Dvorce or legal separaton from the Employee; Death of the Employee. Qualfyng Events for Dependent Chldren: Loss of dependent chld status under the plan rules; Voluntary or nvoluntary termnaton of the Employee's employment for any reason other than gross msconduct; Reducton n the hours worked by the Employee resultng n a loss of elgblty for health benefts; Employee becomes enttled to Medcare; Death of the Employee. 62

68 If you and/or your Dependents do not elect COBRA Coverage, you and/or your Dependent s group health coverage wll end f one of these Qualfyng Events occurs. Reportng Requrements Your Employer must notfy the Fund Offce f the Employee s employment s termnated, hs or her hours are reduced resultng n a loss of elgblty for health benefts, he or she becomes enttled to Medcare or he or she des. Ths notfcaton must be n wrtng and must be provded wthn thrty days of the Qualfyng Event. Falure to provde such tmely notfcaton may subject the Employer to federal excse taxes. The Partcpant or the affected Dependent must notfy the Fund Offce wthn 60 days of dvorce, legal separaton or loss of elgblty by a Dependent chld. Both the Partcpant and the affected Dependent are jontly responsble for ths notce. If you or your Dependent fals to gve wrtten notce to the Fund Offce wthn the requred sxty days, the affected person wll lose the rght to COBRA Coverage. Fnancal Responsblty for Falure to Gve Notce If a Covered Person fals to gve wrtten notce wthn sxty days of the date of the Qualfyng Event, or an Employer wthn thrty days of the Qualfyng Event, and as a result, the Plan pays a clam for a Covered Person whose coverage termnated due to a Qualfyng Event and who does not elect COBRA Coverage under ths provson, then the Covered Person or the Employer, as approprate, must remburse the Plan for any clams that should not have been pad. If a Covered Person fals to remburse the Plan, then all amounts due may be deducted from other benefts payable on behalf of that ndvdual or on behalf of the Partcpant, f the Covered Person was hs or her Dependent. Notce and Electon Form COBRA Coverage requres tmely electon of the coverage. The Fund Offce wll, wthn fourteen (14) days of recevng notce of the Qualfyng Event, send to the affected Covered Person a COBRA Notce and Electon Form. Ths form wll descrbe the cost of coverage and the condtons under whch the COBRA Coverage wll termnate. In order to obtan COBRA Coverage, the Electon Form must be completed and returned to the Fund Offce wthn sxty (60) days after recept. Detals of Contnuaton Coverage If you choose COBRA Coverage, the coverage provded s dentcal to the coverage provded under the Plan to smlarly stuated Covered Persons. If the coverage provded under the Plan s modfed after you elect COBRA Coverage, your coverage also wll be modfed. Chldren born to or placed wth you for adopton durng the COBRA perod also may receve coverage for the duraton of your COBRA Coverage perod. 63

