TEAMSTERS LOCAL 97 BENEFITS FUND

 

 

SUMMARY PLAN DESCRIPTION

 

TIER III PLUS

 

 

 PLAN OF BENEFITS

 

February 1, 2009

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEAMSTERS LOCAL 97 BENEFITS FUND

BOARD OF TRUSTEES

 

Union Trustees

 

John Gerow

c/o Teamsters Local 97

485 Chestnut Street

Union, NJ  07083

 

Maria S. Perez

c/o Teamsters Local 97

485 Chestnut Street

Union, NJ  07083

 

Employer Trustees

 

Daniel J. Reiman

c/o Borough of Carteret

20 Cooke Avenue

Carteret, NJ  07008

 

John Lamela

c/o Jackson Twp. Board of Education

151 Don Connor Blvd.

Jackson, NJ 08527

 

Fund Manager

 

Elaine C. Alessio

 Teamsters Local 97 Benefits Fund

 485 Chestnut Street

Union, NJ  07083

(908) 810-0022

 

Fund Counsel

 

Mets, Schiro, & McGovern, LLP

655 Florida Grove Road

 P.O. Box 668

Woodbridge, NJ  07095

 

Fund Accountants

 

Ennis, Prezioso & Company, LLC

Certified Public Accountants

440 Sylvan Avenue

Englewood Cliffs, NJ  07632

 

Fund Consultant

 

O’Sullivan Associates, Inc.

110 Marter Avenue, Suite 304

Moorestown, NJ  08057

TEAMSTERS LOCAL 97 BENEFITS FUND

 

A MESSAGE FROM THE BOARD OF TRUSTEES

 

Dear Participant:

 

We are pleased to provide you with this updated booklet which summarizes the benefits available to you and your eligible dependents through the Teamsters Local 97 Benefits Fund as of September 15, 2007.  This booklet supersedes all previous booklets and other notices.

 

This booklet also describes the eligibility rules for obtaining these benefits, the procedures for submitting claims, your right to continue coverage if you end your employment, as well as other important information concerning your rights and obligations under the Plan.

 

The Teamsters Local 97 Benefits Fund maintains several levels of benefits.  The particular benefit level that applies to you is determined by the contribution rate paid by your employer.  The Fund has made every effort to be certain that you have received the correct Summary Plan.

Description, but if there is any question about the level of benefits that applies to you, please call the Fund Office.

 

Please read this booklet carefully and share it with your family.  Familiarize yourself with the benefits available to you and your eligible dependents as well as your rights and obligations under the Plan.  Keep this booklet available for future reference.

 

You will notice that certain words are capitalized throughout the booklet. These words are defined terms and have specific meanings for purposes of this booklet.

 

We will notify you when we make changes to the rules, regulations, procedures or schedule of benefits, as required by law. Please keep these written notices of changes with your booklet so that you will always have the most up-to-date information about the Plan.

The Trustees may at any time modify or eliminate (without prior notice to you) any of the benefits and/or eligibility requirements for benefits set forth in this booklet.  The Trustees have full authority and discretion to interpret the Plan of benefits and make final and binding determinations about your eligibility and rights to benefits. No benefits are guaranteed.

This booklet contains a summary in English of your rights and benefits under the Teamsters Local 97 Benefits Fund.  If you have difficulty understanding any part of this booklet, or in filing a claim, contact the Fund at 485 Chestnut Street, Union, NJ  07083.  If you have any questions about your benefits, please feel free to call the Fund Office at (888) 270-FUND for assistance.  The Fund Office hours are 8:30 A.M. to 4:30 P.M., Monday through Friday.

 

Este panfleto contiene un sumario en Ingles de los derechos y beneficios bajo este Fondo.  Si tiene cualquier problema de entender este panfleto, comuniquese con el Gerente del Fondo at 485 Chestnut Street, Union, NJ  07083.  Las Horas de Oficina son de 8:30 a.m ha 4:30 p.m. de lunes hasta viernes.  Puede lIamar la oficina de Fondo a (888) 270-FUND para asistencia.

 

Sincerely,

 

Board of Trustees

Teamsters Local 97 Benefits Fund

 

TEAMSTERS LOCAL 97 BENEFITS FUND

 

IMPORTANT!

All claims should be reported immediately

 

 

NOTIFY:

 

Teamsters Local 97 Benefits Fund

485 Chestnut Street

Union, NJ  07083

(888) 270-FUND

 

 

IF:

 

You get married

A child is born or adopted

Your dependent child reaches age 19

Your dependent child attends a college or university

You are divorced

You change your address

You want to change your beneficiary

 

 

IT IS YOUR RESPONSIBILITY TO ENSURE THAT THE FUND HAS UP-TO-DATE INFORMATION ON FILE FOR YOU, INCLUDING PROPER DOCUMENTATION FOR DEPENDENTS.

 

ALL CLAIMS MUST BE SUBMITTED WITHIN

ONE YEAR (12 MONTHS) OF THE DATE

OF SERVICE OR THE CLAIM WILL BE DENIED. SUBMIT YOUR MEDICAL BILLS PROMPTLY!

TEAMSTERS LOCAL 97 BENEFITS FUND

 

TABLE OF CONTENTS

 

Introduction.................................................................................................................            1

     Definitions.................................................................................................................            2

 

Eligibility And Effective Dates Of Coverage..........................................................            6

     Who Is Eligible For Coverage?................................................................................            6

     When Do Benefits Begin?........................................................................................            8

     When Do Benefits End?..........................................................................................             8

     Temporary Leave Of Employment...........................................................................             9

     Continuation Of Coverage During Leave Under The Family Medical Leave Act.....            9

 

COBRA Continuation Coverage..............................................................................          10

     COBRA....................................................................................................................           10

     Health Insurance Portability And Accountability Act.................................................          14

     Military Duty In The United States Armed Forces....................................................          15

 

Coordination Of Benefits..........................................................................................          16

     Coordination With Other Coverages........................................................................          16       

     Coordination With Automobile Insurance.................................................................           18

     Subrogation Cases Involving A Third Party..............................................................           19

 

Plan Benefits..............................................................................................................           21

     Lifetime Maximum Benefit Limitations.....................................................................          22

     Time Limits...............................................................................................................           22       

     Misrepresentation And Fraud...................................................................................          22

     Assignment And Alienation.......................................................................................          22

     Overpayments..........................................................................................................          22

     Notices Sent To Participants Or Dependents.........................................................          22

 

Hospitalization............................................................................................................          24

     Network And Non-Network Coverage......................................................................          24

     Comparison Of Coverage For Network And Out-Of-Network Services..................          25

     Hospitalization Benefits............................................................................................          25

     Hospital Exclusions..................................................................................................          28

     How To Claim A Hospital Benefit.............................................................................          28

 

Major Medical Benefits.............................................................................................           30

     Annual Deductible....................................................................................................           30

     Surgical And Anesthesia Benefits............................................................................           32

     How To Claim Major Medical Benefits.....................................................................           32

     Major Medical Exclusions.........................................................................................           33

     General Limitations And Exclusions........................................................................           34

     The Women’s Health And Cancer Rights Act Of 1998...........................................           36 

 

Dental Benefits...........................................................................................................          37

     General Benefits Provided.......................................................................................           37

     Maximum Benefit Limit.............................................................................................          37

     Special Limitations Applicable To Specific Dental Services....................................          38       

     Dental Expenses Not Covered.................................................................................          38

     How To Claim Dental Benefits.................................................................................          39 

TEAMSTERS LOCAL 97 BENEFITS FUND

 

TABLE OF CONTENTS (CONT’D)

 

Optical Benefits.......................................................................................................             40

     Covered Optical Expenses...................................................................................             40

     How To Claim Optical Plan Benefits.....................................................................             40

     Optical Plan Exclusions........................................................................................             40

 

Prescription Drug Benefits....................................................................................             41

     Covered Drugs......................................................................................................             41

     Exclusions.............................................................................................................             41

     Dispensing Limits..................................................................................................             43

     Generic And Brand Name Drugs..........................................................................             43

     Mail Service Prescription Drug Program..............................................................             43

 

Life Insurance Benefits..........................................................................................             44

     Death Benefit.........................................................................................................             44

     Accidental Death, Dismemberment And Loss Of Sight Benefits.........................             44 

     Exclusions.............................................................................................................              45

     Conversion Privilege.............................................................................................             45

     How To Claim Life Insurance And Accidental Death And Dismemberment

     Benefit...................................................................................................................             45

 

Claim Denial And Appeal Procedures...................................................................             46

     Claim Denial..........................................................................................................             46

     Appeal....................................................................................................................             47

     Determination Of Appeal.......................................................................................             47

     Incompetence........................................................................................................             48

     Trustees’ Right To Information..............................................................................             48

     Mailing Address Of Claimant.................................................................................             48

     Recovery Of Certain Payments............................................................................             49

 

Notice Of Privacy Practices...................................................................................             50

     Introduction............................................................................................................             50

     Permitted Uses and Disclosures..........................................................................             50 

     Your Rights............................................................................................................              53

     Complaints............................................................................................................             55

     For Questions Or Requests.................................................................................             55

 

Technical Details.....................................................................................................              56       

 

General Information................................................................................................             59

     Where To Get Help...............................................................................................             59

     Donde Obtener Asistencia....................................................................................             59

    

 

 

This booklet is a Summary Plan Description of the Teamsters Local 97 Benefits Fund as it applies to eligible Participants and their covered dependents, effective as of January 1, 2009. This booklet supersedes and replaces all previous materials.

 

The Fund provides benefits to employees of employers whose collective bargaining agreements with the Union, or other written agreements, require that contributions be made to the Fund on behalf of such employees.

 

The Teamsters Local 97 Benefits Fund is a "jointly-administered" fund.  It is sponsored by and administered under the direction of a Board of Trustees made up of representatives appointed by Local 97, I.B.T. and the contributing Employers.  The Board of Trustees establishes the benefits and policies of the Fund, the rules and regulations necessary for carrying out those benefits and policies, and generally oversees the administration of the Fund.  The Board of Trustees and the Fund Manager are assisted by professional advisors.

 

The Board of Trustees, acting as a body, has sole authority and discretion to interpret and construe the terms of this Plan and the Agreement and Declaration of Trust governing the Fund, including provisions establishing eligibility for benefits, the manner in which hours of work are credited for eligibility, the continuance or discontinuance of benefits, the status of any person as a covered or non-covered Participant, and the level and type of benefits, as well as all other matters.  The Board reserves the right, in its sole and absolute discretion, to make exceptions on a case by case basis from the rules set forth herein, where the exception is cost-justified, is consistent with sound medical practices, and is in the interest of the Fund as a whole.  Any determination made by the Board of Trustees with respect to a Participant's rights or benefits will be entitled to the maximum deference permitted by law and will be final and binding upon all Participants and beneficiaries.

 

It is anticipated that the Plan will remain in effect indefinitely.  However, the Board of Trustees reserves the right to amend, modify or terminate the Plan at any time, in accordance with the Agreement and Declaration of Trust governing the Fund.  The Trustees specifically reserve the right to change, eliminate, or add to the benefits provided to Participants and beneficiaries.  They also reserve the right to adopt new Fund rules and regulations, to modify the rules and regulations and to terminate the existing Plan.  In addition, the continuance of the Plan is subject to the maintenance of collective bargaining agreements which provide for Employer contributions to the Fund. No benefits or rules described in this booklet are guaranteed (vested) for any Participant or eligible dependent.  All benefits and rules may be changed, reduced or eliminated at any time by the Board of Trustees, in their sole discretion. All material modifications to the Plan of benefits or the rules adopted by the Board of Trustees will be communicated in writing and distributed to the Participants, as required by law, so that the Participants may have current information concerning their rights and benefits. 

 

If it ever becomes necessary to terminate the Plan, the Trust Agreement provides that assets then remaining in the Fund, after providing for claims, liability and administrative expenses, will be applied in such manner as the Board of Trustees may determine to provide, to the extent possible, for the payment of benefits provided under the Plan to eligible Participants and their covered dependents.  In no event will any of the assets of the Fund revert to any Employer or to the Union, except, in the case of an overpayment where a refund is permitted by law.  Upon final liquidation of the Fund, Participants and beneficiaries would have no further rights or interest in the Fund. 

 

No local union, local union officer, business agent, local union employee, employer or employer representative, association or association representative, individual Trustee, consultant, attorney or any other person may speak for or on behalf of this Fund, or commit or legally bind the Board of Trustees of this Fund in any matter whatsoever relating to the Fund, unless such person shall have been given express authority from the Board of Trustees to act in such matter.  Statements by the Fund Office, whether oral or written, cannot modify the benefits  described in this booklet. All inquiries, requests for ruling, interpretations, and decisions must be directed to the full Board of Trustees in care of the Fund Office. 

 

In reading this document, note that whenever a pronoun or other word describes a masculine person, such pronoun or word also includes a feminine person, unless the context clearly indicates otherwise. In addition, the words used in the singular person also include plural persons, unless the context clearly indicates otherwise.

 

DEFINITIONS

 

When reading this booklet, you may encounter some terms with which you may not be familiar or which may have specific meaning for purposes of this booklet.  The following definitions are provided to help you understand what these terms mean and how they are applied.

 

Accidental: a loss due solely to violent, external, and unintentional means.

 

Beneficiary: a person designated by an active Employee to receive any death benefits payable under the Plan.

 

Board Of Trustees Or Trustees: the joint Board of Trustees of the Teamsters Local 97 Benefits Fund.

 

Collective Bargaining Agreement(s): the labor agreement(s) between the Union and participating Employers, which provide(s) for the payment of contributions to the Fund.

 

COBRA: the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, April 7, 1986, as amended.

 

Covered Employment: work for which an Employer is required to and does make contributions to the Fund under a Collective Bargaining Agreement or a Participation Agreement. 

 

Covered Expense: a charge that is allowable under the Plan for a Medically Necessary service or supply.

 

Custodial Care: all services and supplies, including room and board, which are provided primarily to assist an eligible Participant or his/her eligible Dependent in the activities of daily living and which do not require the continuous attention of trained medical or paramedical personnel. Such care may include, but are not limited to, preparation of special diets, supervision over medication that can be self-administered, assistance in getting in or out of bed, walking, bathing, dressing, and eating. Services and supplies may be deemed to be Custodial Care without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed.  

 

 

 

Deductible: the out-of-pocket expense that you must pay each year before a Major Medical benefit, and, if applicable, prescription drug benefit, is payable under the Plan. (See Page 30).

 

Dentist: a person who is duly licensed and acting within the scope of his license to practice dentistry, including a Physician furnishing dental care which he is licensed to provide.

 

Disability Or Disabled: your inability to perform substantially all of the duties of your occupation in Covered Employment because of a medically determined physical or mental Illness or Injury.

 

Eligible Employee: an Employee who has met the eligibility requirements of the Plan or who elected COBRA continuation coverage and submitted timely premium payments.

