Plan Provisions

General Plan Provisions

PAYMENT OF BENEFITS

Health care benefits are payable individually for you and each of your eligible dependents up to but not to exceed the maximum benefits stated on the Schedule of Benefits according to the following provisions:

1. Doctors and hospitals should send their bills directly to Blue Cross and Blue Shield of Illinois (BCBSIL) who handles all payments on behalf of the Plan for covered medical expenses incurred from such providers. BCBSIL pays the doctor or hospital the Plan’s share of such expenses.After BCBSIL has made the payment to the doctor or hospital, the doctor or hospital will bill you for any remaining charges. It is your responsibility to pay these charges directly to the hospital or doctor-do not file a claim for the charges or send them to the Fund Office.
2. Dental benefits under the Dental PPO Plan, and Vision benefit payments will be made to you (the employee) unless you assign benefits.Assigning benefits means that you or your spouse sign a form that tells the Fund Office to make payments directly to the provider of the services and supplies instead of to you. You will be sent an Explanation of Benefits telling you what the Fund Office paid. You are responsible for paying any amounts not paid by the Fund Office.

   You do not have to file claims for benefits received under the Dental HMO Plan or the Prescription Drug Program.

3. The Plan will reimburse you the Plan’s share of out-of-network doctor expenses.
4. Benefits are payable only when the information necessary to process your claim has been received by the Fund Office or BCBSIL, as applicable.
5. If the Trustees decide that a person isn’t mentally, physically, or otherwise capable of handling his business affairs, the Plan may pay benefits to his guardian or to the individual who has assumed his care and principal support, if there is no guardian. If the person dies before all due amounts have been paid, the Trustees may make payment to his estate, to his surviving spouse, parent, child, or children, or to any individual the Trustees believe is entitled to the benefits.
6. In determining the satisfaction of any deductible amounts and the amount of benefit payments, a charge for any service or supply is considered to have been incurred on the date the service was rendered or on the date the supply was provided.

Any payments made by the Plan in accordance with these rules will fully discharge the Plan’s liability to the extent of its payments.

COORDINATION OF BENEFITS (C.O.B.)

Benefits are coordinated when both you and your spouse (and/or your dependent children) are covered by this Plan as well as by one or more other group health plans. Coordination allows benefits to be paid by two or more plans, up to but not to exceed 100% of the allowable expenses on the claim. It also prevents the two plans from making duplicate payments.

Note: If a dependent child is employed and has other coverage due to such employment, that child’s coverage under this Plan will terminate.

General C.O.B. Information

1. C.O.B. applies only to health care benefits-it doesn’t apply to Life Insurance, Death Benefits, AD&D Insurance, AD&D Benefits or Weekly Disability Benefits.
2. Benefits are coordinated on all employee and dependent claims.
3. Benefits will be coordinated separately on each claim.
4. You must file a claim for any benefits you are entitled to from all other sources. Whether or not you actually file claims with these other sources, this Plan’s benefits will be calculated as though you have received any benefits you are entitled to from the other sources. For example, if a person is eligible for Medicare, the Plan will assume that he is enrolled for both Part A and B of Medicare. The Plan will coordinate with both Parts of Medicare even if the person is not enrolled for both Parts.
5. The Fund Office may release or receive necessary information about your claims to or from other sources. You must furnish the Fund Office with any information necessary to process claims.
6. If another plan pays benefits on a claim first when this Plan should have paid first, this Plan may pay directly to the other plan the benefits it should have paid. If this Plan pays benefits on a claim first when another plan should have paid first, the Trustees may recover the amounts paid directly from the other plan, or from a person if the other plan has already made its payment to a person.
7. Benefits are paid under C.O.B. for “allowable expenses,” which are expenses that are eligible to be considered for reimbursement.
8. Benefits are coordinated with other group plans, including group Blue Cross and Blue Shield and blanket insurance plans, group prepayment coverage, union welfare plans, labormanagement trusteed plans, employer organization plans, or employee benefit organization plans, and federal or state or other governmental plans. Benefits are also coordinated with Medicare under certain circumstances. If you or a dependent are covered under another plan, you can contact the Fund Office to find out whether that plan fits the definition of a group plan.
9. A plan that is required to pay its benefits before another plan pays its benefits is the “primary” plan (pays first); the plan that pays its benefits after the other plan has paid its benefits is the “secondary” plan (pays second).
10. If another plan is the primary plan but some or all of the benefits otherwise payable by that plan are denied or reduced because of the claimant’s failure to comply with that plan’s required procedures governing receipt of medical care, this Plan’s secondary benefits will only be those that would have been payable if the claimant had complied with all of the required procedures of the other plan. The required procedures could include, but are not limited to, complying with utilization review or cost containment procedures such as hospital preadmission review or certification, second surgical opinions, certification of chemical dependency or mental health treatment, or any other required notification or procedure of the other plan.
11. When anyone in your family who is covered under another group health plan has a claim, be sure that claims are filed with all plans and that all required information about other coverage is provided on all forms.