69 You do not have to show that you are n good health to elect COBRA Coverage. However, under COBRA, you wll have to pay the cost for your Contnuaton Coverage. Payment Provsons COBRA Coverage requres tmely monthly payments. The payment due date s the frst day of the month n whch COBRA Coverage begns. For example, payments for the month of November must be pad on or before November 1st. The monthly cost of COBRA Coverage s based on 102% of the full monthly cost of the coverage under the Plan. If any ndvdual or famly coverage s extended beyond 18 months because of enttlement to Socal Securty dsablty ncome benefts (descrbed below), the cost of COBRA Coverage s based on 150% of the full monthly cost of COBRA coverage durng the 11-month extenson of COBRA Coverage. The Fund Offce wll tell you the cost of COBRA Coverage at the tme you receve your notce of enttlement to COBRA Coverage. There s an ntal grace perod of 45 days to pay the frst amounts due startng wth the date COBRA Coverage was elected. The payment due for the ntal perod of COBRA Coverage must nclude payment for the perod of tme datng back to the date that coverage termnated. There s then a grace perod of 30 days after the due date for each of the subsequent monthly amounts due. If payment of the amounts due s not receved by the end of the applcable grace perod, the COBRA Coverage wll termnate. Once a tmely electon of COBRA Coverage has been made, t s the responsblty of the Covered Person seekng COBRA Coverage to make tmely payment of all requred payments. The Fund wll not send notce that a payment s due or that t s late, or that COBRA Coverage s about to be or has been termnated due to the untmely payment of a requred payment. Maxmum Perods of COBRA Coverage for Each Qualfyng Event Qualfed Benefcary Qualfyng Event Perod of Coverage Employee Spouse Dependent chld Termnaton Reducton n hours 18 months (Ths 18-month perod may be extended for all qualfed benefcares f certan condtons are met n cases where a qualfed benefcary s determned to be dsabled for purposes of COBRA.) Spouse Dependent chld Dependent chld Enttled to Medcare Dvorce or 36 months legal separaton Death of covered employee Loss of dependent chld status 36 months If your Dependent s coverage s contnued for 18 months as a result of a Qualfyng Event lsted above and, durng the COBRA perod, a second Qualfyng Event occurs that enttles the Dependent to contnue coverage, your Dependent may elect to contnue coverage up to a combned maxmum of 36 months. For example, f you retre and you and your Dependents elect COBRA Coverage from May 1, 2000 and you then become enttled to Medcare on 64

70 November 1, 2000, your Dependents can elect to contnue coverage for the balance of 36 months, measured from May 1, If your coverage s contnued under the Plan after you stop workng because of one of the Qualfyng Events lsted n ths Secton, your COBRA Coverage perod wll be measured from the date that your coverage ends. Enttlement to Socal Securty Dsablty Income Benefts Extended COBRA Benefts 29-Month Perod (Dsablty Extenson): If a qualfed benefcary of COBRA benefts s determned under Ttle II or XVI of the Socal Securty Act to have been dsabled wthn the frst 60 days of the commencement of COBRA coverage, then that qualfed benefcary and all of the qualfed benefcares n hs or her famly may be able to extend COBRA contnuaton coverage for up to an addtonal 11 months. In addton, a qualfed benefcary who has been determned under Ttle II or Ttle XVI of the Socal Securty Act to have been dsabled before the frst day of COBRA contnuaton coverage, and who has not been determned to be no longer dsabled at any tme between the date of that dsablty determnaton and the frst day of COBRA contnuaton coverage, s consdered to be dsabled wthn the frst 60 days of COBRA contnuaton coverage. The qualfed benefcary may lose all rghts to the addtonal 11 months of coverage f notce of the determnaton s not provded to the plan admnstrator wthn 60 days of the date of the determnaton and before the expraton of the 18-month perod. The qualfed benefcary who s dsabled or any qualfed benefcares n hs or her famly may notfy the plan admnstrator of the determnaton. 18 to 36-Month Perod (Specal Rule): If an Employee becomes enttled to Medcare benefts (ether Part A or Part B) before experencng a termnaton of employment or a reducton of employment hours, the perod of coverage for the Employee s spouse and dependent chldren ends wth the later of the 36-month perod that begns on the date the Employee became enttled to Medcare, or the 18 or 29 month perod that begns on the date of the Employee s termnaton of employment or reducton of employment hours. However, the Employee s Medcare enttlement s not a qualfyng event because t does not result n loss of coverage for the Employee s dependents; thus, the 36-month coverage perod would be part regular plan coverage and part contnuaton coverage. 18 to 36-Month Perod (Second Qualfyng Event): Your spouse and dependent chldren who experence a second qualfyng event may be enttled to a total of 36 months of COBRA coverage. The second qualfyng event may nclude your death, the dvorce or legal separaton from the Employee, your enttlement to Medcare benefts (under Part A, Part B or both), or a dependent chld ceasng to be elgble for coverage as a dependent under ths Plan. The followng condtons must be met n order for a second event to extend a perod of coverage: 65