 

Employee: a person employed by an Employer in work covered under a Collective Bargaining Agreement or a Participation Agreement on whose behalf contributions are required to be made to the Fund.

 

Employer: any Employer that is obligated, under a Collective Bargaining Agreement or other written agreement, to make contributions to the Fund on behalf of its covered employees.

 

ERlSA: the Employee Retirement Income Security Act of 1974, P.I. 93-406, Sept. 2, 1974, as amended.

 

Experimental:

 

a. any medical procedure, equipment, treatment or course of treatment, or drug or medicine that is meant to investigate and is limited to research;

 

b. techniques that are restricted to use at centers which are capable of carrying out disciplined clinical efforts and scientific studies;

 

c. procedures which are not proven in an objective way to have therapeutic value or benefit; and/or

 

d. any procedure or treatment which is obsolete or whose effectiveness is medically questionable.

 

Government approval of a procedure, equipment, treatment, drug, medicine or technique is not necessarily sufficient to prove that it is beneficial or appropriate or effective for a particular diagnosis or treatment of a covered person's particular condition.  Any or all of the following five criteria may, within the Trustees' sole discretion, be applied in determining whether such procedure, etc., is experimental or investigative, obsolete or ineffective:

 

1. Any medical device, drug or biological product must have received final approval to market by the U.S. Food and Drug Administration (FDA) for the particular diagnosis or condition. Once FDA approval has been granted for a particular diagnosis or condition, use of the medical device, drug or biological product for another diagnosis or condition may require that any or all of these five criteria be met.

 

2. Conclusive evidence from the published peer-reviewed medical literature must exist that the procedure has a definite positive effect on health outcomes.

 

3. Demonstrated evidence as reflected in the published peer-reviewed medical literature must exist that over time the procedure leads to improvement in health outcomes, i.e., the beneficial effects outweigh any harmful effects.

 

4. Proof, as reflected in the published peer-reviewed medical literature, must exist that the procedure is at least as effective in improving health outcomes as established procedure, or is usable in appropriate clinical contexts in which established procedure is not employable.

 

5. Proof, as reflected in the published peer-reviewed medical literature, must exist that improvement in health outcomes (as defined in 3. above) is possible in standard conditions of medical practice, outside clinical investigatory settings.

 

Fund: the Teamsters Local 97 Benefits Fund.

 

Fund Office: Teamsters Local 97 Benefits Fund, 485 Chestnut Street, Union, NJ  07083, (888) 270-FUND. 

 

Hospital: an institution that: (1) is duly licensed as a Hospital (if licensing is required in the state); (2) operates primarily for the diagnosis, treatment and rehabilitation of sick, injured or disabled persons as in-patients; (3) provides 24-hour nursing services by registered or graduate nurses on duty or call; (4) has a staff of one or more licensed physicians available at all times; (5) provides organized facilities for diagnosis and surgery either on its premises or at an institution with which the establishment has a formal arrangement for the provision of such facilities; (6) is not primarily a clinic, nursing, rest or convalescent home or an extended care facility or a similar establishment and is not (other than incidentally) a place for treatment of alcoholism or drug addiction, and (7) has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.  Confinement in a special unit of a Hospital used primarily as a nursing, rest or convalescent home or extended care facility is deemed to be confinement in an institution other than a Hospital.

 

Illness: a sickness, disorder or disease resulting in an unsound condition of the mind or body, including, but not limited to, pregnancy, child birth and related conditions.

 

Injury: a wound or damage sustained accidentally and by external force.

 

Maintenance Drugs: drugs which are prescribed for an extended period of time and are necessary to sustain good health. Examples are drugs used to treat high blood pressure, diabetes and arthritis.

 

Medically Necessary: any service, treatment or supply, including a Hospital confinement, furnished or prescribed by a Physician or other licensed provider to identify or treat an Illness or injury, that:

 

•   is necessary for the diagnosis and treatment of the Illness or Injury for which it is      performed;

 

•   is based upon valid medical need;

 

•   meets generally accepted standards of medical practice;

 

•   is required for reason other than the convenience of the patient or provider; and

 

•   is the most appropriate level of service or supply that can safely be provided for the patient.

 

The fact that services or supplies are furnished or prescribed by a Physician or other licensed provider does not necessarily mean that they are Medically Necessary.  (See page 21).

 

Medicare:  any health insurance benefits provided under Title XVIII of the Social Security Act of 1965, as amended.

 

Mental Or Nervous Disorder:  a neurosis, psychoneurosis, psychopathy or other mental or emotional disease or disorder.

 

Participant:  an Eligible Employee.

 

Participation Agreement: an Agreement between the Fund and an Employer which provides for the payment of contributions to the Fund on behalf of Employees not covered by a Collective Bargaining Agreement.

 

Physician: a duly licensed doctor of medicine or osteopathy acting within the scope of his license. The Plan covers expenses for professional medical services of licensed social workers, and chiropractors certified in the state where their practice is located.

 

Plan: the Plan of benefits and eligibility rules maintained by the Teamsters Local 97 Benefit Fund as set forth herein and as amended from time to time.

 

Preferred Provider Organization (PPO): a group of selected physicians, specialists, Hospitals, and other treatment centers which have agreed to provide their services to Fund Participants and beneficiaries at a negotiated rate under the terms of an agreement. These medical providers are sometimes referred to as "Network providers" or "Panel providers" interchangeably throughout this booklet. Similarly, medical providers that are not under contract to provide services at negotiated rates are referred to as "Non-network", "Out-of-Network" and "Non-panel providers".

 

Reasonable And Customary (R&C):  the fee regularly charged and received by a person, group or entity for services, treatments or supplies covered under the Plan to the extent such fee does not exceed the general level of charges by others who render or furnish such services, treatments or supplies in the locality where the charge is incurred, for illness or injury comparable in nature and severity.  The term "locality" means a county or such greater geographically significant area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made.  (See page 21).

 

Union: Local 97, I.B.T. and any additional unions having Collective Bargaining Agreements with Employers requiring that contributions be made to the Teamsters Local 97 Benefits Fund on behalf of Covered Employees.

 

 

 

WHO IS ELIGIBLE FOR COVERAGE?

 

As an Employee employed by an Employer for whom contributions are required to be made to the Teamsters Local 97 Benefits Fund pursuant to a Collective Bargaining Agreement or other written agreement, you and your eligible Dependent(s) are eligible to participate in the Fund.

 

Who Are Your Eligible Dependents?

 

Your eligible dependents are:

 

•   Your legal spouse; (see page 7 regarding civil unions)

 

•   Your unmarried dependent child(ren) under age 19.

 

•   Your unmarried dependent child(ren) age 19 or over who is/are: (1) attending an       accredited college, university, or high school as full-time student; and (2) chiefly       dependent upon you for support; and (3) who normally reside in your household. Such   child(ren) will continue to be eligible until they are no longer full-time students or until      their 23rd birthday, whichever occurs first.  You must provide the Fund Office with proof     of your child's full-time student status for each semester in order for your child(ren) to          be eligible for benefits under this paragraph. Acceptable form of proof is a letter for the           semester from the school registrar indicating that the child is a full-time student.  "Full-       time student" is defined as enrolled for at least twelve (12) credits per semester.

 

•  Your unmarried child(ren) of any age who would otherwise lose coverage because of           the Plan's age limitations who is incapable of self support due to a physical handicap, developmental disability, mental retardation or mental Illness, provided that the      child becomes so incapable prior to age 19, and who is dependent on you for support        as of the date on which coverage would otherwise end. You must provide written proof           of your child's handicap within 31 days after the date that coverage for the child would     normally end. Coverage under the Plan may be continued for as long as the incapacity        and dependency continue, subject to periodic review by the Fund, but, in any event,             will terminate no later than the date on which your coverage terminates.

 

For purposes of this section, the term "child(ren)" includes: 

 

•   your biological and/or legally adopted child(ren);

 

•   your stepchild(ren) - the natural child of your legal spouse, who resides with you and is        chiefly dependent on you for support;

 

•   a child who has been placed with you for adoption from time of placement, where you          assumed a legal obligation for total or partial support of the child in anticipation of     adoption;

 

•   a child for whom you are the legal guardian, are required to provide support, and who is       chiefly dependent upon you for support; .a child for whom you are required to provide health coverage pursuant to a Qualified Medical Child Support Order (QMSCO).  If you            

 

 

    have questions about QMCSOs or think you may have received one, contact the Fund        Office. The Fund Office has procedures governing such orders. Copies of these     procedures are available upon request from the Fund Office without charge. All   QMSCOs must be submitted to the Fund Office for review and approval.

 

Individuals eligible for coverage as Employees will also be covered as dependents if they meet the eligibility rules as a covered dependent of another Eligible Employee (such as when both husband and wife are Eligible Employees).

 

Coverage under the Teamsters Local 97 Benefit Fund for Civil Union Couples

 

The Trustees of the Plan has approved providing coverage for Civil Union Couples.

 

On February 19, 2007, The Civil Union Law went into effect. This law established “civil unions” between same-sex couples within the State of New  Jersey.

 

The Civil Union Law provides for the recognition of civil unions formed in New Jersey as well as the states of Connecticut and Vermont. New Jersey also recognizes same-sex marriages performed in Massachusetts, Canada, Belgium, the Netherlands, South Africa, and Spain as Civil Unions. Domestic partnerships formed in California are also recognized in New Jersey.

 

Domestic partnerships established in Hawaii, Maine, or the District of Columbia and those established in New Jersey prior to February 19, 2007 will continue to be accepted for benefits under the provisions of the Domestic Partnership Act.

 

After February 19, 2007, same sex couples are permitted to establish a civil union but may no longer enter into a domestic partnership in New Jersey.

 

Enrollment of a Civil Union Partner for Teamsters Local 97 Benefit Coverage

 To add a civil union partner to the coverage, you must submit the appropriate enrollment application to the Fund Office. You must provide a photocopy of the New Jersey Civil Union Certificate or a valid certificate from another jurisdiction that recognizes same-sex civil unions or domestic partnerships. If the application is received within 60 days of the date of the civil union, the effective date of coverage will be the date of the civil union. If the application is submitted after the 60 days of the date of the civil union, the effective date will be the day the application is received.

 

Taxability of the Civil Union Partner Benefit

 It is important to note that because the federal internal revenue code does not view a civil union partner in the same manner as a spouse, the cost of a civil union partner’s coverage may be subject to federal taxes (similar to the current tax liability of domestic partners).

 The value of the employer health benefits provided to a civil union partner is normally subject to federal income taxes, Social Security, and Medicare taxes as imputed income. Please note that the value of the Civil Union benefit is not taxable under New Jersey law.

If the civil union partner meets the IRS definition of a dependent for tax purposes, the benefit will not be subject to federal taxes.

 

 

 

 

 

WHEN DO BENEFITS BEGIN?  

 

Generally, Hospital, Major Medical, Prescription, Dental, Vision and Life Insurance benefits begin on the first day of the month following the receipt of three (3) months of contributions on your behalf, provided you are actively employed at that time.  The exact date depends on the date that contributions are required to be paid on your behalf by your Employer as set forth in the Collective Bargaining Agreement or Participation Agreement between the Union and your Employer. If your Employer fails to commence making contributions on your behalf when required under the Collective Bargaining Agreement or a Participation Agreement, you will be granted eligibility retroactive to the date your Employer was required to commence making such contributions, once the contributions are made.

 

CHECK YOUR COLLECTIVE BARGAINING AGREEMENT

FOR THE DATE CONTRIBUTIONS MUST COMMENCE BEING

PAID ON YOUR BEHALF

 

Coverage for your eligible Dependent(s) will begin on the date you become eligible for coverage or on the date you acquire an eligible Dependent, whichever occurs later.

 

Enrollment Forms

 

All Participants must complete an enrollment form obtained from their Employer or the Fund Office. At the time of enrollment, your marriage certificate and birth certificates for your eligible dependent child(ren) must be submitted with your enrollment form. No claims will be paid until the appropriate documents are provided to the Fund Office.  Copies will not be accepted.  Originals will be copied at the Fund office and returned to you the same day.  Please enclose a stamped, self-addressed envelope when sending in your documents.

 

WHEN DO BENEFITS END?

 

Your coverage under this Plan will remain in effect until the last day of the month a contribution was made on your behalf.  However, if your employer is required to contribute on your behalf while you are on leave or otherwise not actively employed, the Fund will treat you as "actively employed" for such period.

 

Coverage for your eligible dependents stops when your coverage stops, or when they are no longer eligible, whichever occurs first. However, you and your dependents may be entitled to continue coverage on a self-pay basis subject to certain restrictions for a limited period of time.  See COBRA Continuation Coverage, page 10.

 

In the event that your Employer ceases to be a contributing Employer for any reason, coverage for you and your dependents will cease on the last day of the calendar month for which contributions are both required to be made and actually made to the Fund. You will not be eligible for COBRA Continuation Coverage if your benefits are terminated because your Employer ceases to be required to contribute to the Fund.

 

 

NOTE: Coverage for you and your eligible dependents may be terminated immediately if your Employer fails to make required contributions to the Fund on your behalf.  The Fund Office will notify you prior to such termination. IMPORTANT.  You will not be eligible for COBRA continuation coverage if your benefits are terminated due to your Employer's failure to remit required contributions.

 

TEMPORARY LEAVE OF EMPLOYMENT

 

If you terminate Covered Employment and subsequently return to work with an Employer after your coverage under the Fund has terminated, your coverage will be reinstated on the first day of the month following receipt of one (1) month's contribution provided your temporary leave is shorter than the time that you have been covered under the Plan.  If your temporary leave is longer than the time covered under the Plan, your coverage will begin the first of the month following the receipt of three (3) months' contributions.

 

If you have a temporary termination of Covered Employment and you return to Covered Employment while your coverage is still in effect, there will be no break in your coverage, provided that you remain in Covered Employment until at least one (1) month of contributions is received on your behalf. Under these circumstances, your coverage for all benefits will remain in effect as if your temporary separation had not occurred. This will also be true if you have remained covered by this Plan because you have elected and paid COBRA premiums as described on page 13.

 

CONTINUATION OF COVERAGE DURING LEAVE UNDER THE FAMILY MEDICAL LEAVE ACT

 

You may be entitled to have contributions made on your behalf while you are not working under the Family Medical Leave Act (FMLA). The FMLA entitles eligible employees to take up to a maximum of 12 weeks of unpaid leave during any 12-month period for specified family or medical purposes, such as the birth of a child, child care for the employee's children, the adoption of a child by the employee, the need to care for a family member with a serious health condition, or the employee's inability to perform the duties of his position because of a serious health condition. You should check with your Employer to determine if your Employer is covered under the FMLA and if the leave you wish to take is covered by the FMLA.

