Group Life and AD&D Plan TABLE OF CONTENTS (Click on any item below to go to that section) Introduction Group Life and AD&D Overview Life Insurance Optional Life Insurance Dependent Life Insurance Proof of Good Health AD&D Insurance Optional AD&D Coverage What is Not Covered Filing Claims If Your Claim is Denied To Contact the Claims Administrator End of Coverage Life Insurance Extension for Disability Life Insurance Conversion This SPD provides an overview of your plan s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and PeaceHealth and are subject to each state s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. For additional information, please contact AskHR (855-333-6947). Introduction This section: Outlines the core Life and AD&D insurance coverage provided by PeaceHealth at no cost to you. Explains your options for purchasing additional coverage for yourself, your spouse/domestic partner, or your dependents. Describes the circumstances under which you must provide proof of good health in order to obtain higher levels of insurance coverage. Explains the procedure for submitting claims Group Life and AD&D Overview The Group Life and Accidental Death and Dismemberment (AD&D) Plan is offered to provide a
level of financial protection for you and your dependents. Life insurance provides benefits to your beneficiary if you die. Accidental death and dismemberment insurance provides benefits if you die or are severely injured in an accident. Group Life and Accidental Death and Dismemberment (AD&D) insurance is provided to FlexAbility Benefit Plan members through MetLife Insurance. This section summarizes information contained in the group insurance certificate. When there is a dispute between this summary and the certificate, the certificate will supersede any provision listed in this summary. To obtain a copy of the certificate, please contact your local Human Resources department Life Insurance Through PeaceHealth, you receive Core Life Insurance at no cost to you. Your core life insurance benefits are determined by your base salary. Under this plan, if you die, your beneficiary will receive your core life insurance benefits in a single sum or, if desired, in installments. The maximum benefit is $50,000. Core Life Benefit Maximum Benefit Minimum Benefit 50% of your annual base pay $50,000 $5,000/each Note: Base pay is rounded to the next higher multiple of $l,000. Core life insurance amounts are reduced beginning at age 70. When you are: Your core life insurance benefit is: 70 years of age 65% of the amounts shown in the table above 75 years of age 45% of the amounts shown in the table above 80 years of age 30% of the amounts shown in the table above Optional Life Insurance Our Life Insurance plan allows you to purchase additional "optional" insurance, based on your annual base pay, as shown in the table below. You can purchase as much as 5 times your annual base pay up to a maximum of $1,000,000.
Option 1X annual base pay 2X annual base pay 3X annual base pay 4X annual base pay 5X annual base pay Maximum $1,000,000 Note: Base pay is rounded to the next higher multiple of $l,000. The amounts of your Optional Life Benefit are not subject to reduction. Dependent Life Insurance Core Life Insurance coverage is also provided for your dependents in the amount of $1,000 per dependent. Again, this is provided by PeaceHealth at no cost to you. If desired, you may purchase additional coverage for your spouse/domestic partner and dependents, as shown in the table below. Note that you can purchase increasing levels of coverage for your spouse/domestic partner; however, the coverage for each dependent remains the same for all options. Coverage for dependents applies only to children birth to 26 years of age. Option Spouse/Domestic Partner Dependents 1 $5,000 $5,000/each 2 $10,000 $5,000/each 3 $25,000 $5,000/each 4 $50,000 $5,000/each Dependent life insurance is in effect only if your personal insurance is in effect. Your dependents are eligible for dependent life insurance coverage on the date you become eligible for life insurance or on the date the person becomes your dependent, whichever is later. The amount of dependent life insurance coverage on any one of your dependents cannot be more than 100 percent of the amount of personal life insurance coverage you have. Any reduction in your life insurance coverage may result in a reduction of your dependent coverage as well. Changes to coverage amounts become effective on the date the change occurs. Proof of Good Health During Open Enrollment, you have the opportunity to elect the same level of Life Insurance coverage or increase coverage for you or your spouse/domestic partner. In some cases, you may need to provide proof of good health.
For Yourself If you do not have optional life coverage and you elect coverage during open enrollment, then Evidence of Insurability (EOI) is required. If you want to increase one level above, no EOI is required, provided you have not been hospitalized in the past 90 days. If you have, you must provide EOI. If you want to increase more than one level above, EOI is required. If you want to elect 4 or 5 times your annual base pay, you must provide EOI. New Hires Only: You can elect Life Insurance coverage in the amount of 1, 2, or 3 times your base pay with no proof of good health (EOI) if you have not been hospitalized in the last 90 days. For Your Spouse/Domestic Partner You can elect Dependent Life Insurance coverage for your spouse/domestic partner in the amount of $5,000 or $10,000 with no proof of good health (Evidence of Insurability.) New hires only: You are first required to answer whether or not your spouse/domestic partner has been hospitalized in the last 90 days. If you elect coverage in the amount of $25,000, no Evidence of Insurability is required unless your spouse/domestic partner has been hospitalized in the past 90 days. If so, you must provide Evidence of Insurability. If you elect coverage in the amount of $50,000, Evidence of Insurability is required. Accelerated Life Insurance If you become terminally ill while insured under this life insurance plan, you are eligible to receive up to 80 percent of the benefit while still living. (This also applies to dependent life insurance.) A terminal illness is defined as a medical condition that, in the opinion of a physician, is expected to result in death within 24 months. To receive this benefit you must: Become terminally ill while insured under the life insurance plan. Provide satisfactory proof that you have a terminal illness and submit to an independent physical examination, if requested. Continue to make premium payments on the full amount of the life insurance before receiving the accelerated benefit. Any benefits received under this provision may be taxable income and you should consult a personal tax advisor prior to electing this benefit. Other requirements may apply. For more information, please contact your Claims Administrator. AD&D Insurance Through PeaceHealth, you receive core AD&D Insurance at no cost to you. Your core AD&D benefits are determined by your base salary, as shown in the table below. The maximum benefit you may receive is $50,000.