71 1. The ntal qualfyng event s the Employee s termnaton, or reducton of hours, of employment, whch calls for an 18-month perod of contnuaton coverage; 2. The second event that gves rse to a 36-month maxmum coverage perod occurs durng the ntal 18-month perod of contnuaton coverage (or wthn the 29-month perod of coverage f a dsablty extenson apples); 3. The second event would have caused a qualfed benefcary to lose coverage under the Plan n the absence of the ntal qualfyng event; 4. The ndvdual was a qualfed benefcary n connecton wth the frst qualfyng event and s stll a qualfed benefcary at the tme of the second event; and 5. The ndvdual meets any applcable COBRA notce requrement n connecton wth a second event, such as notfyng the plan admnstrator of a dvorce or a chld ceasng to be a dependent under the plan wthn 60 days after the event. If all condtons assocated wth a second qualfyng event are met, the perod of contnuaton coverage for the affected qualfed benefcary (or benefcares) s extended from 18 months (or 29 months) to 36 months. Termnaton of COBRA Coverage If you and/or your Dependent elect COBRA Coverage, the Cobra Coverage wll cease on the frst of the followng dates: 1. The date the Plan termnates or the Plan no longer provdes coverage to smlarly stuated Partcpants or Dependents. 2. The date a requred payment s due and unpad after the applcable grace perod. 3. The date you and/or your Dependent(s) frst become covered under another group health Plan as long as t s after the Qualfyng Event. Ths may not apply f you and/or your Dependent have a pre-exstng condton, whch s not covered under the new Plan. Contact the Fund for addtonal nformaton when you and/or your Dependent(s) become covered under another group Plan. 4. The date you or your Dependent(s) frst become elgble for Medcare, as long as t s after the Qualfyng Event. 5. The date the applcable perod of COBRA Coverage ends; or 6. The frst month that begns more than thrty days after the date of the Socal Securty Admnstraton s determnaton that you or your Dependent(s) are no longer dsabled, n stuatons where coverage was beng extended for eleven months, so long as the perod of Contnuaton Coverage does not exceed twenty-nne months. 66

72 7. Your Employer ceases to mantan any group health Plan for ts Employees through the Fund. 67

73 SECTION 15 SHORT TERM DISABILITY BENEFITS Elgblty Benefts are only avalable f you were an Employee and elgble for benefts under the Plan rules on the date the dsablty began. You are elgble for benefts f: a) you become totally dsabled as defned above, and b) on the date the dsablty commenced, you had at least three consecutve years of elgblty n the Unted Beneft Fund and the three consecutve years of elgblty were mmedately pror to the date the dsablty commenced. Approved perods of Leave of Absence durng the three consecutve year perod wll be counted as perods of elgblty for ths purpose. You are not enttled to dsablty benefts under ths Plan f you are recevng benefts from any penson fund. Beneft Amount The Short Term Dsablty Beneft s a monthly amount of (see appendx) wth a maxmum payout of (see approprate appendx). Commencement of Benefts Benefts wll commence on the frst day of the month followng a contnuous 4-week perod from the date dsablty began or the date maxmum benefts under the New York State Dsablty Benefts Law or New Jersey State Dsablty Benefts Law have been pad, whchever s later. Benefts due but not pad to a deceased partcpant wll be pad to the desgnated benefcary. However, f a partcpant s dsabled for a perod of at least four consecutve months and then returns to Covered Employment for a perod of less than sx consecutve months, and the partcpant s subsequently dsabled for a perod of at least two consecutve months, he or she wll be enttled to benefts on the frst day of the month followng the last month of dsablty. If an Employee who s recevng dsablty benefts under ths Plan and subsequently returns to Covered Employment becomes dsabled agan, he or she s enttled to benefts wthout beng subject to a watng perod, provded the return to Covered Employment was for a perod of less than sx consecutve months. You must notfy the Fund and submt proof of the dsablty wthn 90 days of the date of the dsablty began n order to collect hs beneft. Ths tme perod may be waved by The Board of Trustees n ther sole dscreton for good cause shown by the Employee. 68