 

Your Employer has an obligation to continue your medical coverage during a leave of absence under the provisions of the FMLA.  In order to continue your coverage through this Fund, your Employer must continue to make contributions on your behalf for each week you are on an approved FMLA leave. Contact the Fund Office if you are planning to take FMLA leave so that the Fund is aware of your Employer's responsibility to make contributions during your absence. Note that if you do not return to work after your FMLA leave ends, you may be required to repay the amount your Employer paid towards your coverage.

 

 

 

COBRA

 

The Consolidated Omnibus Budget Reconciliation Act of 1985, more commonly known as COBRA, provides that you and/or your eligible dependents can continue health care coverage on a temporary basis in certain instances where coverage under the Plan would otherwise end. In order to continue health coverage under COBRA, you or your dependents are required to pay the full cost for such coverage during the continuation period. If you elect coverage, you will receive the same coverage as is provided by the Fund to similarly situated employees.

 

The Internal Revenue Service (IRS) has issued a notice (Notice 98-12), in question and answer format, to assist employees and their families in determining whether to elect COBRA continuation coverage.  These questions and answers are available at the IRS Internet site (http://www.irs.ustreas.gov) and at the Department of Labor (DOL) Internet site (http://www.dol.gov/dol/pwba). Copies of the Notice are also available upon request from the Fund Office. 

 

Qualifying Events

 

COBRA continuation coverage is available should the occurrence of any of the following events result in loss of coverage under the Fund:

 

•   termination of your employment (for reasons other than gross misconduct) or reduction      in hours of employment; 

 

•   your death; 

 

•   you become eligible for Medicare;

 

•   you and your spouse become divorced or legally separated; and

 

•   your child ceases to be a "Dependent" as defined under this Plan (e.g., due to reaching       the age limitation).

 

Reporting Requirements

 

Your Employer must notify the Fund Office of the occurrence of any of the following qualifying events:

 

•   termination of your employment;

 

•   reduction of your working hours resulting in a loss of coverage;

 

•   your eligibility for Medicare; and

 

•   your death.

 

This notification must be in writing and must be furnished within 30 days of the occurrence of the qualifying event.  Failure to provide such timely notification will subject the Employer to penalties under federal law and can result in your not getting the opportunity to elect to continue coverage.

 

 

 

You, your spouse or your dependent must notify the Fund Office of the occurrence of the following qualifying events:

 

•   your divorce or legal separation; and

 

•   your child ceasing to be a "Dependent" as defined under this Plan.

 

    This notification must be furnished in writing to the Fund Office within 60 days of the            occurrence of the qualifying event.  Failure to furnish such notification within the           required 60 days may result in the loss of the Opportunity to elect continuation          coverage.

 

Notice And Election Form

 

Within 14 days of receipt of notice that a qualifying event has occurred, the Fund Office will send the affected person(s) COBRA Notice and Election Form.  This form will contain the details of the various coverage options available, their cost, and the conditions under which the continuation coverage will terminate.

 

The form must be returned to the Fund Office within 60 days after receipt. If you or your dependent(s) do not return the form within that time, coverage will be terminated as of the date of the qualifying event. Your initial premium payment must be made within 45 days of the date you return the election form.  This payment must include all amounts due retroactively from the date on which coverage would otherwise have terminated under the Plan.  Thereafter, payments must be made in a timely manner in order to maintain coverage.  If payments are not made in a timely manner, your COBRA continuation coverage will terminate.

 

You can elect coverage for yourself alone, for yourself and all eligible dependents who were covered on the day before your qualifying event, or for any of such dependents alone.  Your spouse and your dependent children have the right to choose continuation coverage for themselves if they lose coverage as a result of a qualifying event.

 

Addition Of New Dependents While On COBRA  

 

lf you have a newborn child or a child placed with you for adoption while you are on COBRA coverage, that child will be eligible for coverage for the balance of your COBRA coverage period. You must notify the Fund within 30 days after the birth or placement.  Adding a child may cause an increase in the amount you must pay for COBRA coverage if you are not already paying for family coverage.

 

Type Of Coverage

 

Two types of COBRA continuation coverage may be elected by you, your spouse or your eligible dependents.  The first type, called "core coverage" provides the following benefits:

 

•   basic hospital and medical benefits;

 

•   surgical expense benefits;

 

•   diagnostic x-ray and laboratory expenses;

 

 

 

•   Major Medical benefits; and

 

•   prescription drug benefits.

 

The second type of coverage, called "core plus non-core coverage" provides the above benefits plus the following additional benefits to you and your eligible dependents:

 

•   vision care benefits; and

 

•   dental benefits.

 

Death benefits and accidental death and dismemberment benefits are not available under COBRA continuation coverage. You may have the right to convert these benefits to a self pay contract (see page 45).

 

Once the selection of core or core plus non-core coverage has been made, it is permanent for the duration of the continuation coverage period.

 

Duration Of Continuation Coverage

 

lf COBRA continuation coverage is chosen, the Fund will make available health coverage which, as of the time that coverage is provided, is identical to the coverage provided under the Plan to similarly situated covered persons.  If coverage for similarly situated covered persons is modified after continuation coverage has been elected, the continuation coverage will be modified accordingly.

 

The maximum duration of the continuation coverage is shown on the following chart:

 

	Maximum Period For COBRA Coverage
Qualifying Event	Employee	Dependent Spouse	Dependent Spouse
Employee's termination of employment (for other than gross misconduct)	18 months	18 months	18 months
Employee's reduction in hours worked (making employee ineligible for coverage)	18 months	18 months	18 months
Death of Employee	N/A	36 months	36 months
Employee becomes divorced or legally separated	N/A	36 months	36 months
Employee becomes entitled to Medicare	N/A	36 months	36 months
Employee or Qualified Dependent is disabled at start of COBRA period or within first 60 days of COBRA coverage**	29 months	29 months	29 months
Dependent child ceases to be an Eligible Dependent (e.g., is older than 19 and not enrolled as a full-time student)	N/A	N/A	36 months

 

 

 

 

**  If during the 18-month continuation period you, your spouse or dependents become disabled   and receive a determination of disability from the Social Security Administration, the 19-  month coverage period may be extended for all family members for up to a maximum of 29     months from the date of the qualifying event.  The disability extension is only available where       the disability commenced prior to or within the first 60 days of COBRA continuation coverage             and the Fund Office is provided with a copy of the Social Security determination before the        expiration of the 18-month period.  This extension period will end at the earlier of the end of           29 months or when the disabled person becomes entitled to Medicare.

 

CONTINUED COVERAGE IS CONDITIONED UPON

THE TIMELY PAYMENT OF PREMIUMS

 

Multiple Qualifying Events

 

If you or your qualified dependent(s) are entitled to COBRA coverage as a result of your termination of Covered Employment or reduction of working hours, and another qualifying event occurs within 18 months after the first qualifying event, COBRA coverage for your qualified dependents may be extended up to a maximum of 36 months from the date of the first qualifying event.  Example:  If you terminate employment and elect COBRA coverage for you and your qualified dependents, and you die within 18 months after your termination of employment, your Dependents may extend their COBRA coverage for an additional 18 months, for a total of 36 months from the date your employment terminated.

 

Premium Payments

 

When you, your spouse or your eligible dependents become eligible to receive COBRA continuation coverage, you will be advised of the premium charge for both the core and core plus non-core coverage.  The COBRA premium charge is 102% of the cost of coverage. However, any individual who receives coverage for an extension of 11 months due to a Social Security disability (as set forth above) must pay 150% of the cost of coverage during the 11-month disability extension.

 

Once continuation coverage is elected, premium payments must be made on time for the duration of the continuation period in order to keep the coverage in effect.  The premium due date is the first day of the month in which continuation coverage begins.  For example, premiums for the month of November must be paid on or before November 1.

 

Be aware that the Fund does not issue a bill for COBRA, other than the initial notice. It is the Participant's responsibility to make COBRA payments on a timely basis.

 

The premium due for the initial period of continuation coverage will include payment for the period of time dating back to the date on which Plan coverage terminated.  Subsequent premium payments are due on the first day of each month. Failure to pay the full premium by each due date will result in a loss of all coverage.  Coverage may not be reinstated once it is lost due to a failure to pay premiums.

 

 

 

Termination Of Continuation Coverage

 

In addition to the expiration of the 18, 29, or 36-month periods, continuation coverage may be terminated for any of the following reasons:

 

• timely premium payment has not been made;

 

•  you (or your spouse or dependents) become covered under another health plan (and no       pre-existing condition exclusion applies);

 

•  you, your spouse or dependent obtained a disability determination from Social Security,        but are no longer disabled, the Fund no longer provides group health coverage to any        employees; and

 

•  you become eligible for Medicare.

 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

 

Recent changes in federal law may affect your health coverage if you are enrolled or become eligible to enroll in health coverage that excludes coverage for pre-existing medical conditions.

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before you enroll.  Under  the law, a pre-existing condition exclusion generally may not be imposed for more than 12 months (18 months for a late enrollee).  The 12-month (or 18-month) exclusion period is reduced by your prior health coverage.  The Teamsters Local 97 Benefits Fund does not have a pre-existing condition exclusion. If you buy health insurance other than through an employer group health plan, a certificate of prior coverage may help you obtain coverage without a pre-existing condition exclusion.  Contact your state insurance department for further information.

 

You have the right to receive a certificate of prior health coverage since July 1, 1996.  You may need to provide other documentation for earlier periods of health care coverage.  Check with your new Fund Manager to see if your new plan excludes coverage for pre-existing conditions and if you need to provide a certificate or other documentation of your previous coverage.

 

To get a certificate, please contact the Fund Office.

 

The certificate must be provided to you promptly.  You may also request certificates for any of your dependents (including your spouse) who were enrolled under your health coverage.

 

 

Special Enrollment Rights

 

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward you or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). 

 

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If the event was a marriage, the coverage is required to be effective no later than the first day of the first calendar month beginning after the date the completed request for enrollment is received by the plan. In the case of birth, adoption, or placement for adoption, coverage is required to be effective no later than the date of the event.

 

MILITARY DUTY IN THE UNITED STATES ARMED FORCES

 

If you enter the Armed Forced of the United States, you may elect to continue coverage under the Plan for you and your dependents pursuant to the provisions of the Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA).  The maximum period of coverage under such election is the lesser of 18 months from the date your absence due to military service begins or the day after the date on which you fail to apply for or return to a position of employment. If the period of military service is less than 31 days, your coverage (and your dependents' coverage) will continue during the period of military service.  If the period of military service exceeds 31 days, you will be required to pay the applicable COBRA premium to

continue coverage. If you do not elect to continue coverage during the period of military service, you will be entitled to have your coverage reinstated on the date you return to covered employment with a contributing employer. 

 

No exclusion or waiting period will be imposed, except in the case of certain service-connected disabilities.  These rights granted under USERRA are dependent upon uniformed service that ends honorably.  Contact the Fund Office for further details regarding your rights and obligations under USERRA.

 

 

 

 

COORDINATION WITH OTHER COVERAGES

 

Quite frequently, when both husband and wife work outside the home, Participants and members of their family are covered under more than one Plan of employee benefits.  As a result, there may be a duplication of benefit coverage.  Duplication occurs when two Plans are paying benefits for the same dollar of medical expense.  For this reason a "coordination of benefits" provision has been included in our Plan for all covered benefits, excluding Life Insurance benefits.

 

Under the Coordination of Benefits provision, if a Participant or any of his dependents is also insured or entitled to health insurance coverage under any other group Plan, the total payment received for anyone person from all such programs combined may not amount to more than 100% of the "allowable expenses".

 

Benefits are reduced only to the extent necessary to prevent an individual from recovering more money than was charged.  A Participant must report any duplicate group health coverage to the Fund Office.  As the secondary payor, the Teamsters Health and Benefit Fund will pay the difference between "allowable expenses" under the Plan and whatever the primary Plan actually paid. Typically, an individual with duplicate coverage should have limited out-of-pocket expenses.

 

The important thing to remember is that Coordination of Benefits is designed to conserve your health care dollars.  This protects the entire Fund from unnecessary increases in cost. 

 

Allowable Expense

 

Allowable Expense means any Medically Necessary, Reasonable and Customary expense, at least a part of which is provided by any one of the Plans that covers the person for whom a claim is made.

 

Which Plan Pays First

 

The Plan under which benefits are payable first is the primary Plan. All other Plans are called secondary Plans.  The secondary Plans pay any remaining unpaid allowable expenses.  No Plan pays more than it would have paid without this provision. 

 

The rules below determine which Plan's benefits are payable first:

 

a.  A Plan which does not have Coordination of Benefits provisions is always primary and pays first.

 

b.  A Plan that covers the individual as an Eligible Employee pays first.

 

c. The individual is covered as an Eligible Employee under two Plans, the Plan which has covered him longer is primary.

 

d.  A Plan which covers the individual as an active Eligible Employee pays before a Plan which covers the individual as a laid-off Participant or retiree.

 

 

 

e.  A Plan which covers the individual as an Eligible Employee pays before a Plan which covers the individual as a dependent.

 

The rules below determine which Plan's benefits are payable first, if a dependent child is covered under two or more Plans:

 

a.  If the parents are not divorced or separated:

 

     The Plan that covers the parent whose date of birth occurs earlier in the calendar year pays first. If the birthday of both parents occurs on the same date, the Plan which has covered the parent for the longer period of time pays first. The "Birthday Rule" will always be applied to determine the Fund's claim liability even if the other Plan does not have the provisions of this paragraph (i.e. Gender Rule).

 

b.  If the individual is a dependent child of legally separated or divorced parents, the "order of payment" used to determine the primary Plan is as follows:

 

1. The Plan of the parent with custody of the child pays first.

 

2. The Plan of the stepparent with custody of the child pays before the Plan of the parent without custody.

 

3. If a court order makes one parent financially responsible for the health care expenses of the child, that parent's Plan will pay first.  The Plan of the other parent will be secondary, and the Plan of any stepparent will be last.

 

Finally, if the Fund Office has made payment of any amount that is in excess of that permitted by this Coordination of Benefits, the Fund Office has the right to recover such amount from any party that has " received such overpayment.

 

Coordination Of Benefits With Medicare For Active Employees

 

If you or your spouse is age 65 or older, you are eligible for insurance benefits under Title XVIII of the Social Security Act of 1965 (Medicare). You do not have to be retired to receive these benefits. Medicare includes hospital insurance benefits (Part "A"), as well as supplementary medical insurance (Part "B").  While you remain actively working and eligible for coverage under this Plan, regardless of your age, you will receive the same benefits from the Health Fund as an eligible Participant under age 65.  Medicare will provide secondary coverage for some care, if the Fund does not pay the full cost. In technical terms, the Fund is "primary" (pays first) for your covered medical and hospital expenses, while Medicare is "secondary" (pays second).

