Glossary
When a word or phrase defined below is used on this site, the definition shown below for that word or phrase will apply unless stated otherwise.
Except where stated otherwise, where the term “you” or “your” is used in this section, it means an eligible employee or eligible retiree.
ACTIVE EMPLOYEE BENEFIT PLAN; ACTIVE PLAN – The program of benefits for active eligible employees and their eligible dependents provided by the Local 734 Welfare Fund and described in the Summary Plan Description booklet.
ACTIVE WORK; ACTIVELY AT WORK – The active full-time performance of your customary duties at your usual place of employment. You are a full-time employee if your principal occupation is with a participating employer, if you are regularly scheduled to work at least 30 hours per week, and if you are covered by a collective bargaining agreement.
ALLOWABLE CHARGE – The maximum covered medical expense for a service or procedure provided by a non-PPO provider (including physicians, hospitals and other covered facilities). The allowable charge is the lesser of the reasonable and customary charge, or the PPO approved amount (the amount a PPO provider could have charged for the same service or procedure in accordance with the PPO agreement). You will be responsible for amounts in excess of the allowable charge even if the allowable charge is less than some determinations of what is reasonable and customary. Allowable charge limitations apply to out-of-network services only.
CALENDAR YEAR – The 12-month period starting on January 1 of any year and ending on December 31 of that same year.
CHEMICAL DEPENDENCY – The abuse of, addiction to, or dependency on the use of drugs, narcotics, alcohol, or any other chemical (except nicotine).
COLLECTIVE BARGAINING AGREEMENT – The negotiated labor agreements between the Union and an employer requiring contributions to the Fund.
CONTRIBUTIONS – Payments made by a participating employer to the Fund on behalf of the employer’s employees.
COVERED PERSON – (1) An eligible employee and any person in his family or household who meets the definition of a “dependent,” provided all eligibility requirements for dependent coverage have been satisfied for any such dependent; or (2) An eligible retiree and his legal spouse provided that such person is not covered by another group health care plan or Medicare.
COVERED UNDER THE PLAN – A person is eligible to receive Plan benefits applicable to his status as an eligible employee or as a dependent.
CUSTODIAL CARE – Care that is comprised of services and supplies which are provided to a covered person primarily to assist him in the activities of daily living.
DEPENDENT – An individual who is:
- The spouse of an eligible employee or eligible retiree, provided the employee or retiree is not legally separated from her.
- An unmarried child of an eligible employee (see “Definition of Child” below):
- Who is less than 19 years old; or
- Who is age 19 or older but less than age 23, is enrolled full-time in a state-accredited secondary school, university, college, trade school, etc., is dependent on you for the major portion of his support, and maintains a permanent residence in your home; or
The registrar of the child’s school must submit a completed enrollment verification form each term (semester, quarter or trimester). If all required enrollment verification forms are received for a school year that starts in the fall, the child will be covered through the following August 31 even if the child is not in school during the summer.
- Who is age 19 or older, is incapable of selfsustaining employment because of mental incapacity or retardation or physical handicap (hereafter called a “handicap”), and meets all of the following conditions: he must meet the definition of a dependent child except for age; he must be incapable of supporting himself due to his handicap; and he must be primarily dependent upon you for support. If a child meets these conditions, and continues to meet these conditions, he will be covered under the Plan as long as you remain eligible. Proof of the child’s handicap or continued handicap may be required.
Definition of Child – For purposes of this definition, a “child” means any of the following:
- A child born of a valid marriage of yours;
- With respect to a female employee—A child born to you;
- With respect to a male employee—A child of yours not born of a valid marriage either for whom you may have been determined to be the legal parent, or you are listed on the child’s birth certificate as the father and later marry the child’s mother (in which case such child’s coverage will begin on the date of your marriage to the child’s mother);
- A natural child of yours who is not a child born of a valid marriage of yours, provided the child is recognized by the Trustees as an “alternate recipient” under the terms of a court order which the Trustees determine to be a Qualified Medical Child Support Order. A copy of the court order will be required by the Fund Office before claims for the child will be considered for payment;
- A child for whom you have legal guardianship, or a child legally adopted by you or placed in your home for adoption (provided that the child lives with you in your home in a regular parentchild relationship); or
- A stepchild of yours, meaning any child of your spouse who was born to your spouse or who was legally adopted by your spouse before your marriage to your spouse, provided that the stepchild is dependent on you for the primary portion of his support and maintenance and lives with you in a regular parent-child relationship.
Dependent children under 14 days of age are not eligible for the Dependent Death Benefit.
If your spouse or child is on active duty with the armed forces of any country, the spouse or child will not be considered a dependent.
If a child is eligible under this Plan as an employee, the child will not be considered a dependent under the Plan.
If a child is employed and becomes covered under another group health due to such employment, the child will not be considered a covered dependent under this Plan. Benefits will terminate on the day before the other coverage becomes effective.