74 Dsablty Benefts under ths Plan wll stop on the frst day of the month followng the occurrence of any one of the followng condtons: a. Death. b. The date dsablty, as defned, ceases. c. The date the Partcpant become elgble to receve a penson that s equal to or greater than the dsablty payments. d. The Partcpant s 65th brthday. e. The date satsfactory nformaton s receved whch would make the Employee nelgble under the Plan. f. The date the partcpant receves the maxmum payout under ths Plan. Medcal Proof To apply for ths beneft, the Employee must provde the Plan wth medcal proof of dsablty certfed by a qualfed physcan. The Fund may requre that you submt to a medcal examnaton by a qualfed medcal doctor selected by the Fund for determnaton of dsablty or contnued dsablty. If so, the cost of the examnaton wll be pad for by the Plan. All determnatons as to an employee s dsablty are made n the sole and absolute dscreton of The Board of Trustees or ther desgnees. Exclusons Dsabltes resultng from one or more of the followng causes wll not be consdered n the determnaton of total dsablty : 1. war (whether declared or not), nsurrecton, rebellon or partcpaton n a rot of cvl commoton; 2. commsson of or attempt to commt assault, battery or felony; or 3. ntentonal self-nflcted njures. 69

75 SECTION 16 IMPORTANT INFORMATION ABOUT THE PLAN Fund Admnstraton: The Fund s admnstered by a jont Board of Trustees consstng of a Unon representatve and an Employer representatve. The Employer Trustee s Thomas D Ambroso. The Unon Trustee s Andrew Talamo. All can be reached at the Fund Offce, Metropoltan Ave. Mddle Vllage, New York Fnancal Informaton: Benefts are provded from the Fund's assets that are accumulated under the provsons of the collectve barganng agreements and the Trust Agreement and held n a Trust for the purpose of provdng benefts to Partcpants and Dependents and defrayng reasonable admnstratve expenses. The Fund Offce wll provde you wth nformaton as to whether the Employer s contrbutng to ths Plan on behalf of Partcpants workng under the collectve barganng agreement upon wrtten request. Plan Benefts: All of the types of benefts provded by the Plan are set forth n ths Plan Booklet, ncludng those benefts admnstered by Omn Admnstrators, General Vson Servces, and Natonal Prescrpton Admnstrators. The complete terms of these self-nsured benefts are set forth n ths Plan. Except for those benefts that may become payable for Hosptal, surgcal, or other medcal expenses, no rghts or benefts may be assgned. Name of Plan: The UNITED BENEFIT FUND Employer Identfcaton Number (EIN): Plan Number: 501 Type of Plan: An employee welfare benefts plan, ncludng medcal benefts, dental benefts, and vson benefts. Type of Admnstraton: Omn Admnstrators admnsters all self-nsured benefts. There s no admnstraton by the Fund for dental servces by D.D. Servces, because the Partcpant pays all costs drectly. Vson Screenng, and Natonal Prescrpton Servces process ther own clams. Plan Admnstrator: The name and address of the Plan Admnstrator s: Omn Admnstrators Inc Broadway, Sute 1303 New York, NY Phone (718)