Core AD&D Benefit Maximum Benefit Minimum Benefit 50% of your annual base pay $50,000 $5,000 Note: Base pay is rounded to the next higher multiple of $l,000. Under this plan, AD&D benefits are paid to you or your beneficiary in the event you are injured in an accident resulting in your death or a permanent loss within one year of the accident date. The table below lists some of these benefits: Loss AD&D Benefit Death Pays 100% of coverage Permanent loss of two hands, feet, or Pays 100% of coverage eyes in one accident Permanent loss of one hand, foot, or eye Pays 50% of coverage Permanent loss of hands or feet is defined as severance at or above the wrists or ankle joints respectively. Permanent loss of eyes is defined as complete and permanent sight loss. Click here for more detailed information. If you die as a result of an accident, your beneficiary would receive benefits from both the group Life and the AD&D plans. Beginning at age 70, core AD&D benefits are reduced on the same schedule as your personal life insurance. For schedule details, go to Life Insurance. Optional AD&D Coverage As with Life Insurance, our AD&D Insurance plan allows you to purchase additional "optional" insurance, based on your annual base pay, as shown in the table below. You can purchase as much as 5 times your annual base pay up to a maximum of $500,000. Option 1X annual base pay 2X annual base pay 3X annual base pay 4X annual base pay 5X annual base pay Maximum of $500,000 Note: Base pay is rounded to the next higher multiple of $l,000.
What Is Not Covered AD&D Insurance does not cover losses caused by: Physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity. Infection, other than infection occurring in an external accidental wound. Suicide or attempted suicide. Intentionally self-inflicted injury. Service in the armed forces of any country or international authority. However, services in reserve forces does not constitute service in the armed forces, unless in connection with such reserve service an individual is on active military duty as determined by the applicable military authority other than weekend or summer training. For purposes of this provision reserve forces are defined as reserve forces of any branch of the military of the United States or of any other country or international authority, including but not limited to the National Guard of the United States or the national guard of any other country. Any incident related to: o Travel in an aircraft as the pilot, crew member, flight student or while acting in an capacity other than a passenger; o Travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight; o Parachuting or otherwise exiting from an aircraft while such aircraft is in flight, except for self-preservation; o Travel in an aircraft or device used: For testing or experimental purposes; By or for any military authority; or For travel or designed for travel beyond the earth s atmosphere Committing or attempting to commit a felony. The voluntary intake or use by any means of: o Any drug, mediation or sedative, unless it is: Taken or used as prescribed by a Physician; or An over the counter drug, medication or sedative taken as directed; o Alcohol in combination with any drug, medication, or sedative; or o Poison, gas, or fumes; War, whether declared or undeclared; or act of war, insurrection, rebellion or riot. Filing Claims In the event of a death, send proof of death to your local Human Resources department within 90 days. Human Resources will complete the necessary paperwork and file a claim on your behalf. Benefits are paid in a lump sum unless you have requested and had approved another method of payment. Benefits are paid to your designated beneficiary. If no beneficiary is designated, then benefits are paid
according to this list: Your spouse Your children Your parents Your brothers and sisters Your estate If Your Claim Is Denied If your claim is denied, either in full or in part, and you do not agree with the reason, submit a letter and supporting information to Human Resources within 60 days of receiving the denial. State why you believe the claim should not have been denied, providing any supporting data, questions, or comments you think are appropriate. You will receive a written confirmation that your appeal is being reviewed. At that time, you may be required to submit additional documents for the review. Human Resources will forward your claim to the Claims Administrator, who will review it and give a final decision no later than 60 days from receipt of your request. If there are any special circumstances, you will be notified and given the final decision no later than 120 days from receipt of your request. To Contact the Claims Administrator Phone: 800-638-6420 (prompt 2) MetLife Insurance Company - Group Life Claims PO Box 6100 Scranton, PA 18505-6100 Overnight address: End of Coverage MetLife Insurance Company - Group Life Claims c/o Diversified Information Technologies 123 Wyoming Avenue Scranton, PA 18503 Coverage for both Life and AD&D Insurance ends on the last day of the month in which you retire or terminate your employment. If the insurer ends the plan, or your employer ends the insurance contract,
coverage would end on the date the plan or insurance contract is ended. Dependent insurance coverage automatically terminates when your personal insurance coverage terminates. If you take a leave of absence, coverage automatically continues while you are on an approved leave if you pay your premiums. For more information, contact your local Human Resources department. Life Insurance Extension for Disability If you become totally disabled before age 60 and die within one year after the disability begins, your life insurance benefits will be paid to your beneficiary. If you become totally disabled under the age of 60 and give satisfactory proof of disability within one year of the start of the disability, coverage will be extended without premium beginning with the second year of your continued coverage during disability. For more information, contact your Human Resources Department. Life Insurance Conversion If your life insurance ends, you may have the right to convert this policy to an individual whole life policy. You must apply for conversion within 31 days of your loss of coverage. Contact your Human Resources Department to apply.