Only dependent spouses are covered under the Retiree Comprehensive Plan or Basic 65 Plan. No coverage is provided for dependent children of retirees.
DOCTOR; PHYSICIAN – A legally qualified physician or surgeon who is a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) and is licensed to practice medicine and surgery in all of its branches. A dentist (D.D.S.), a podiatrist (D.P.M.), a chiropractor (D.C.), or an optometrist (O.D.) will be considered a doctor under this Plan only for services performed within the scope of each such individual’s specialty and license and only within the provisions and limitations of the Plan.
ELIGIBLE EMPLOYEE – An employee who has met the Plan’s eligibility requirements and is entitled to receive the benefits provided under the Plan to active employees.
ELIGIBLE RETIREE – A retired employee who has satisfied all the eligibility and self-payment requirements for the retiree benefits described on this site.
EMERGENCY – The sudden, unexpected and acute onset of a sickness, ailment, condition, disease, disorder or injury showing symptoms of sufficient severity that, if immediate medical attention is not obtained, they could reasonably be expected to result in: permanently placing the person’s health in jeopardy, serious impairment to bodily functions, serious and permanent dysfunction of any body organ or part, or other serious medical consequences.
Emergencies include but are not limited to conditions such as heart attacks, strokes, loss of consciousness or respiration, convulsions, etc., and certain accidental injuries which appear to be so serious or threatening to a body part that emergency room treatment is indicated.
If emergency treatment is obtained as a result of symptoms which could reasonably be interpreted as an emergency under the above definition, that condition will be considered an emergency even if the final diagnosis is of another condition.
For purposes of the Medical Care Review Program, an emergency hospital admission is an admission as an inpatient to a hospital directly from a hospital emergency room to which a person has gone for treatment of a condition that meets the above definition of an emergency.
If a person is taken for treatment to the nearest hospital or trauma center by police, fire department or ambulance under circumstances over which the person has no control, the condition will also be considered an emergency except when the transportation is to a hospital for reasons related to the use of alcohol or non-legal use of controlled substances.
A condition will not be considered an emergency if the first treatment by a doctor is provided more than 24 hours after the onset of the symptoms.
EMPLOYEE
- Anyone who performs work within the jurisdiction of the Bakery, Cracker, Pie, Yeast Drivers and Miscellaneous Workers Union Local 734 of the International Brotherhood of Teamsters and who is working for an employer obligated to contribute to the Local 734 Welfare Fund under the terms of a collective bargaining agreement; and
- Any full-time employee of the Union, the Pension Fund, and the Welfare Fund on whose behalf contributions are made to the Fund.
EMPLOYER; PARTICIPATING EMPLOYER
- Any person, firm, association, partnership or corporation which enters into a collective bargaining agreement providing for contributions to the Fund on behalf of its employees; and
- The Union, the Pension Fund, and the Welfare Fund for the purpose only of making contributions to the Fund on behalf of their full-time employees.
EXPERIMENTAL OR INVESTIGATIVE – A treatment, procedure, facility, equipment, drug, device or supply will be considered to be “experimental or investigative” if it falls within any one of the following categories:
- It is not yet generally accepted among experts as accepted medical practice for the patient’s medical condition; or
- It cannot be lawfully marketed or furnished without the approval of the U.S. Food and Drug Administration or other federal agency, and such approval had not been granted at the time the treatment, procedure, facility, equipment, drug, device, or supply was rendered, provided or utilized; or
- It is the subject of ongoing Phase I or Phase II clinical trials, or is the research, experimental, study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnoses, or if the prevailing opinion among experts regarding any such treatment, procedure, facility, equipment, drug, device, or supply is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnoses.
Determination of whether a treatment, procedure, facility, equipment, drug, device or supply is experimental or investigative shall be determined solely by the Trustees, in their sole discretion and judgment, in consultation with medical experts of their choosing.
FUND; TRUST FUND – The entire Trust of the Local 734 Welfare Fund created and administered according to the Trust Agreement.
HOME HEALTH AGENCY
- A hospital possessing a valid operating certificate authorizing the hospital to provide home health services; or
- A public agency or private organization (or a subdivision) which meets all of the following requirements: it is primarily engaged in providing skilled nursing services and other therapeutic services in the homes of its patients; it has established policies governing the services that it provides; it provides for the supervision of its services by a doctor or a licensed nurse; it maintains clerical records on all of its patients; it is licensed according to the applicable laws of the state in which the patient receiving the treatment lives and of the locality in which it is located or in which it provides services; and it is eligible to participate in Medicare.
HOME HEALTH AIDE – A health worker, other than a licensed doctor, nurse or professional therapist, who is on the staff of a home health agency and performs personal health care services such as: helping the patient to bathe, helping the patient in and out of bed to exercise, helping the patient with medications which are ordinarily self-administered, and other services which are intimately related to the health care of the patient and have been specifically ordered by a doctor.