76 Agent for Servce of Legal Process: For dsputes arsng under the Plan, servce of legal process may be made on: Board of Trustees UNITED BENEFIT FUND Metropoltan Ave Mddle Vllage, NY Servce may also be made upon an ndvdual Trustee. CLAIMS ADMINISTRATOR UMR, Inc. 333 West Vne Street Sute 500 Lexngton, KY (877) (Toll-free) Contrbutons to the Plan: All contrbutons to the Plan are made by Employers pursuant to the terms of collectve barganng agreements between the Unon and varous Employers or under wrtten agreements wth the Fund. These agreements set forth the condtons under whch Employers are requred to contrbute to the Plan and the rate(s) of contrbuton. A copy of any agreement and a lst of contrbutng Employers may be obtaned by Partcpants upon wrtten request to the Plan Admnstrator, and s avalable for examnaton by Partcpants at the Fund Offce. Plan Year: The Plan s fscal records are kept on a twelve-month perod begnnng each January 1 and endng on the followng December 31. Plan Amendments or Termnaton: The Board of Trustees ntends to contnue the benefts descrbed n ths booklet. However, the Trustees reserve the rght to amend or termnate ths Plan, or any part of t at any tme. Benefts provded by the Plan and Plan elgblty rules: 1. Are not guaranteed and may be changed or dscontnued by the Board of Trustees; 2. Are subject to the rules adopted by the Board of Trustees; 3. Are subject to the Trust Agreement that establshes and governs the Fund operatons; and 4. Are subject to the provsons of any group nsurance polces or other contracts purchased by the Trustees. Notce - No Fund Lablty: Use of the servces of any Hosptal, clnc, doctor, or other provder renderng health care, whether desgnated by the Fund or otherwse, s the voluntary act of the Partcpant or Dependent. Ths s not meant to be a recommendaton or nstructon to use the provder. You should select a provder or course of treatment based on all approprate factors, only one of whch s coverage by the Fund. Provders are ndependent contractors, not Employees of the Plan. The Fund makes no representaton regardng the qualty of servce or treatment of any provder and s not responsble for any acts of 71

77 commsson or omsson of any provder n connecton wth Fund coverage. The provder s solely responsble for the servces and treatments rendered. Informaton About You and Your Dependents In addton to nformaton you must furnsh n support of any clam for benefts under ths Plan, you or your Dependents must furnsh, wthn 60 days after the event, any nformaton you or they may have that may affect elgblty for coverage under the Plan. Ths ncludes, but s not lmted to: 1. Change of name; 2. Change of address; 3. Marrage, dvorce, or death of you or any spouse or Dependent chld; 4. Any nformaton regardng the status of a Dependent chld; 5. Medcare enrollment or ds-enrollment; and 6. The exstence of other medcal or dental coverage. 72

78 SECTION 17 ERISA RIGHTS As a Partcpant n the Plan descrbed heren you are enttled to rghts and protectons under the Employee Retrement Income Securty Act of 1974 (ERISA). ERISA provdes that all Plan Partcpants shall be enttled to: 1. Examne, wthout charge, at the Plan admnstrators offce and at all other specfed locatons, such as work-stes and unon halls, all other documents governng the Plan, ncludng nsurance contracts and collectve barganng agreements, and a copy of the latest annual report (Form 5500 seres) fled by the Plan wth the U.S. Department of Labor. 2. Obtan, upon wrtten request to the Plan admnstrator, copes of documents governng operaton of the Plan, ncludng nsurance contracts and collectve barganng agreements, and copes of the latest annual report (Form 5500 seres) and updated summary Plan descrpton. The admnstrator may make a reasonable charge for the copes. 3. Receve a summary of the Plans annual fnancal report. The Plan admnstrator s requred by law to furnsh each Partcpant wth a copy of the summary annual report. 4. Contnue health care coverage for yourself, spouse or dependents f there s a loss of coverage under the Plan as a result of a qualfyng event. You or your dependents may have to pay for such coverage. Revew ths summary plan descrpton and the documents governng the Plan on the rules governng your COBRA contnuaton coverage rghts. Reducton or elmnaton of exclusonary perods of coverage for pre-exstng condtons under the Plan, f you have credtable coverage from another plan. You should be provded a certfcate of coverage, free of charge, from your group health plan or health nsurance ssuer on request or when you lose coverage under the plan, when you become enttled to elect COBRA contnuaton coverage, when your COBRA contnuaton coverage ceases, f you request t before losng coverage, or f you request t up to 24 months after losng coverage. Wthout evdence of credtable coverage, you may be subject to a pre-exstng condton excluson or lmtaton for 12 months (18 months for late enrollees) after your enrollment date n your coverage. In addton to creatng rghts for Fund partcpants, ERISA mposes dutes upon the people who are responsble for the operaton of Employee beneft Funds. The people who operate your Fund, called Fducares of the Fund, have a duty to do so prudently and n the nterest of you and other partcpants and dependents. No one, ncludng your Employer, your unon, or any other person may fre you or otherwse dscrmnate aganst you n any way to prevent you from obtanng a welfare beneft or exercsng your rghts under ERISA. If your clam for a 73