 

If a claim is incurred by an eligible dependent covered by Medicare, while you maintain eligibility as an active employee, the Fund is "primary" (pays first) and Medicare is "secondary" (pays second).

 

Coverage For Disabled Participants Or Participants' Disabled Dependents

 

If you or one of your eligible dependents, while under the age 65, are entitled to Medicare benefits:

 

 

a. Solely because you or one of your eligible dependents are in the first 18 months of end stage renal disease (ESRD) care, or solely on the basis of a total and permanent disability (except ESRD), as defined by the Social Security Administration, this Plan will be the primary payer of your medical expenses, provided that you are insured under this Plan as an active Participant or as a dependent of an active Participant.  Medicare will provide coverage on a secondary basis.  Therefore, any covered charges should be submitted to this Plan for payment. Afterwards, any unpaid balance should be submitted to Medicare for their consideration.

 

If you are actively employed, Part A Coverage under Medicare is not automatic when you reach age 65, unless you have applied for Social Security benefits.  Since Part A coverage is not automatic, you and your spouse MUST register with Social Security for Part A, when you reach age 65.  You do not have to receive Social Security payments – that is, actually retire – but you must apply and establish your entitlement to such benefits in order to be covered by Medicare.

 

You should also enroll in Part B during the seven-month period beginning three-months before and ending three months after your 65th birthday.  Failure to apply for Medicare coverage under Part A and Part B, when you are eligible to do so, will result in a higher cost to you for Medicare coverage at the time you finally apply.

 

Information necessary to the administration of this provision will be required at the time a claim is submitted.  Remember that the Plan may exchange benefit information with other insurance companies, organizations, and individuals, and has the right to recover any overpayment made to you if you neglect to report coverage under the Plan.  In order to obtain all benefits available to you, a claim should be filed under each Plan.

 

COORDINATION WITH AUTOMOBILE INSURANCE

 

No benefits shall be paid by the Plan for expenses incurred in an automobile accident except to the extent such expenses exceed the limits of coverage provided under the participant's automobile insurance (also known as "No Fault Insurance"). Each participant or dependent who maintains a vehicle or motorcycle is required to obtain at least $250,000 of personal injury protection or similar coverage if that coverage is available in the state in which the vehicle is insured. If personal injury coverage is available, but only at a lower amount, then you are required to obtain the maximum amount available. Where personal injury protection insurance is available in the amount of $250,000 or more, you must obtain coverage at no less than $250,000. If Personal Injury Protection insurance is available but not at $250,000, then you must obtain the maximum amount of coverage that is available. If no such coverage is available at all in your state, and you cannot obtain it, then and only then will you be excused from obtaining personal injury protection.

 

In the event that a medical claim is filed arising out of an automobile or motorcycle accident, and you have either no personal injury insurance or less than $250,000, the Benefit Fund will investigate whether you are excused from having had full $250,000 in coverage. Also, if the "No-Fault" insurance carrier denies coverage due to the involvement of alcohol or substance abuse, no benefits are payable under this Program.

 

 

 

 

 

SUBROGATION CASES INVOLVING A THIRD PARTY

 

This Fund has subrogation rules, which apply when you are injured or become ill and someone else is potentially responsible for your Illness or Injury.  Under this Plan, you and your Covered Dependent(s) may accept payment of Plan benefits that arise from or are related to an Injury or Illness that was caused by the act or omission of a third party.  By accepting payment of any such Plan benefits, you and/or your Covered Dependent(s) agree that the Plan will be subrogated to your right of recovery (or that of your Covered Dependent(s)) and entitled to reimbursement of any Plan benefits paid.  Payment of benefits is conditioned upon your compliance with the Fund's subrogation rules.  The Plan's subrogation and/or reimbursement rights include all claims, demands, actions and rights of recovery against any third party or insurer (including a Workers' Compensation insurer or governmental agency) and will apply to the extent of any and all payments of Plan benefits made or to be made by the Plan.

 

The Plan's subrogation rules are in place to assist you by paying your qualified claims while you proceed against the responsible third party.  They also prevent a situation where you are compensated twice for the same Injury or Illness – once by the Fund when it pays your medical bills and a second time by the third party when it pays you damages for your loss.  These rules help to insure that assets are available for all of the Fund's Participants and beneficiaries.

 

If you are injured or become ill and a third party (including an insurance company or a Worker's Compensation carrier) is potentially liable to you for the Illness or Injury, the Plan will advance payment of benefits on your behalf, but only under the following conditions:

 

1. You and/or your Covered Dependent(s) must sign and return the Fund's Subrogation (Lien) Agreement and any other forms or documents requested by or on behalf of the Plan.  Benefits will not be paid on your behalf unless the Fund Office receives a copy of the Agreement signed by you (and your attorney if one has been retained).  Failure to return the Agreement does not waive, compromise, diminish, release or otherwise prejudice the Plan's subrogation/reimbursement rights.

 

2. You must take whatever action necessary to protect the Fund's subrogation/reimbursement rights. You must not take any action to waive, compromise, diminish, release or otherwise prejudice the Plan's subrogation/reimbursement rights.

 

3. The Fund may take any legal action it deems necessary to protect its right to recover Plan benefits paid, and may attempt to settle any such action in the name of and with the cooperation of the affected individual.  However, in doing so, the Plan will not represent, nor provide legal representation for, any Participant or dependent with respect to that person's damages to the extent those damages exceed Plan benefits paid.

 

4. The Participant or dependent must notify the Fund Office prior to starting any legal action or other proceeding that may relate to or involve the potential recovery of benefits paid by the Plan.  The Participant or dependent must keep the Fund Office informed of all material developments with respect to any such claims, actions or proceedings.  The Fund may, but is not required to, intervene in any such claims, actions or proceedings.

 

 

lf you or your dependent(s) recover money from a third party, you must reimburse the Fund for the benefits it paid out on you/your dependent's behalf, up to the amount of your recovery. (Example:  the Fund pays out $15,000. in medical claims on your behalf.  Later, you recover $25,000. from a third party. You must reimburse the Fund for the $15,000. of medical benefits paid on your behalf). Any and all amounts paid or payable to you and/or your dependent(s) by any third party or insurer by way of settlement or otherwise must be used to reimburse the Fund, regardless of whether those payments are characterized in the settlement or judgment as being paid on account of expenses for which Plan benefits were paid.

 

Your obligation to repay the Fund has priority over other obligations you may have, including any obligation to pay attorney's fees out of the recovery.  You may not reduce the amount you owe the Fund to account for the payment of attorney's fees or other obligations.

 

If you recover money, but fail or refuse to repay the Fund, the Fund may offset any future Plan benefits that may become payable on behalf of you and/or your dependent(s), including death benefits, until the amount not reimbursed is recovered. Benefits will not be paid on you and/or your dependents' until such time as the Fund recoups the full amount due to be reimbursed under these rules.

 

The Fund may also choose to bring legal action against you to collect monies due under these subrogation rules.  If the Fund prevails, you may be liable for not only the benefits paid, but also the Funds' reasonable attorney's fees and costs incurred in connection with such action.

 

If you have any questions regarding these subrogation rules, please feel free to contact the Fund Office.

 

 

 

The Fund provides Hospitalization, Major Medical, Dental, Optical, Prescription and Life Insurance benefits.

 

The Fund provides benefits for Injury or Illness, as defined herein.  Benefits payable are based upon Reasonable and Customary charges for Covered Expenses resulting from services and supplies that qualify as Medically Necessary care and treatment.  How the Fund makes these determinations is discussed below. Note that all Hospitalization and Major Medical benefits are subject to the life time maximum benefit limitation, as set forth below.

 

Recognized Charges

 

The amount of benefits payable depends, in part, on the use of network or non-network services.  The Teamsters Local 97 Benefits Fund will not pay more than the contracted network rate  for services and supplies.  The annual deductible will apply in most non-network cases, however, will be waived in some, such as anesthesia, emergency room doctors (if services were provided in a network hospital), and in some cases (after appeal) when a member has no choice in the selection of the provider.

 

The Plan, as specified in this booklet, only uses a Reasonable and Customary fee schedule for certain services and supplies which have dates of services prior to May 1, 2007.  The Network fee schedule will be less than the generally accepted Reasonable and Customary charges and will result in a balance that you will be responsible to pay.  The way to avoid balances of this type is to USE NETWORK PROVIDERS.

 

Before incurring medical expenses you may wish to check the Fund's allowable charge and ask your Physician about his charge for a particular procedure.  Otherwise you may be responsible to pay a large part of the expense out of your own pocket.

 

Medically Necessary Care

 

The Plan covers only Medically Necessary care and/or treatment, defined as any service, treatment or supply, including a Hospital confinement, furnished or prescribed by a Physician or other licensed provider to identify or treat an Illness or Injury, that:

 

•    is necessary or the diagnosis and treatment of the Illness or Injury for which it is performed;

 

•    is based upon valid medical need;

 

•    meets generally accepted standards of medical practice;

 

•    is required for reason other than the convenience of the patient or provider; and

 

•    is the most appropriate level of service or supply that can safely be provided for the patient.

 

The fact that service or supplies are furnished or prescribed by a Physician or other licensed provider does not necessarily mean that they are Medically Necessary.

 

LIFETIME MAXIMUM BENEFIT LIMITATIONS

 

All Hospitalization and Major Medical benefits under this Plan are subject to a lifetime maximum of $1,000,000 per person.  Once $1,000,000 in Hospitalization and/or Major Medical benefits has been paid, no further payments will be made by this Plan.

 

TIME LIMITS

 

ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR (12 MONTHS) OF THE DATE OF SERVICE OR THE CLAIM WILL BE DENIED. SUBMIT YOUR MEDICAL BILLS PROMPTLY!

 

MISREPRESENTATION AND FRAUD

 

In the event a participant or his dependents receive(s) benefits, as a result of misleading representations or any type of false information or other fraudulent representations to the Fund, such persons will be liable to repay all amounts paid by the Fund.  Fraud includes such person's failure to disclose any other group health coverage under which such person is entitled to receive reimbursement of a claim submitted to the Fund for payment. The Board of Trustees may sue the Participant or dependent for fraud and hold them liable for all costs of collection, including interest and attorneys' fees, and may revoke eligibility and/or offset future claim payments to recoup the amount owed.

 

The Fund reserves the right to determine what proof is necessary to determine whether the medical expenses for which claim is made were actually incurred and on the dates specified. The Fund further reserves the right to require a medical examination, by a Physician of its choosing, of a Participant or beneficiary whose injury or sickness is the basis for a claim, when and as often as it may be reasonably required.

 

ASSIGNMENT AND ALIENATION

 

No benefit payable under the provisions of the Plan will be subject in any manner to assignment, alienation, sale, transfer, pledge, encumbrance or charge, and any attempt to assign, alienate, sell, transfer, pledge, encumber or charge such benefits is void; provided, however, that a Participant or Dependent may assign payment of benefits to the provider that rendered the services or supplies by executing a proper assignment of benefits. No benefit payable under the terms of this Plan shall be in any manner subject to the debts, contracts, or liabilities of, or claims against, an Eligible Employee, covered dependent or Beneficiary, including claims or creditors, claims for alimony and support, and any like claims.

 

OVERPAYMENTS

 

If a payment made to a Participant or assigned to a provider is later determined to be an overpayment, the Board of Trustees may revoke eligibility, bring suit and/or offset future claim payments in order to recover said overpayment.

 

NOTICES SENT TO PARTICIPANTS OR DEPENDENTS

 

The Board of Trustees and/or Fund Office will give notice by mail to Participants of actions taken with respect to eligibility, claims and other important matters affecting your rights and obligations under the Plan.

 

 

All such notices will be sent to your home address as it appears in the Fund Office's records.  To protect yourself and your rights, be sure the Fund Office has your current address on file.  If you fail to notify the Fund Office of your current address, you may miss receiving important information about your benefits.

 

Any notice sent to you at the address in the Fund Office's records will be deemed to have been received by you.  The time in which you must reply to such a notice will not be extended based upon your failure to advise the Fund Office of your current address.

 

 

This section describes your Hospitalization benefits, including the PPO networks offered by the Fund.  The Fund's reimbursement levels and your out-of-pocket expenses vary depending on whether you use net-work or out-of-network providers, so please read this Section carefully.

 

NETWORK AND NON-NETWORK COVERAGE

 

Network Coverage

 

An important aspect of this Plan is the use of Preferred Provider Organizations (PPOs).  These PPOs have established networks of hospitals, physicians, radiologists and laboratories that have agreed to provide all covered services to you with only a small out-of-pocket cost.

 

The Fund has contracted with the MagnaCare Physician and Hospital Network to make available a network of physicians, hospitals and other health care providers at a reduced cost to you and the Fund.  If you choose a MagnaCare physician, you do not have to pay any deductible and are responsible only for a $20 Co-payment for each physician visit.

 

If you are hospitalized in a facility that participates in the Magnacare Network, the Fund will pay for 100% of the negotiated rate.  If you use a non-network Hospital, you will be responsible for payment of a 20% Co-payment.

 

Each Participant will receive an Identification Card and Directories to assist you in locating network providers in your area. NOTE: Although the directory is updated periodically, please contact MagnaCare toll free (800-235-7267) or the Fund Office for up-to-date information if you want to locate a physician or hospital or confirm that your current physician is in the MagnaCare Network.

 

Each of the providers in MagnaCare's Directory has been screened by MagnaCare's or the other PPO's enrollment committee to assure quality service to our Participants. Each contracting provider has agreed to provide all covered service at limited out-of-pocket cost to our Participants. From time to time the Fund may contract with other organizations in the Fund's efforts to bring you the best and most cost effective health coverage that can be afforded.

 

Non-Network Coverage

 

You also have the choice of using Physicians, Hospitals and other health care providers outside the MagnaCare and Magnet Networks.  If you use a non-network provider for physician and outpatient services covered under the Fund's Major Medical provisions, the Fund will pay up to 100% of the Network Allowance for such services after you have paid the applicable Annual Deductible and subject to the Fund's maximum benefit limitations.  If you use a non-network Hospital for services covered under the Plan's Hospitalization benefits, the Fund will pay up to 80% of the Reasonable and Customary charge, subject to the Fund's maximum benefit limitations.  Out of network non-acute facilities will be paid at 100% of MagnaCare repricing with no deductible.