HOSPICE – A public agency or private organization (or part of either) primarily engaged in providing a coordinated set of services at home or in outpatient or institutional settings to persons suffering from a terminal medical condition. The agency or organization must be eligible to participate in Medicare; must have an interdisciplinary group of personnel that includes the services of at least one doctor and one R.N.; must maintain clerical records on all patients; must meet the standards of the National Hospice Organization; and must provide, either directly or under other arrangements, the services listed as covered hospice expenses in the section titled “Provisions Governing Hospice Care”.
Benefits will be payable for hospice care only if Med-Care precertifies the care.
HOSPITAL – An institution which is engaged primarily in providing medical care and treatment to sick and injured persons on an inpatient basis at the patients’ expense and which fully meets the requirements of No. 1 or No. 2 or No. 3 below:
- It is a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations;
- It is a hospital, a psychiatric hospital, or a tuberculosis hospital, as defined in Medicare, which is eligible to participate in and to receive payments from Medicare; or
- It is an institution which: (a) provides diagnostic and therapeutic facilities for the medical and surgical diagnosis, treatment, and care of injured and sick individuals under the supervision of a staff of doctors licensed to practice medicine; (b) is operated continuously with organized facilities for operative surgery on the premises; (c) provides on the premises 24-hour-a-day nursing services by or under the supervision of registered nurses (R.N.’s); and (d) is not, other than incidentally, a place for rest, for the aged, for drug addicts or alcoholics or a nursing or convalescent home.
LICENSED NURSE – A professional nurse who is legally entitled to use the title “Registered Nurse (R.N.)” or “Licensed Practical Nurse (L.P.N.).”
MEDICALLY NECESSARY – The use of only those services, treatments or supplies provided by a hospital, doctor, or other qualified provider of medical services or supplies that are required, in the judgment of the Trustees, to identify or treat an injury, disease or sickness. The service or supply must be consistent with the symptoms, diagnosis and treatment of the condition; must be appropriate according to acceptable standards of good medical practice; must not be solely for the convenience of the patient, doctor or hospital; must be the most appropriate which can be safely provided to the patient under the circumstances; and must not be experimental or investigative. In addition, if more than one alternative is available, medically necessary means the most cost-effective alternative that can meet the individual’s essential health needs.
MEDICARE – The Health Insurance for the Aged Program under Title XVIII of the Social Security Act and the Social Security Amendments of 1965, as this Program is currently constituted and as it may later be amended.
MENTAL OR NERVOUS DISORDER (MENTAL/NERVOUS DISORDER) – A neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind, regardless of whether such disease or disorder has causes or origins which are organic, physiological, traumatic, or functional.
PLAN; BENEFIT PLAN – The program of benefits established by the Trustees and described in this site (or the Plan booklet), known as the Local 734 Welfare Fund Plan of Benefits, as they may be changed from time to time.
REASONABLE AND CUSTOMARY; REASONABLE AND CUSTOMARY CHARGE – An amount determined by comparing a particular charge with the charges made for similar services and supplies in the locality concerned to individuals of similar age, sex, circumstances and medical condition. The result of this comparison determines the amount that is the maximum allowable charge to be considered a covered expense under this Plan. Data and recommendations from standard tables available for such purposes weigh heavily in the Plan’s determination of reasonable and customary charges and payment policies.
RETIREE COMPREHENSIVE PLAN – The program of benefits for eligible retirees and their eligible spouses provided by the Local 734 Welfare Fund and described in this Summary Plan Description booklet.
SELF-PAYMENTS – Payments made to the Plan by employees and dependents to continue Plan coverage under the rules governing COBRA coverage.
SUMMARY PLAN DESCRIPTION – The book, which provides you with an easy-to-understand summary of the Plan Document. If any information in this summary is unclear or incorrect, the provisions of the Plan Document will govern.
TMJ – Temporomandibular joint syndrome, craniomandibular disorders and other conditions of the joint linking the jaw bone and the skull, along with the complex of muscles, nerves, and other tissues related to that joint.
TOTALLY DISABLED – You (the employee) are considered “totally disabled” if you are prevented, solely due to non-occupational accidental bodily injury or sickness, from engaging in your regular or customary occupation, and you are not performing any kind of work for compensation or profit. A dependent is considered “totally disabled” if he is prevented, solely due to non-occupational accidental bodily injury or sickness, from engaging in substantially all of the normal activities of a person of like age and sex in good health.
TRUSTEES – The Union and Employer Trustees who are responsible for the operation of the Trust Fund through which this Plan of Benefits is provided.
UNION – The Bakery, Cracker, Pie, Yeast Drivers and Miscellaneous Workers Union Local 734 of the International Brotherhood of Teamsters.