79 welfare beneft s dened n whole or n part, you must receve a wrtten explanaton of the reason for denal. You have the rght to have the Fund revew and reconsder your clam. Under ERISA, there are steps you can take to enforce the above rghts. For nstance, f you request materal from the Fund and do not receve them wthn 30 days, you may fle sut n a Federal Court. In such a case, the court may requre the Fund Admnstrator to provde the materals and pay up to $ a day untl you receve the materals, unless the materals were not sent because of reasons beyond the control of the Admnstrator. If you have a clam for benefts, whch s dened or gnored, n whole or n part, you may fle sut n a Federal Court. If t should happen that Fund Fducares msuse the Fund s money or f you are dscrmnated aganst for assertng your rghts, you may seek assstance from the U.S. Department of Labor, or you may fle sut n a Federal Court. The court wll decde who should pay the court costs and legal fees. If you lose, the court may order you to pay these costs and fees f, for example, t fnds your clam s frvolous. If you have any questons about your Plan, you should contact the Fund Offce. If you have any questons about ths statement or about your rghts under ERISA, you should contact the nearest offce of the Penson and Welfare Benefts Admnstraton, U.S. Department of Labor, lsted n your telephone drectory or the Dvson of Techncal Assstance and Inqures, Penson and Welfare Benefts Admnstraton, U.S. Department of Labor, 200 Consttuton Avenue, N.W., Washngton D.C DISCLOSURE REQUIREMENTS Under current Department of Labor nterm dsclosure rules, Summary Plan Descrptons ( SPD ) and Summares of Materal Modfcatons ( SMM ), whch are the documents Funds are requred to provde to employees, must: Notfy partcpants and benefcares of materal reductons n covered servces or benefts (for example, reductons n benefts or ncreases n deductbles and co-payments) generally wthn 60 days of adopton of the change. Ths compares to current requrements under whch Plan changes can be dsclosed as late as 210 days after the end of the Plan year n whch a change was adopted. Dsclose to partcpants and benefcares nformaton about the role of ssuers (e.g., nsurance companes and HMOs) wth respect to ther group health plan. In partcular, the name and address of the ssuer, whether and to what extent benefts under the Plan are guaranteed under a contract or polcy of nsurance ssued by the ssuer and the nature of any admnstratve servces (e.g., payment of clams) provded by the ssuer. 74