 

 

 

COMPARISON OF COVERAGE FOR NETWORK AND OUT-OF-NETWORK SERVICES

 

MagnaCare Network Out-Of-Network Providers  

 

	MagnaCare Network	Out-Of-Network Providers
Physician Visit	Fund pays 100% after your $20. Co-payment	Fund pays 100% of network allowance after Annual Deductible; Participant pays difference
Surgery	Fund pays 100% after your $20. Co-payment	Fund pays 100% of network allowance after Annual Deductible; Participant pays difference
Anesthesia	Fund pays 100% after your $20. Co-payment	Fund pays 100% of network allowance after Annual Deductible; Participant pays difference
Laboratory Services	Fund pays 100% (no Co-payment)	Fund pays 100% of network allowance after Annual Deductible; Participant pays difference
Radiology-X-rays, MRI Sonograms, C-scan	Fund pays 100% (no Co-payment)	Fund pays 100% of network allowance after Annual Deductible; Participant pays difference
Hospitalization	Fund pays 100% of the negotiated rate	Fund pays 80% of R&C charges;  Participant pays difference

 

HOSPITALIZATION BENEFITS

 

Amount of Coverage

 

Except as otherwise provided, the Plan will pay 100% of the negotiated rate if you are hospitalized in a participating MagnaCare/Magnet Hospital.

 

Payment for in-patient facility charges of Hospitals that are not members of a contracted PPO will be paid at             80% of the Reasonable and Customary charges.  You will be responsible for 20% of Reasonable and Customary charges, plus any amount over the Fund's recognized charges. This benefit is not subject to the Deductible.

 

NOTE: Non-network Hospitals have no limit on the amount they may charge.  The bill from these facilities will be larger than the charges of a Network Hospital. Therefore, the balance that you will be responsible for will be a substantial amount of money. You can greatly reduce this large out-of-pocket cost by using Network Hospitals.

 

Covered Days Of Care

 

The Plan will pay for covered hospital services for a maximum of 180 days of in-patient hospitalization for one or more consecutive hospital confinements ("Covered Days").  If you use all 180 days, another 180 days will become available after at least 90 days pass since the last date of covered inpatient hospitalization.  The 90-day waiting period does not apply to Hospital confinements for an unrelated cause or diagnosis.  This benefit is subject to the lifetime maximum benefit limitation (see page 22).

 

Bed, Board and General Nursing Care

 

Semi-private Accommodations: If you are a hospital patient in a semi-private room, your bed, board (including special diets) and general nursing care are covered as set forth above for Covered Days.

 

Private Accommodations: If you occupy a private room, you will receive a daily allowance equal to the hospital's average semi-private room charge toward the cost of bed, board and general nursing care for Covered Days.

 

Other Hospital Services

 

The following services are covered as set forth above if they are necessary for the diagnosis and treatment of the condition for which you are hospitalized:

 

•    bed and board including special diets;

 

•    general nursing care;

 

•    use of operating and cystoscopic rooms;

 

•    x-ray examinations (not including x-ray therapy) consistent with the diagnosis and treatment of the condition for which hospitalization is required;

 

•    drugs and medicines for use in the Hospital (not including radium or radioactive isotopes) which are commercially available for purchase and readily obtainable by the Hospital;

 

•    use of cardiographic equipment;

 

•    anesthesia supplies and use of anesthesia equipment;

 

•    oxygen and use of equipment for its administration;

 

•    dressing and plaster casts;

 

•    use of physiotherapeutic equipment; and

    

•    basal metabolic equipment.

 

Maternity Care

 

Maternity benefits are provided for expenses incurred in a hospital for an Eligible Employee or an Eligible Employee's spouse or dependent on the same basis as for any other Illness or Injury. Regular hospital benefits will be provided for hospital stays involving any pregnancy-related condition, whether or not pregnancy is terminated.

 

 

The Newborns' and Mothers' Health Protection Act of 1996 provides that a Plan may not restrict benefits for any hospital length of stay in connection with childbirth for a mother or newborn child to:

 

1. less than 48 hours following a normal vaginal delivery; or

 

2. less than 96 hours following a caesarean section.

 

In addition, a Plan may not require that an attending provider such as your physician obtain additional authorization for prescribing a length of stay within these limits.  Federal law generally does not prohibit the mother's or newborn's attending provider, after consultation with the mother, from discharging the mother or the newborn earlier than 48 hours (or 96 hours, as applicable).

 

This new law requires that the Fund disclose the above information concerning impermissible restrictions on maternity care.  You should be assured, however, that this Plan has no such restrictions.

 

Newborn Children

 

Under family coverage, benefits are available from birth for:

 

•    the treatment of Illness or Injury;

 

•    nursery care in an approved premature unit for an infant weighing less than 2,500 grams (5.5 pounds);

 

•    incubator care, regardless of the infant's weight; and

 

•    routine nursery care.

 

Emergency Treatment

 

Regular hospitalization benefits are provided when you are not admitted as an inpatient but receive care in a Hospital's emergency room or operating room for:

 

1. emergency first aid during the first visit for treatment of an Injury within 24 hours following such Injury, or

 

2. emergency care during the first visit for treatment within 72 hours of the onset of sudden and serious Illness, or

 

3. minor emergency surgery.

 

NOTE: The emergency room is for emergencies only. The Fund will apply the rules as described above in determining whether an emergency existed.  The key to determine when to use the emergency room is "SUDDEN AND SERIOUS".  If the Fund rejects a claim for an emergency room visit based upon a determination that it was not an emergency, the Fund will pay the claim under the Major Medical provisions as a Physician's office visit.

 

 

Pre-Surgical Testing

 

Diagnostic tests, prescribed by your Physician and completed in the Hospital as a preliminary to scheduled inpatient surgery, are covered under the hospital benefit. These services are paid at either the MagnaCare rate or as a non-network service subject to the 20% Co-payment.

 

Mental Or Nervous Disorders

 

Hospital benefits for Mental or Nervous Disorders are provided for up to 30 days of inpatient care per calendar year.  This benefit is not subject to the Annual Deductible.

 

In the event you require inpatient care for the treatment of a Mental or Nervous Disorder, you must contact the Fund Office for pre-authorization of your treatment.

 

Substance Abuse (Drug And Alcohol) Treatment

 

Substance abuse treatment is provided for up to 28 days of inpatient care limited to a maximum of $10,000.  This benefit is available one period of confinement in a lifetime.  This benefit must be pre-authorized by the Fund Office.

 

Physical Therapy, Physical Medicine And Rehabilitation

 

Regular Hospital benefits are provided for up to 12 days during a calendar year for stays or portions of stays primarily for physical therapy, physical medicine, and rehabilitation, when such services are performed under programs approved by the appropriate State Department of Health and pre-authorized by the Fund Office.

 

HOSPITAL EXCLUSIONS

 

In addition to the General Exclusions listed on page 34, benefits are not paid for:

 

1.  confinement for sanitarium-type, custodial or convalescent care, or for rest cures; or for care in a Hospital for long-term care;

 

2.  services of Physicians or private or special nurses, or other private attendants or their board;

 

3.  care in an institution which does not usually bill and collect charges from patients;

 

4.  expenses incurred during confinement in a Hospital owned or operated by the Federal Government, unless required by law; and

 

5.  hospital stays or any part of a Hospital stay primarily for diagnostic studies.

 

HOW TO CLAIM A HOSPITAL BENEFIT

 

If you use a Network facility, you will not have to submit any paperwork to file your claims. You should just present your Identification Card at the time of service. You must present your Identification Card at each visit to assure that your claims are filed properly.  You should contact the Fund Office if you have not received your Identification Card.

 

If you use a Non-network Hospital or other health care provider, you must file a claim form with the Fund Office along with your original itemized bills from the provider.  Hospital bills are often sent by the Hospital directly to the Fund Office, and payment of approved claims are submitted directly to the Hospital with an explanation.  The name of the insured and patient must be clearly indicated on both the claim form and any attached statements. Claim forms may be obtained from the Fund Office or you may submit a universal (HCFA) claim form prepared by the provider if it is signed by you.  Statements from Physician, surgeons, anesthesiologist, or Hospitals can be attached to the claim form. Complete itemization of services, including CPT codes, ICD codes and a detailed diagnosis is required for each claim.  Return the claim form and all bills to the Fund Office with the name of the insured and patient clearly indicated on each.  While all the charges may not be considered as Covered Expenses, you should submit all your bills so that they can be properly reviewed. You will also receive an explanation of benefits for all claims that are paid or denied.

 

You can be assured of quicker payment of benefits if bills are complete and correct before you submit them.  It is important that you retain a copy of all receipts for all submitted claims. Original bills are the "evidence" needed to pay a claim.

 

The Fund reserves the right to determine what proof is necessary to determine whether the medical expenses for which claim is made were actually incurred and on the dates specified. The Fund further reserves the right to require a medical examination, by a Physician of its choosing, of a Participant or Beneficiary whose injury or sickness is the basis for a claim, when and as often as it may be reasonably required.

 

 

Major Medical benefits provide for coverage for medical and surgical care in excess of the Fund's Hospitalization benefits, including Physician visits, x-ray and laboratory charges, surgery, anesthesia and other medical services and supplies that the Fund determines to be Medically Necessary.

 

Network Coverage

 

If you use a provider, your out-of-pocket costs for expenses covered under the Fund's Major Medical provisions are limited to a $20. Co-payment.

 

Non-Network Coverage

 

If you use a Non-network provider, you are responsible for satisfying the Annual Deductible before the Fund will begin to pay benefits.  The Annual Deductible is $500. for individuals and $1,000. (combined) for family for each calendar year.  The Fund will pay 100% of Network Allowance for covered Major Medical expenses provided by a Non-network provider after you have paid the Annual Deductible. You are responsible for any remaining expenses.

 

ANNUAL DEDUCTIBLE

 

The Deductible is the amount of eligible Major Medical charges that will be deducted before any Major Medical benefits are paid by the Fund. The amount applied to your Deductible is the amount that the Plan recognizes as a covered expense.

 

Each calendar year, a Deductible of $500. for each Eligible Employee or dependent will be applied to all Major Medical services rendered by Non-network providers. The Annual Deductible will have a family limit of not more than $1,000. per family.

 

Physician Visits

 

Services rendered by Physicians and surgeons, including specialists, for the care or treatment of Illness or non-occupational Injuries are covered as set forth, depending on whether you use a MagnaCare provider or a Non-network provider. 

 

Laboratory And Radiological Diagnostic Services

 

Diagnostic services such as laboratory tests, x-rays, sonograms, Cat-scans, and MRI tests are all Covered Expenses.  These services are paid at 100% when performed by Network providers-No Co-payment-and at 100% of Network Allowance, subject to the Annual Deductible, when provided by Non-network providers.  (Note: Non-Network providers can balance bill you for the difference between the “network allowance” and the total charge.)

 

Well-Baby And Well-Child Care

 

Well-Baby Physician visits are covered according to the following schedule:

 

                     First Year                   6 visits per year

                     Second Year              4 visits per year

                     Third Year                  2 visits per year

                     Thereafter                  1 visit per year (annual physical benefits) Inoculations

 

 

Inoculations

 

Generally, infants are given DPT and Polio inoculations at ages two months and six months. Additionally, a booster shot is given at approximately age 18 months.  All inoculations required by the State school system in which the child is enrolled through college are covered.  The Fund will pay for the office visits associated with administering these inoculations, plus the wholesale cost of the inoculation.  If a separate office visit is needed for the measles, mumps and rubella vaccines, this visit will be covered at the same rate.

 

Annual Physical

 

One annual physical is available to all Participants and their dependants each calendar year. In addition, female Participants and female dependants are covered for a separate annual gynecological examination, including Pap smear and mammogram.  This service is reimbursed at either the Network or Non-network rates, depending upon the provider the Participant chooses, and is not subject to the Annual Deductible.

 

Ambulance Services

 

Emergency transportation by ambulance to a Hospital is a covered expense.  This service will be paid for at either the Network rate for Network providers or at 100% of the Network Allowance for Non-network providers.  This benefit is not subject to the Annual Deductible.  When Medically Necessary, transportation between Hospitals will be covered as described above.  Transportation home from the hospital is not a Covered Expense.

 

Mental and Nervous Disorders

 

Outpatient Mental and Nervous Disorder benefits are available up to a maximum of 20 sessions per calendar year when rendered by a licensed psychologist, psychiatrist or certified social worker.  This benefit is reimbursed at either the Network rate less the co-payment for Network providers or Non-network providers.  No Annual Deductible will apply.

 

Outpatient Substance Abuse (Drug and Alcohol) Treatment

 

Substance abuse treatment is covered for outpatient services. This benefit is reimbursed at either the Network rate less the co-payment for Network providers or Non-network providers.  These services are limited to 52 sessions in a lifetime and are not subject to the Annual Deductible.

 

Chiropractic Services

 

Chiropractic services are covered up to a maximum of 20 visits per person per calendar year. Services are reimbursed at 100% less the $20. co-payment for Network providers and at 100% of the network allowance less the co-payment for Non-network providers. Chiropractic claims are limited to two modalities per session.  The term "modality" refers to the hot packs, electric stimulation and other like services commonly performed by chiropractors.

 

 

Durable Medical Equipment

 

The Fund will pay for the rental or purchase (whichever is more cost effective as determined by the Fund) of durable medical equipment.  Durable medical equipment is equipment or supplies designed for prolonged use, which is primarily and customarily used only to serve a medical purpose; is prescribed by a Physician; is Medically Necessary and; is generally useful only to a person with an Illness or Injury.  Durable equipment includes such items as a wheelchair, Hospital bed, etc.  Only equipment recognized and approved as covered equipment by Medicare will be reimbursable under this benefit.

 

Home Health Care

 

Home Health Care benefits are available under a Physician-approved Plan for treatment when such treatment is Medically Necessary and pre-authorized by the Fund Office.  Services must be rendered through a New Jersey or New York State-certified home health care agency. Benefits will be provided only if hospitalization or confinement in a skilled nursing facility would otherwise have been required.

 

Covered services: Services of a registered graduate nurse (R.N.) or licensed practical nurse (L.P.N.) for private duty nursing services when Medically Necessary and prescribed in writing by the attending Physician or surgeon specifically as to duration and type.

 

NOTE: You must obtain prior authorization from the Fund for Home Health Care Coverage.

 

SURGICAL AND ANESTHESIA BENEFITS

 

Surgical Expenses

 

Charges for surgery performed by a licensed Physician are covered for all non-excluded services at 100% less the Co-payment for network physicians and 100% of the Network Allowance less the co-payment for non-network physicians. 

 

Assistant Surgeon

 

If the services of an assistant surgeon are required and the Hospital does not provide one, benefits are payable for services of a surgical assistant at the Network Allowance.

 

Anesthesia

 

This service is covered at 100% of the network allowance.  This benefit is not subject to the deductible.

 

HOW TO CLAIM MAJOR MEDICAL BENEFITS

 

If you use a Network provider, you will not have to submit any paperwork to file your claims. You should just present your MagnaCare Card at the time of service.  You must present your Identification Card at each visit to assure that your claims are filed properly. You should contact the Fund Office if you have not received or cannot locate your MagnaCare Card.