80 Tell partcpants and benefcares whch Department of Labor offce they can contact for assstance or nformaton on ther rghts under ERISA and HIPAA. You can reach The Department of Labor at GRANDFATHERED STATUS The Unted Beneft Fund beleves that the followng Plans are grandfathered health plan under the Patent Protecton and Affordable Care Act (the Affordable Care Act ): ) The Affordable Care Act allows grandfathered health plan to preserve some knds health coverage optons and restrctons that were already n effect when that law was enacted. Beng a grandfathered health plan means that your plan may not nclude certan consumer protectons of the Affordable Care Act that apply to other plans, for example, the requrement for the provson of preventve health servces wthout any cost sharng. However, grandfathered health plans must comply wth certan other consumer protectons n the Affordable Care Act, for example, the elmnaton of lfetme lmts on benefts. Questons regardng whch protectons apply and whch protectons do not apply to a grandfathered health plan and what mght cause a plan to change from grandfathered health plan status can be drected to the UBF fund offce at You may also contact the Employee Benefts Securty Admnstraton, U.S. Department of Labor at or fnd addtonal nformaton at Ths webste has a table summarzng whch protectons do and do not apply to grandfathered health plans. HIPAA PRIVACY PRACTICES The followng s a descrpton of certan uses and dsclosures that may be made by the Plan of your health nformaton under the Health Insurance Portablty and Accountablty Act of 1996 ( HIPAA ): Dsclosure of Summary Health Informaton to the Plan Sponsor In accordance wth HIPAA s Standards for Prvacy of Indvdually Identfable Health Informaton (the prvacy standards ), the Plan may dsclose summary health nformaton to the Plan Sponsor, f the Plan Sponsor requests the summary health nformaton for the purpose of: Obtanng premum bds from health plans for provdng health nsurance coverage under ths Plan; or Modfyng, amendng or termnatng the Plan. Summary health nformaton may be ndvdually dentfable health nformaton and t summarzes the clams hstory, clams expenses or the type of clams experenced by ndvduals n the Plan, but t excludes all dentfers that must be removed for the nformaton to be dedentfed, except that t may contan geographc nformaton to the extent that t s aggregated by fve-dgt zp code. 75

81 Dsclosure of Protected Health Informaton ( PHI ) to the Plan Sponsor for Plan Admnstraton Purposes In order that the Plan Sponsor may receve and use PHI for plan admnstraton purposes, the Plan Sponsor agrees to: Not use or further dsclose PHI other than as permtted or requred by the Plan documents or as requred by law (as defned n the prvacy standards); Ensure that any agents, ncludng a subcontractor, to whom the Plan Sponsor provdes PHI receved from the Plan agree to the same restrctons and condtons that apply to the Plan Sponsor wth respect to such PHI; Not use or dsclose PHI for employment-related actons and decsons or n connecton wth any other beneft or employee beneft plan of the Plan Sponsor, except pursuant to an authorzaton whch meets the requrements of the prvacy standards; Notfy partcpants of any PHI use or dsclosure that s nconsstent wth the uses or dsclosures provded for of whch the Plan Sponsor, or any Busness Assocate of the Plan Sponsor becomes aware, n accordance wth the health breach notfcaton rule. Notfy the Federal Trade Commsson of any PHI use or dsclosure that s nconsstent wth the uses or dsclosures provded for of whch the Plan Sponsor, or any Busness Assocate of the Plan Sponsor becomes aware, n accordance wth the health breach notfcaton rule. Report to the Plan any PHI use or dsclosure that s nconsstent wth the uses or dsclosures provded for of whch the Plan Sponsor becomes aware; Make avalable PHI to the partcpant n accordance wth the prvacy standards. Make a partcpant s PHI avalable for the partcpant to amend to the extent requred by the prvacy rules. Make avalable the nformaton requred to provde an accountng of dsclosures. Make ts nternal practces, books and records relatng to the use and dsclosure of PHI receved from the Plan avalable to the Secretary of the U.S. Department of Health and Human Servces ( HHS ), or any other offcer or employee of HHS to whom the authorty nvolved has been delegated, for purposes of determnng complance by the Plan wth the prvacy standards. 76

82 If feasble, return or destroy all PHI receved from the Plan that the Plan Sponsor stll mantans n any form and retan no copes of such PHI when no longer needed for the purpose for whch dsclosure was made, except that, f such return or destructon s not feasble, lmt further uses and dsclosures to those purposes that make the return or destructon of the PHI nfeasble; and Ensure that adequate separaton between the Plan and the Plan Sponsor, as requred by the prvacy rules. o o The Fund Admnstrator s the contact person for all PHI nformaton requests. In the event any of the ndvduals n the Fund Admnstrator s offce do not comply wth the provsons of the Plan documents relatng to use and dsclosure of PHI, the Plan Admnstrator shall mpose reasonable sanctons as necessary, n ts dscreton, to ensure that no further noncomplance occurs. Such sanctons shall be mposed progressvely (for example, an oral warnng, a wrtten warnng, tme off wthout pay and termnaton), f approprate, and shall be mposed so that they are commensurate wth the severty of the volaton. Plan admnstraton actvtes are lmted to actvtes that would meet the defnton of payment or health care operatons, but do not nclude functons to modfy, amend or termnate the Plan or solct bds from prospectve ssuers. Plan admnstraton functons nclude qualty assurance, clams processng, audtng, montorng and management of carve-out plans, such as vson and dental. It does not nclude any employment-related functons or functons n connecton wth any other beneft or beneft plans. Dsclosure of Certan Enrollment Informaton to the Plan Sponsor The Plan shall dsclose PHI to the Plan Sponsor only upon recept of a certfcaton by the Plan Sponsor that the Plan Sponsor agrees to comply wth the above prvacy rule provsons. Pursuant to the prvacy standards, the Plan may dsclose to the Plan Sponsor nformaton on whether an ndvdual s partcpatng n the Plan or s enrolled n or has dsenrolled from a health nsurance ssuer or health mantenance organzaton offered by the Plan to the Plan Sponsor. Dsclosure of PHI to Obtan Stop-loss or Excess Loss Coverage The Plan Sponsor hereby authorzes and drects the Plan, through the Plan Admnstrator or the thrd party admnstrator, to dsclose PHI to stop-loss carrers, excess loss carrers or managng general underwrters ( MGUs ) for underwrtng and other purposes n order to obtan and mantan stop-loss or excess loss coverage related to beneft clams under the Plan. Such dsclosures shall be made n accordance wth the prvacy standards. 77

83 Other Dsclosures and Uses of PHI Wth respect to all other uses and dsclosures of PHI, the Plan shall comply wth the prvacy standards. HIPAA has a number of specal rules, and the nformaton presented covers only basc ponts. If you want to know more about how HIPAA apples to group health plans, the Department of Labor offers a booklet Questons and Answers: Recent Changes n Health Care Law. You may request ths booklet free of charge by callng (1-800) Ths booklet s also avalable on the Internet at More nformaton about HIPAA s also avalable at the Health Care Fnancng Admnstraton (HCFA) Internet ste at m. 78

84 SECTION 18 ANCILLARY BENEFITS LIFE INSURANCE New Fund partcpants wll be covered wth a basc lfe nsurance beneft of (see appendx) after eght (8) weekly contrbutons have been made to the Fund on your behalf. On the frst month, when twenty-sx (26) weekly contrbutons have been made on your behalf to the Fund, you wll have your lfe nsurance coverage ncreased by an addtonal (see appendx) for a total coverage of (see appendx). On the frst month followng 52 weekly contrbutons made to the Fund on your behalf, your lfe nsurance coverage wll be ncreased by an addtonal (see appendx) for a total coverage of (see appendx). If a partcpant des whle nsured, the Fund wll pay the schedule amount of lfe nsurance n force at the tme of death wth the exempton that f death s a result of sucde, no benefts wll be pad. Payment wll be made upon recept of due proof of death. If there s no survvng benefcary named, payment wll be made to the partcpant s Estate. Change of Benefcary You may change your benefcary at any tme by flng a wrtten request wth the Fund. The change becomes effectve upon recept of your request and wll be retroactve to the date your request was sgned. The change wll not affect any payment that was already released. No Converson Prvleges Upon termnaton of coverage there s no converson of ths Lfe Insurance snce the Fund provdes coverage only to actve partcpants. 79