 

 

If you use a Non-network Physician, or other health care provider, you must file a claim form with the Fund Office along with your original statements or bills from the provider.  The name of the insured and patient must be clearly indicated on both the claim form and any attached statements.  Claim forms may be obtained from the Fund Office or you may submit a universal

 

(HCFA) claim form prepared by the provider if it is signed by you. Statements from Physician, surgeons, anesthesiologist, or Hospitals can be attached to the claim form. Complete itemization of services, including CPT codes, ICD codes and a detailed diagnosis is required for each claim. Return the claim form and all bills to the Fund Office with the name of the insured and patient clearly indicated on each. While all the charges may not be considered as Covered Expenses, you should submit all your bills so that they can be properly reviewed.

 

You can be assured of quicker payment of benefits if bills are complete and correct before you submit them. It is important that you retain a copy of all receipts for all submitted claims.  Original bills are the "evidence" needed to pay a claim.

 

The Fund will pay approved claims directly to you or, if specified, to your service provider.  You will also receive an explanation of benefits for all claims that are paid or denied.

 

The Fund reserves the right to determine what proof is necessary to determine whether the medical expenses for which claim is made were actually incurred and on the dates specified. The Fund further reserves the right to require a medical examination, by a Physician of its choosing, of a Participant or beneficiary whose injury or sickness is the basis for a claim, when and as often as it may be reasonably required.

 

MAJOR MEDICAL EXCLUSIONS

 

In addition to the General Exclusions set forth on page 34, the following services and supplies are NOT covered by the Fund's Major Medical benefits:

 

•   air conditioners, air-purification units, humidifiers and electric heating units;

 

•   childhood disorders - treatment of learning disorders, behavioral problems, mental   retardation, hyperkinetic syndrome, or autism of childhood;

 

•   dental services and other services of a type usually performed by a dentist (These   services may be covered under the Plan's Dental Benefit described on page 37); 

 

•   eye examinations for obtaining eyeglasses (These services be covered under the    Plan's Optical Benefit described on page 40);

 

•   telemetric services or patient-operated diagnostic tests;

 

•   podiatry expenses are not covered – i.e., orthotics, casting, fabrication and dispensing of     orthotics; surgical shoes or dispensing thereof; surgical trays and sterile packs; outpatient            operating, room fees; fees for surgical assistant; pre-and post-op x-rays and serial x-rays        during surgery;* injection of local anesthetic.*

           

*   These expenses are included as part of the surgical allowance and will not be covered as a     separate expense.

 

 

GENERAL LIMITATIONS AND EXCLUSIONS

 

In addition to any limitations or specific exclusions described in this Summary Plan Description, there are general limitations and exclusions, which apply to all benefits.  No payments will be made for expenses incurred for you or your eligible dependents:

 

•    for services, supplies or treatments which are not Medically Necessary, as defined herein;

 

•    for fees which are in excess of the Fund’s Allowance or Reasonable and Customary charges for such services, supplies, or treatment, as defined herein;

 

•    for charges which are not received by the Fund Office, along with all required supporting information necessary to process the claim, within 12 months from the date services were rendered;

 

•    for services or supplies not listed herein as Covered Expenses;

 

•    for cosmetic surgery, unless required because of:

 

-    an accidental bodily Injury;

 

-    reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or

 

-    reconstructive surgery, when required due to a congenital disease or anomaly of a dependent child which has resulted in a functional defect;

 

•    for Infertility procedures;

 

•    for Artificial insemination, in-vitro fertilization, G.I.F.T. or like procedures, and any services associated with such procedures;

 

•    for expenses incurred as a result of past or present services in the armed forces of any government,

 

•    for loss caused by war or any act of war;

 

•    for an Injury or an 'Illness that is employment-related or that is covered under Workers' Compensation Law, occupational ,disease law, or similar laws;

 

•    or expenses for military service-related care in a veterans' facility or a Hospital operated by the United States, unless required by law;

 

•    for any charges which you or your dependent are not legally required to pay, including charges that would not have been assessed if no insurance coverage existed;

 

•    or services for which there is no legally enforceable charge; or charges for Custodial Care;

 

 

 

•    for meals, meal preparation, personal comfort or convenience items, housekeeping services, custodial care, and protective companion services;

 

•    for charges incurred for the completion of claim forms and mailing fees;

 

•    for charges incurred for handling fees, unless directly related test results;

 

•    for expenses incurred as a result of failure to keep a scheduled a appointment;

 

•    for interest or other penalties;

 

•    for any services rendered by a Physician or any other provider of medical services to himself or his immediate family, including parents, spouse, brothers, sisters, children, and grandchildren;

 

•    for any expenses for which you or your dependent is in any way paid or entitled to payment for those expenses by or through a public program;

 

•    for Experimental procedures, equipment, treatment or course of treatment, as defined herein;

 

•    for Experimental drugs or substances not approved by the Food and Drug Administration, or for drugs labeled "caution limited by Federal law to investigational use";

 

•    for speech therapy; except if provided by a licensed speech therapist to restore speech lost or impaired due to surgery, radiation therapy, or other treatment which affects the vocal chords; cerebral thrombosis (cerebral vascular accident); brain damage due to accidental injury or organic brain lesion (aphasia) and then limited to 30 visits per year.

 

•    for sleep disorders, including sleep studies;

 

•    for services of a naturopath, homeopathic, hypnotherapy, faith-healer or other like services;

 

•    for expenses incurred for functional visual training;

 

•    for any expenses related to surrogate parenting;

 

•    for routine care of the feet out of the Hospital (except for diabetics); 

 

•    for any expenses related to foot care for treatment, services, or supplies in connection with: corns; calluses; nails; weak, strained, or flat feet; any instability or imbalance of the feet; or shoes, orthotics, or any other inserts;

 

•    for travel, except as specifically covered by this Plan;

 

•    for services rendered by interns, residents, and Physicians in training;

 

•    for medical treatment of obesity (except morbid obesity) including but not limited to, specialized medical weight reduction programs and medications;

 

 

 

•    for any services or supplies for or in connection with acupuncture;

 

•    for any expenses related to transsexual surgery, counseling or like services or treatment;

 

•    for services rendered in the treatment of TMJ; and

 

•    for nerve conduction testing;

 

•    for epidural injections for pain management except for three days following a surgical procedure or during a surgical procedure.

 

The Women's Health And Cancer Rights Act Of 1998

 

If you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction along with that mastectomy, your plan must provide in a manner determined in consultation with the attending physician and you, coverage for the following:

 

·         reconstruction of the breast on which the mastectomy was performed;

·         surgery and reconstruction of the other breast to produce a symmetrical appearance;

·         prostheses and physical complications at all stages of the mastectomy, including lymphedemas.

 

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.

 

GENERAL BENEFITS PROVIDED

 

The Dental Benefits pay up to the amounts shown in the Schedule of Covered Dental Expenses, The complete fee schedule may be obtained by contacting the Fund Office. Covered Dental Expenses included under the Plan are the charges of a Dentist which a Participant is required to pay for dental services listed in the Schedule of Covered Dental Services and received while coverage is in effect.

 

For each service, however, the Covered Dental Expense will not be more than the amount set forth in the Schedule for the particular dental service.  If the charges are less than the Schedule amount for a particular service, the amount included as a Covered Dental Expense will equal the actual charges.

 

MAXIMUM BENEFIT LIMIT

 

The Dental Plan has a $2,000. annual per person maximum.  This maximum is compiled on a calendar year basis, and renews each January 1st.

 

Alternative Benefit Provision

 

When more than one dental service could provide suitable treatment based on common dental standards, the Fund will determine the dental service on which payment will be made and the expenses that will be included as Covered Expenses.

 

Prior Approval

 

Treatment plans for dental services of $300 or more must be submitted to the Network for prior approval before the services are performed. For any treatment plans anticipated to be in excess of $300, your Dentist must submit a full mouth series of x-rays and a detailed treatment plan along with your certified claim form to the Network prior to performing any work.

 

The Fund reserves the right to accept the Network’s determination of benefits payable, taking into account alternative procedures based on accepted standards of dental practice.  To the extent that your treatment plan does not comply with generally accepted standards of dental practice, the Fund reserves the right to reduce or eliminate benefits which would have otherwise been Covered Expenses.

 

Pre-determination of benefits by the Network does not guarantee payment. The estimate of benefits payable may change based on the benefits a person qualifies for at the time services are completed. In order to receive dental coverage, you must satisfy the Plan Eligibility criteria at the time services are rendered. 

 

Network Dentists

 

An important benefit of this Fund is the Network of Dentists.   Each of these Dentists has agreed to provide all covered services at minimal out-of-pocket costs. Participants and their dependents will be charged only a small Co-payment of approximately 10% of the Fund's allowable charge when using these providers.

 

 

 

Each Participant in the Dental Plan has been given a directory listing the panel providers.  Use this list to receive the dental services you need, while reducing your out-of-pocket costs.

 

A Participant and his eligible dependents may use any licensed Dentist of his choice. However, charges in excess of the scheduled allowance are the Participant's responsibility.

 

SPECIAL LIMITATIONS APPLICABLE TO SPECIFIC DENTAL SERVICES

 

Examinations:               Two per calendar year.

 

X-rays:                           Full mouth series once every two years; check-up x-rays once each        year.

 

Prophylaxis:                  2 per calendar year, but not more than once in a six-month period.

 

Periodontic:                  Must be performed by a board-certified periodontist.  A curettage and      prophylaxis are not payable on the same day. Pre-operative x-rays and periodontal charting are necessary for periodontal work.

 

Endodontics:                Pre- and post-operative x-rays are necessary.

 

Crowns and Bridges: Replacement is payable once every three (3) years.

 

Prosthetics:                  Benefits are payable for insertion of prosthetics once every three years. Re-alignment and adjustment benefits are payable after a one-year      waiting period from the day of insertion.  After an initial realignment or                adjustment, benefits are available for realignment or adjustment once      every two years.

 

General Anesthesia:   Payable only for oral surgery.

 

Fillings:                         Three surfaces per tooth.

                                                                                                              

DENTAL EXPENSES NOT COVERED

 

In addition to the General Exclusions set forth on page 34, no payment will be made for:

 

•    services performed for cosmetic reasons;

 

•    replacement of a lost or stolen appliance;

 

•    replacement for a crown, bridge or removable denture within three years of the original insertions;

 

•    any replacement of a bridge, crown, or denture which can be made usable according to common dental standards;

 

•    procedures, appliances or restorations whose main purpose is to:

 

1.  change vertical dimension;

 

2.  diagnose or treat TMJ dysfunction;

 

3.  stabilize periodontally involved teeth; and

 

4.  restore occlusion

 

•    bite registrations, precision or semi-precision attachments or splinting;

 

•    surgical implants;

 

•    instructions for plaque control, oral hygiene, diet;

 

•    any Experimental procedure not approved by the American Dental Association;

 

•    expenses incurred by the Participant or dependents, to the extent that benefits are payable through "no-fault" insurance law or an uninsured motorist law for such expenses;

 

•    damage to teeth covered by Workers' Compensation; and

 

•    orthodontia for patients over 23.

 

HOW TO CLAIM DENTAL BENEFITS

 

Network and non-Network providers should mail your claim to the Network for processing.  Your dentist will receive payment directly from the Network, however, if you use a non-Network dentist, you will be paid according to the out of network fee schedule and you will be responsible for the entire remaining balance. You must also comply with the pre-determination of benefits provisions of the Plan as described on page 37.

 

 

 

 

COVERED OPTICAL EXPENSES

 

Vision examination, lenses, and frames or contact lenses when Medically Necessary are covered once every claim year.  These Covered Expenses are reimbursed up to a maximum of $35. for the examination, and $75. for either frame and lenses, or contact lenses.  You will be responsible for payment of all services after the allowable reimbursement has been reached.

 

HOW TO CLAIM OPTICAL PLAN BENEFITS

 

The easiest way to obtain your optical benefit is to call the Fund Office for an optical voucher. You will also receive a list of participating providers.  The Fund Office will verify your eligibility and issue you a voucher.  Participating providers will take your voucher at the time of service and bill the Fund directly for the amount of your allowance.  You are responsible for any balance which exceeds your allowance.

 

If you choose to go to your own private doctor, you may do so. Most doctors request that you pay them first, as they will not accept payment directly from us.  If this occurs, send us the signed optical vouchers along with your receipt, and the Fund will reimburse you for the amount of your allowance towards the cost of either the exam or the glasses or both. If the charge is more than this Plan allows, you will be responsible to pay the extra cost.

 

OPTICAL PLAN EXCLUSIONS

 

If you do not request a voucher in advance, submit your paid bills to the Fund and payment will be made directly to you in the amount of your allowance if you were eligible for the optical benefit at the time of service.

 

In addition to the General Exclusions set forth on page 34, no payment will be made for:

 

•    medical or surgical treatments;

 

•    drugs or medications;

 

•    non-prescription lenses;

 

•    examinations or materials not listed as a covered service;

 

•    replacement of lost, stolen, broken, or damaged lenses;

 

•    services or materials provided by Federal, State, Local Government or Workers'

     Compensation;

 

•    examinations, procedures training or materials not listed; and

 

•    industrial 3(mm) safety lenses and safety frames with side shields.

 

 

This Plan provides a prescription drug benefit that allows Participants and their eligible dependents to obtain prescription drugs with the payment of a $5. Co-payment for Generic name drugs, a $15. Co-payment for “preferred” Brand name drugs and a $30. Co-payment for “non-preferred” Brand name Drugs.

 

Your Prescription Plan Covers:

 

1. Prescriptions which require compounding;

 

2. Prescriptions for legend drugs (drugs which, by law cannot be dispensed by a pharmacy without a prescription); and

 

3. Insulin or prescriptions with specific dosage, but no other injectable or companion implements.

 

COVERED DRUGS

 

The following drugs are covered by this Plan:

 

•    Federal Legend Drugs;

 

•    State Restricted Drugs;

 

•    Compounded Medications of which at least one ingredient is a legend drug;

 

•    Insulin, Insulin Needles and Syringes;

 

•    Oral Contraceptives and patches;

 

•    Lancets, Blood/Urine Test Strips and Tapes;

 

•    Disposable/Reusable Syringes;

 

•    Allergy Serums; and

 

•    Legend Vitamins including Fluoride for children.

 

EXCLUSIONS:

 

In addition to the General Exclusions set forth on page 34, the following are excluded from coverage unless specifically listed as a benefit under "Covered Drugs":

 

•    Non-Federal Legend Drugs;

 

•    Contraceptive jellies, creams, foams or devices;

 

•    Non-lnsulin Syringes;

 

•    Fertility drugs, growth hormones, or sex hormones except for those in treatment of menopause;

 

 

•    Drugs to deter smoking

 

•    Anorexiants;

 

•    Amphetamines;

 

•    Retin-A (except for acne vulgaris);

 

•    Immunosuppressants;

 

•    Therapeutic devices or appliances;

 

•    Drugs whose sole purpose is to promote or stimulate hair growth (i.e., Rogaine) or for cosmetic purposes only (i.e., Renova)

 

•    Immunization agents;

 

•    Biologicals, blood or blood plasma;

 

•    Drugs labeled "Caution-limited by Federal law to investigative use" or Experimental drugs, regardless of whether a charge is made to the individual;

 

•    Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed Hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent Hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals;

 

•    Any prescription refilled in excess of the number of refills specified by the Physician, or any refill dispensed after one year from the Physician's original order;

 

•    Charges for the administration or injection of any drug;

 

•    Medicines and other drugs which are patents;

 

•    Durable equipment for administering medicine;

 

•    Drugs or medicines that are non-prescription or available as "over-the-counter" drugs;

 

•    Prescriptions which an eligible person is entitled to receive without charge from any Workers' Compensation Laws, or any municipal, state or federal program;

 

•    Anti-obesity medications, except in the case of morbid obesity; and

 

•    Multi-vitamins, B-Complex vitamins, Hematinics, Vitamin B-12, other vitamins (except pre-natal vitamins are covered).

 

 

DISPENSING LIMITS

 

The amount of drug (including Insulin) which is to be dispensed at the pharmacy per prescription or refill will be in quantities prescribed for up to a 31-day supply.  This dispensing limitation does not apply to the mail-order service described below.

 

GENERIC AND BRAND NAME DRUGS

 

The generic name of a drug is its chemical name.  The brand name is the trade name under which the drug is advertised and sold. By law, generic and brand name drugs must meet the same standards for safety purity, strength and effectiveness.  When authorized by your Physician, generic drugs save your Plan money, which helps to maintain your current prescription benefit.

 

MAIL SERIVCE PRESCRIPTION DRUG PROGRAM

 

The Mail Service Prescription Drug Plan is an expansion of your current Prescription Drug Plan. The Mail Service has a co-payment of $10. for Generic name drugs, $30. for “preferred” Brand name drugs and $60. for “non-preferred” Brand name drugs. If you or your eligible dependents take prescription medication on an ongoing basis, such as Maintenance Drugs, you can now enjoy several important advantages:

 

•    immediate savings;

 

•    you can receive up to a 90-day supply of medication at one time;

 

•    no waiting for reimbursement;

 

•    convenience of home delivery, postage paid; and

 

•    security of receiving larger quantities of medication at one time.

 

Also, Choice 90 pharmacies are available for your maintenance prescriptions.  You can go to a participating Choice 90 pharmacy with your written prescription and get a 90-day supply of your medication.  Call the Fund office for a participating Choice 90 pharmacy in your area.

 

 

90-Day Supplies Of Medication

 

The law requires that pharmacists dispense the exact quantity prescribed by the Physician. Thus, to receive a 90-day supply of a medication, your Physician must prescribe sufficient dosage to last 90 days.  If your Physician authorized refills, they can only be dispensed when your initial order has nearly expired, so be sure to ask your Physician to prescribe a 90-day supply, plus refills, whenever appropriate.

 

PLEASE NOTE: CERTAIN CONTROLLED SUBSTANCES AND SEVERAL OTHER PRESCRIBED MEDICATIONS MAY BE SUBJECT TO OTHER DISPENSING LIMITATIONS AND TO THE PROFESSIONAL JUDGMENT OF THE PHARMACIST.

 

The Plan provides for payment of benefits to a designated Beneficiary upon the death of Eligible Employee while covered by this Plan. The Plan also provides accidental death, dismemberment, and loss of sight benefits. These benefits are provided through the Hartford Insurance Company.

 

DEATH BENEFIT

 

The Death benefit is payable in a lump sum payment, subject to the exclusions listed below, to the person or persons designated by you as Beneficiary.  Payment will be made upon the submission of satisfactory proof of death to the Fund. 

 

Amount of Benefits: $5,000.

 

ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFITS

 

Accidental Death, Dismemberment and Loss of Sight benefits provide lump sum payment of benefits to an Eligible Employee for accidental loss of limb or sight, and to an Eligible Employee's Beneficiary for accidental loss of life, payable according to your loss up to a maximum of the death benefit. Loss of sight must be entire and irrevocable and must occur while covered by the Fund. Benefits are payable only for losses caused solely by, and resulting within 90 days of, an accidental bodily Injury.  The loss of life benefit is paid in addition to the Death benefit.

 

Designated Beneficiary

 

In order to designate your Beneficiary, you must submit a completed designation of Beneficiary form to the Fund Office.  If you designate more than one Beneficiary, each surviving Beneficiary will receive an equal share of the Life Insurance Benefit unless you indicate otherwise on the form.  You may change your Beneficiary at any time by submitting to the Fund Office a new Beneficiary form, which has been properly completed by you.  The appropriate form may be obtained by calling the Fund Office.

 

If your Beneficiary dies before you, or if you have not designated a Beneficiary, your Life Insurance Benefit will be paid to the surviving class of Beneficiary in the following order:

 

your surviving spouse;

 

your surviving children, in equal shares;

 

your surviving parents, in equal shares;

 

your surviving brothers and sisters, in equal shares; and

 

your executors or administrators.

 

If your Beneficiary is a minor, the benefit will be paid to his or her legally appointed guardian.

 

 

 

EXCLUSIONS

 

These benefits do not apply to death, dismemberment or loss of sight due to:

 

•    war or any act of war, whether war is declared or not, or any Injury received while in any armed service of a country which is at war or engaged in armed conflict;

 

•    any intentionally self-inflicted Injury, suicide, or suicide attempt, whether sane or insane;

 

•    any Injury received as a result of doing any work for pay or profit;

 

•    taking drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed for or administered to you by a licensed Physician; and

 

•    an accident caused by your intoxication while operating a motor vehicle.

 

CONVERSION PRIVILEGE

 

In the event of termination of your coverage under this Plan, the Group Life Policy permits you to convert your Life Insurance without physical examination to an individual Life Policy.  You may convert to any one of the forms customarily issued by the Ullico Insurance Company including the option of one-year term insurance to precede such other forms of insurance.  You must make written application directly to Ullico within 31 days after termination of your coverage under this Plan. In the event of your death during this 31-day period, the amount of your Life Insurance would be payable to your Beneficiary.

 

HOW TO CLAIM LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

 

In the event of the death of an Eligible Employee, the Fund Office must be provided with an original death certificate. The Fund Office will file the appropriate application for life insurance benefit with the life insurance company on behalf of the designated Beneficiary.  If the death is accidental, the accidental death benefit will automatically be paid.

 

To apply for the Dismemberment Benefit, you must supply the Fund Office with the appropriate medical evidence.  The Fund Office will submit the appropriate application for benefits with the insurance company.

 

 

 

CLAIM DENIAL

 

In order to carry out their responsibility for interpreting the plan and making determinations under it, the Trustees have exclusive authority and discretion to determine whether an individual is eligible for any benefits under a plan; to determine the amount of benefits, if any, an individual is entitled to from a plan; to interpret all of the plan's provisions and to interpret all of the terms used in the plan.  All such determinations and interpretations made by the Trustees of their designee shall be final and binding upon any individual claiming benefits under a plan; shall be given deference in all courts of law to the greatest extent allowed by applicable law; and shall not be overturned or set aside by any court of law unless found to be arbitrary and capricious or made in bad faith.  All such determinations shall be based exclusively upon clearly defined and ascertainable criteria contained in the plan.

 

If a claim is wholly or partially denied, the Fund Office will notify you within a reasonable period of time, not later than the following:

 

Type Of Claim	Time Limit For Claim Denial	Extension Permitted
Medical, Dental, Vision
- Urgent Claims (as medically determined)	72 hours	None
- Pre-Service Claims	15 days	30 days
- Post-Service Claims	30 days	15 days
- Concurrent Claims (claims for ongoing course of treatment)	Prior to termination of care (if sufficient notice)	None
Accidental Death And Dismemberment, Life Insurance	90 days	90 days

 

If your claim lacks information required by the Fund Office to make a determination, you will be notified within a reasonable period of time.  Extensions are permitted if the Fund Office determines that special circumstances beyond its control require an extension of time for processing the claim.  In such case, you will be provided with written notice of the extension prior to the termination of the time responding.

 

The Fund Office’s notification of a claim denial will set forth the following:

 

C    the specific reason or reasons for the denial;

C    specific reference to plan provisions on which the denial is based;

C    a description of any additional material or information necessary for you to complete the claim and an explanation of why such material or information is necessary;

C    a description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of your right to bring a civil action under section 502(a) of ERISA after you have exhausted the appeals process;

C    if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, the specific rule, guideline, protocol, or other similar criterion relied upon in making the determination, or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the denial and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to you upon request; and

 

C    if the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

 

APPEAL

 

If your claim is denied, you or your duly authorized representative may appeal the denial to the Board of Trustees within the following timeframe:

 

Type Of Claim	Time Limit For Appealing Denial
Medical, Dental, Vision	180 days
Accidental Death And Dismemberment, Life Insurance	60 days

 

You may submit written comments, documents, records, and other information relating to the claim for benefits.  In addition, upon request and free of charge, you may have reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits and, in the case of a disability claim, a listing of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the benefit determination.

 

DETERMINATION OF APPEAL

 

The Board will make a determination of your appeal with a reasonable period of time, but not later than the following:

 

Type Of Claim	Time Limit For Claim Denial	Extension Permitted
Medical, Dental, Vision
- Urgent Claims	72 hours	None
- Pre-Service Claims	15 days	30 days
- Post-Service Claims	Board meeting (if claim Received 30 days prior)	15 days
- Concurrent Claims (claims for ongoing course of treatment)	Prior to termination of care (if sufficient notice)	None
Accidental Death And Dismemberment, Life Insurance	Board meeting (if claim received 30 days prior)	Next Board Meeting

 

If your claim is determined at a Board meeting, you will be notified of the determination upon review as soon as possible but not later than five days after the determination is made.

 

If the denial of a claim for medical, dental, or vision benefits was based in whole or in part on a medical judgment, the Board will consult with a health care professional who is neither an individual who was consulted in connection with the denial that is the subject of the appeal, nor the subordinate of any such individual and who has appropriate training and experience in the field of medicine involved in the medical judgment.  In addition, the determination on appeal will not afford deference to the initial claim denial.

 

The Board will provide a written notification of the benefit determination on review.  In the case of denial, the notification will set forth the following:

 

C    The specific reason or reasons for the denial.

C    Specific reference to plan provisions on which the denial is based.

C    A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.

C    An internal rule, guideline, protocol, or other similar criterion if one was relied upon in making the adverse determination, the specific rule, guideline, protocol, or other similar criterion relied upon in making the determination; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion  will be provided free of charge to the claimant upon request.

C    if the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the specific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request.

C    A statement of your right to sue under Section 502(a) of ERISA.

 

INCOMPETENCE

 

In the event it is determined that a claimant is unable to care for his/her affairs because of illness, accident, or incapacity, either mental or physical, any payments due may, unless claim has been made therefore by a duly appointed guardian, committee, or other legal representative, be paid to the spouse or such other object of natural bounty or the claimant, as the Trustees will determine in their sole discretion.

 

TRUSTEES' RIGHT TO INFORMATION

 

The Trustees have the right to require a participant or a dependent to produce and provide any and all evidence or proof of any fact which the Trustees, in their discretion, decide to be relevant or necessary.  The failure to provide such information or evidence will justify any action of the trustees in denying any claim made by such participant or dependent.  If any participant or dependent submits false information or false claims to the provider or to the Trustees, the Trustees shall have the right, in their sole discretion, to disqualify such participant or dependent from eligibility for benefits for any time period determined to be appropriate by the Trustees.

 

MAILING ADDRESS OF CLAIMANT

 

If a claimant fails to inform the Trustees of a change of address and the Trustees are unable to communicate with the claimant at the address last communicated to the Trustees and a letter, sent by first class mail, to such claimant is returned, any payments due the claimant will be held without interest until payment is successfully made.

 

RECOVERY OF CERTAIN PAYMENTS

 

The Trustees will have the right to recover any benefit payments made in reliance on any false or fraudulent statements, information, or proof submitted, as well as any benefit payment made in error to a claimant or to a third party on a claimant’s behalf, such recovery maybe made by reducing other benefit payments made to or on behalf of the claimant, by commencing a legal action or by such other methods as the Trustees, in their discretion, determine to be appropriate.  The Trustees have the authority to disqualify a participant and his or her dependents from coverage or from future benefits either for a specific dollar amount or for a specified period of time.

 

 

 

 

 

 

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

THIS NOTICE ALSO APPLIES TO YOUR ELIGIBLE DEPENDENTS.  PLEASE SHARE IT WITH THEM.

 

INTRODUCTION

 

The plan is a covered entity within the meaning of the Health Insurance Portability and Accountability Act of 1996, commonly known as "HIPAA".  Under HIPAA, the plan is legally required to provide you with notice of our legal duties and privacy practices with respect to protected health information ("PHI").  PHI includes any individually identifiable information that relates to your physical or mental health, the health care that you have received or payment for your health care, including name, address, date of birth and Social Security number.

 

We are legally required to maintain the privacy of your PHI.  The primary purpose of this notice is to describe the legally permitted uses and disclosures of PHI some of which may not apply to this plan in practice.  This notice also describes your right to access and control your PHI.

 

We are required to abide by the terms of this Notice of Privacy Practices ("Notice").  However, we reserve the right to change the terms of this or any subsequent Notice at any time.  If we elect to make a change, the revised Notice will be effective for all PHI that we maintain at that time.  Within 60 days of any material revision of our privacy practices we will distribute a new Notice.  Additionally, you may contact the Fund Office at any time to obtain a copy of the most recent Notice.

 

This Notice is effective April 14, 2003.

 

PERMITTED USES AND DISCLOSURES

 

We use and may disclose your PHI in connection with your receiving treatment, our payment for such treatment and for health care operations.  Generally we will make every effort to disclose only the minimum necessary amount of PHI to achieve the purpose of the use or disclosure.

 

Treatment: means the provision, coordination or management of your health care.  As a health plan, while we do not provide treatment, we may use or disclose your PHI to support the provision, coordination or management of your care.  For example, we may disclose the fact that you are eligible for benefits to a provider who contacts us to verify your eligibility for benefits under the health plan.

 

Payment: means activities in connection with processing claims for your health care.  We may need to use or disclose your PHI to determine eligibility for coverage, medical necessity and for utilization review activities.  For example, we could disclose your PHI to physicians engaged by the plan for their medical expertise in order to help us determine medical necessity and eligibility for coverage under the plan.

 

 

We may also disclose your PHI to third parties who are known as "Business Associates" that perform various activities (e.g., hospital pre-authorization, case management) for us. In such circumstances, we will have a written contract with the Business Associate which requires the Business Associate to protect the privacy of your PHI.

 

We may also disclose your PHI, and your dependents' PHI, on explanations of benefit forms ("EOBs") and other payment related correspondence, such as pre-certifications, which are sent to you.

 

If you appeal a benefit determination on behalf of an eligible dependent, we may disclose PHI related to that appeal to you.  If you appeal a benefit determination and you designate an authorized representative to act on your behalf, we will disclose PHI related to that appeal to that authorized representative.

 

Health Care Operations: generally means general administrative and business functions that the plan must perform in order to function as a health plan.  For example, we may need to review your PHI as part of the plan's efforts to uncover instances of provider abuse and fraud.  In addition, we may combine the PHI of many participants or their eligible dependents to help us decide on the services for which we should provide coverage.

 

Reminders: We may use your PHI to provide you with reminders.  For example, we may use your child's date of birth to remind you that you may purchase continuation coverage for your 19-year old child who would otherwise lose coverage under the plan.

 

Treatment Alternatives: We may use your PHI to inform you about treatment alternatives.

 

Health-Related Benefits And Services: We may use or disclose your PHI to inform you about other health-related benefits and services that may be of interest to you.

 

Disclosure To Trustees Of The Plan: We may disclose your PHI to the Trustees of the plan in connection appeals that you file following a denial of a benefit claim or a partial payment.  The Trustees may also receive PHI if necessary for them to fulfill their fiduciary duties with respect to the plan.  Such disclosures will be the minimum necessary to achieve the purpose of the use or disclosure.  In accordance with the plan documents, the Trustees must agree not to use or disclose PHI other than as permitted in this Notice or as required by law and not to use or disclose the PHI with respect to any employment-related actions or decisions or with respect to any other benefit plan maintained by the Trustees.

 

Others Involved In Your Health Care Or Payment For Your Health Care: Unless we agree to your request that we not do so, we may disclose your spouse or to another member of your immediate family PHI that is directly relevant to that person's involvement in your health care or payment of your health care.  For instance, your spouse may be told whether or not a claim for services rendered to you has been paid.  We may also disclose your PHI to any authorized public or private entities assisting in disaster relief efforts.

 

Personal Representatives: We may disclose your PHI to your Personal Representative in accordance with applicable state law or the privacy rule.  A Personal Representative is someone authorized by court order or power of attorney, and a parent of a child, in most cases.  In addition, your Personal Representative can exercise your personal rights with respect to PHI.  While generally a parent is the Personal Representative of an unemancipated minor child, under certain circumstances we may require parents to submit requests in writing regarding PHI, other than payment information of such children, in order to evaluate the request.

 

 

Required By Law: We may use or disclose your PHI to the extent that we are required to do so by federal, state or local law.  You will be notified, if required by law, of any such uses or disclosures.

 

Public Health: We may disclose your PHI for public health purposes to a public health authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of preventing or controlling disease (including communicable diseases), injury or disability. If directed by the public health authority, we may also disclose your PHI to a foreign government agency that is collaborating with the public health authority.

 

Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and legal actions.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

 

Abuse Or Neglect: We may disclose your PHI to any public health authority authorized by law to receive reports of child abuse or neglect.  In addition, if we reasonably believe that you have been a victim of abuse, neglect or domestic violence we may disclose your PHI to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.  We will promptly inform you that such a disclosure has been or will be made, unless we reasonably believe that informing you would place you at risk of serious harm, or we would be informing a personal representative of yours who we reasonably believe is responsible for the abuse, neglect, or injury.

 

Food And Drug Administration: Our Prescription Benefits Manager may disclose your PHI to a person or company subject to the jurisdiction of the Food and Drug Administration ("FDA") with respect to an FDA-regulated product or activity for which that person has responsibility, for the purpose of activities related to the quality, safety or effectiveness of such FDA-regulated product or activity.

 

Legal Proceedings: We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal.  In addition, we may disclose your PHI under certain conditions in response to a subpoena, discovery request or other lawful process, in which case, reasonable efforts must be undertaken by the party seeking the PHI to notify you and give you an opportunity to object to this disclosure.

 

Law Enforcement: We may also disclose your PHI, if requested by a law enforcement official as part of certain law enforcement activities.

 

Coroners, Funeral Directors, And Organ Donation: We may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death or other duties authorized by law.  We may also disclose your PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation and transplantation purposes.

 

Research: We are permitted to disclose your PHI to researchers when their research has been approved by an institutional review board that has established protocols to ensure the privacy of your PHI.  However, the plan does not routinely disclose PHI to researchers.

 

 

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI,

if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

 

Military Activity And National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are armed forces personnel (1) for activities deemed necessary by military command authorities, or (2) to a foreign military authority if you are a member of that foreign military service.  We may also disclose your PHI to authorized federal officials conducting national security and intelligence activities including the protection of the President.

 

Workers' Compensation/Jones Act: We may disclose your PHI to comply with Workers' Compensation Laws, the Jones Act and other similar legally established programs.

 

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the institution or law enforcement official if the PHI is necessary for the institution to provide you with health care, to protect the health and safety of you or others, or for the security of the correctional institution.

 

Required Uses And Disclosures: We must make disclosures to you and to the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the federal regulations regarding privacy.

 

Authorization For Other Uses And Disclosures Of Your PHI: Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted by law as described above.  If you authorize us to use or disclose your PHI for purposes other than set forth in the Notice, you may revoke that authorization, in writing, at any time, except to the extent that we have already taken action based upon the authorization.  Thereafter, we will no longer use or disclose your PHI for the reasons covered by your written authorization.

 

YOUR RIGHTS

 

Right To Inspect And Copy: As long as we maintain it, you may inspect and obtain a copy of your PHI that is contained in a Designated Record Set.  A "Designated Record Set" means a group of records that comprise the enrollment, payment, claims adjudication, case or medical management record systems maintained by or for the plan.

 

Under federal law, however, you may not inspect or copy psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.

 

We may decide to deny access to your PHI.  Depending on the circumstances, our decision to deny access may be reviewable by a licensed health professional who was not involved in the initial denial of access and who has been designated by the plan to act as a reviewing official.

 

To request access to inspect and/or obtain a copy of any of your PHI, you must submit your request in writing on a form the plan shall provide to our Privacy Officer at the address below indicating the specific information requested.  We shall impose a fee to cover the costs of copying postage and providing a summary of explanation.  If you want to inspect your PHI, we will make an appointment for you to come to the Fund Office at a reasonable time during normal business hours.

 

Right To Request A Restriction Of Your PHI: You may ask us not to use or disclose any part of your PHI for the foregoing purposes.  You may also request that we not disclose particular portions of your PHI to personal representatives or to family members who may be involved in your care or for notification purposes as described above.  We are not required to agree to a restriction that you may request.  However, if we do agree to the request, we will not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment, or we terminate the restriction with or without your agreement.  If you do not agree to the termination, the restriction will continue to apply to PHI created or received prior to our notice to you of our termination of the restriction.  To request a restriction you must write to our Privacy Officer at the address below indicating what information you want to restrict, whether you want to restrict use, disclosure or both, and to whom you want the restriction to apply.

 

Right To Request To Receive Confidential Communications From Us By Alternative Means Or At An Alternative Location: You may request in writing and we must accommodate your reasonable requests to receive communications of PHI from us by alternative means or at alternative locations.  For example, you can ask that we only contact you at work or by mail or at another address.  Your request must affirm that you believe that the disclosure of the information could endanger you.  Your written request for such confidential communication must be addressed to our Privacy Officer at the address below.

 

Right To Amend Your PHI: If you believe that PHI that we have about you is incorrect or incomplete, you may request it to be amended. Your request must be made in writing and submitted to our Privacy Officer.  In addition, you must provide a reason that supports your request.

 

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

 

C   did not originate with us, unless the person or entity that originates the PHI is no longer available to make the amendment;

C   is not contained in the records maintained by the plan;

C   is not part of the information which you would be legally permitted to inspect and copy; and

C   is accurate and complete.

 

If we deny your request for amendment, you have the right to file a written statement of disagreement with us or you can request us to include your request for amendment along with the information sought to be amended if and when we disclose it in the future.  We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

 

Right To An Accounting Of Disclosures: You have the right to request an accounting or list of disclosures of your PHI made by the plan or its Business Associates.  We are required to comply with your request except with respect to disclosures:

 

C    made in connection with your receiving treatment, our payment for such treatment and for health care operation;

C    made to you regarding your own PHI;

C    pursuant to your written authorization;

C    to a person involved in your health care or payment of your health care for other permitted notification purposes;

 

 

C    for national security or intelligence purposes;

C    to correctional institutions or law enforcement officials; and

C    that are merely incidental to another permissible use or disclosure.

 

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer.  You have the right to receive an accounting of disclosures of PHI made within six years (or less) of the date on which the accounting is requested, but not prior to April 14, 2003.  Your request should indicate the form in which you want the list (e.g., paper or electronic).  The first request within a 12-month period will be free of charge.  For additional requests within the 12-month period, we will charge you for the costs of providing the accounting.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any cost is incurred.

 

Right To Obtain A Paper Copy Of This Notice: You may request a paper copy of our Notice at any time.

 

COMPLAINTS

 

If you believe that your privacy rights have been violated, you may file a complaint with us or to the Secretary of the U.S. Department of Health and Human Services at Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, DC 20201. To file a complaint with us, you must submit your complaint in writing to our Privacy Officer at the address below. We will not retaliate against you for filing a complaint.

 

FOR QUESTIONS OR REQUESTS

 

If you have any questions regarding this Notice or would like to submit a written request as described above, please contact:

 

Teamsters Local 97 Benefits Fund

485 Chestnut Street

Union, NJ  07083

(888) 270-FUND

 

1. PLAN NAME:  Teamsters Local 97 Benefits Fund.

 

2. EDITION DATE:  This Summary Plan Description is produced as of January 1, 2009.

 

3. PLAN SPONSOR:  Board of Trustees of Teamsters Local 97 Benefits Fund.

 

4. PLAN SPONSOR'S EMPLOYER IDENTIFICATION NUMBER:  22-2004832.

 

5. PLAN NUMBER:  501 (assigned by federal government).

 

6. TYPE OF PLAN:  Welfare Plan.

 

7. PLAN YEAR ENDS:  July 31.

 

8. PLAN ADMINISTRATOR:  Board of Trustees of Teamsters Local 97 Benefit Fund, 485 Chestnut Street, Union, NJ  07083.  Phone #: (888) 270-FUND.

 

9. AGENT FOR SERVICE OF LEGAL PROCESS:  Teamsters Local 97 Benefit Fund, 485 Chestnut Street, Union, NJ  07083.  Phone #: (888) 270-FUND

 

10. TYPE OF PLAN ADMINISTRATION:  Direct employees of the Trustees.

 

11. TYPE OF FUNDING:  Part insured, part self-insured.

 

12. SOURCES OF CONTRIBUTIONS TO PLAN:  Employers required to contribute to the Teamsters Local 97 Benefits Fund.

 

13. COLLECTIVE BARGAINING AGREEMENTS:  This plan is maintained in accordance with collective bargaining agreements.  A copy of an agreement may be obtained by you upon written request to the Fund Manager and is available for examination by you at the Fund Office.

 

14. PARTICIPATING EMPLOYERS:  You may receive from the Fund Manager, upon written request, information as to whether a particular employer participates in the sponsorship of the plan.  If so, you may also request the employer=s address.

 

15. PLAN BENEFITS PROVIDED BY:  Life insurance is provided by a policy issued through The Hartford Insurance Co..  Hospital, Medical and Optical Benefits are self-insured and administered through the Fund Office. Dental Benefits are self-insured and administered by DDS Inc. Prescription Benefits are self-insured and administered by SPS.

 

16. ELIGIBILITY REQUIREMENTS, BENEFITS AND TERMINATION PROVISIONS OF THE PLAN:  Described in Previous Sections of this Booklet.

 

17. HOW TO FILE A CLAIM:  See Claim Procedures under each individual benefit section.

 

 

18. REVIEW OF CLAIM DENIAL:  If you submit a benefit application to the plan or to any insurance company, and it is denied, in whole or in part, you will be so notified.

 

If a denial takes place, you are entitled to appeal the decision by writing to the Trustees (or to the insurance company, if appropriate) within 60 days of the denial, at the Fund Office asking that a review of the denial be made.  You, or your representative, may review the pertinent

 

records and documents and you may appear at the reviewing hearing.

 

After review, you will be notified of the results of the review.

 

More specific information regarding this procedure may be obtained from the Fund Office.

 

19. RIGHTS AND PROTECTIONS:  As a participant in this plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).  ERISA provides that all plan participants shall be entitled to:

 

a. Examine, without charge at the Fund Manager's office, all plan documents, including any insurance contracts, collective bargaining agreements and a copy of the latest annual report (Form 5500 Series) file by the plan with the U.S. Department of Labor.

 

b. Obtain, upon written request to the Trustees, copies of documents governing the operations of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Trustees may make a reasonable charge for the copies.

 

c. Receive a summary of the plan's annual financial report.  The Trustees are required by law to furnish each participant with a copy of this summary annual report.

 

In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of this plan.  The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and the other plan participants and beneficiaries.

 

No one, including your employer, your union, or any other person may fire you (or otherwise discriminate against you in any way) to prevent you from obtaining a benefit or exercising your rights under ERISA.

 

If your claim for a benefit is denied, in whole or in part, you must receive a written explanation of the reason for the denial.  You have the right to have the plan review and reconsider your claim.

 

Under ERISA, there are steps you can take to enforce the above rights.  For instance, if you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court.  In such a case, the court may require the Trustees to provide the materials, and pay you up to $110. a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the manager.  If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court.  If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court.  The court will decide who should pay court costs and legal fees.  If

 

you are successful, the court may order the person you have sued to pay these costs and fees.  If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.  If you have any questions about your plan, you should contact the Fund Manager.

 

If you have any questions about this statement or about your rights under ERISA, you may contact the nearest Regional Office of the Pension and Welfare Benefits Administration, Department of Labor.

 

You may also contact the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Ave. N.W. Washington, DC 20210.

 

20. NO INSURANCE UNDER THE PBGC:   Since this plan is not a defined benefit pension plan, it does not have coverage under the Pension Benefit Guaranty Corporation.

 

21. TRUSTEES:  The Plan Sponsor and Fund Manager is the Board of Trustees of the Teamsters Local 97 Benefits Fund.  The following are the individual Trustees that make up the Board as of January 1, 2009:

 

UNION TRUSTEES:                                                 EMPLOYER TRUSTEES:

 

Mr. John Gerow                                                           Mr. Daniel J. Reiman

c/o Teamsters Local 97                                              c/o Borough of Carteret

485 Chestnut Street                                                    20 Cooke Avenue

Union, NJ  07083                                                         Carteret, NJ  07008

 

Ms. Maria S. Perez                                                     Mr. John Lamela

c/o Teamsters Local 97                                              c/o Jackson Twp. Board of Education

485 Chestnut Street                                                    151 Don Connor Blvd.

Union, NJ  07083                                                         Jackson, NJ  08527