Order of Benefit Determination
When a person who has a claim is covered under one or more other group plans in addition to this Plan, the plans will determine their benefits as follows:

1. If a covered person is covered under another plan that doesn’t have C.O.B. rules, the other plan is primary and this Plan is secondary.
2. When the other plan has C.O.B. rules, the plan covering the person for whom the claim is filed other than as a dependent is primary, and the plan covering the person for whom the claim is filed as a dependent is secondary.
3. If you and your spouse are both covered as employees under this Plan and one of you has a claim, the Plan will coordinate benefits on the claim.
4. On claims for children:
   • When the parents are not separated or divorced – The plan covering the parent whose birthday comes first in the year will pay first and the plan covering the parent whose birthday comes later in the year will pay second-the year of birth doesn’t count. For example, if your birthday is in May and your spouse’s birthday is in March, your spouse’s plan will pay benefits on your children’s claims first and this Plan will pay second.
   • When the parents are separated or divorced:
     • If there is a Qualified Medical Child Support Order (QMCSO), the plan covering the parent who has legal responsibility will pay first and the plan covering the other parent will pay second.
     • If there is no QMCSO, and the parent with custody has not remarried, the plan covering the parent who has custody of the child will pay first and the other parent’s plan will pay second.
     • If there is no QMCSO, and the parent with custody of the child has remarried, the plan covering the parent who has custody will pay first, the plan covering the spouse of the parent who has custody (the stepparent of the child) will pay second, and the plan covering the parent without custody will pay last.
     • The birthday rule will apply if a court awards joint custody without specifying that one party has the responsibility to provide health coverage.
   • If both you and your spouse are covered as employees under this Plan, claims for your dependent children will be paid as claims of the husband.
5. If a person is covered under a plan as an employee (or as a dependent of the employee) and is also covered under a plan as a laid off or retired employee (or as the laid-off or retired employee’s dependent), or as a COBRA beneficiary, the plan covering the person as an employee or his dependent will pay benefits before the plan covering the person as a laid-off or retired employee, or COBRA beneficiary, or his dependent.
6. If a covered person is covered under another group health plan and also has COBRA coverage under this Plan because he has one or more preexisting conditions for which the other plan limits or excludes coverage, this Plan will pay primary benefits only on claims for treatment of the preexisting condition(s). The other plan will pay primary benefits on claims for treatment of all other conditions and this Plan will pay secondary benefits for those conditions.
7. If the above rules still don’t clearly show which plan should pay first, the plan that has covered the person for whom the claim is filed for the longest period of time will pay first. The plan which has covered the person for the next longest period of time will pay second, and so on.

C.O.B. WITH NONCOMPLYING PLANS – If it is determined that this Plan should pay second under the rules for order of benefit determination but this Plan is coordinating its benefits with a Plan that is unable or unwilling to pay benefits when due, or says that it always pays second, or uses different rules for order of benefit determination, this Plan will pay its benefits first. However, the amount of the benefits payable by this Plan will be determined as if this Plan were the secondary plan. In such a situation, any payment by this Plan will be the limit of this Plan’s liability.

C.O.B. With Medicare

If an eligible employee or any of his dependents is eligible for Medicare, the Plan will pay benefits, including C.O.B. calculations, as if he is enrolled in both Part A and Part B of Medicare, even if he is not actually enrolled in both Parts.

FOR EMPLOYEES CONTINUING TO WORK AFTER AGE 65 – If you continue to work for a contributing employer for a contributing employer who has 20 or more employees, you are entitled to the same benefits as employees under age 65 as long as you meet the regular eligibility rules. This Plan will usually be your primary provider of health care benefits unless it is legally permitted to pay second. Medicare will pay secondary benefits only for expenses covered by it and which are not paid by the Plan. If your dependent spouse is age 65 or older and eligible for Medicare while you are still working and eligible (regardless of your age), this Plan will usually pay its normal benefits for her before Medicare pays unless it is legally permitted to pay second. If she is covered under her own plan, her plan will pay first, this Plan will usually pay second, and Medicare will pay last.

Example 1: If you are age 64 and working, your spouse is age 66 and retired, and your spouse has retiree coverage through her former employer, the payment order for your spouse’s claims will usually be:

1. This Plan
2. Medicare
3. Your spouse’s employer’s plan

Example 2: If in Example 1 your spouse has an individual Medicare supplement policy instead of employer-sponsored coverage, the individual supplement policy would pay 3rd.

(If you are age 64 and retired with an older spouse eligible for Medicare, your spouse will not be covered under this Plan.)

Example 3: If you are age 64 and working, and your spouse is age 65 and working, the payment order for your spouse’s claims will be:

1. Your spouse’s employer-sponsored plan
2. This Plan
3. Medicare

If you continue to work for a contributing employer who has less than 20 total employees after you are age 65, this Plan will usually pay benefits for you and your spouse after Medicare pays its benefits unless this Plan is legally required to pay first.

You (and/or your spouse) can decline coverage under this Plan. If you do, Medicare will be your only health care coverage. If you and/or your spouse prefer Medicare as your only health care coverage when you are age 65, contact the Fund Office (or your spouse should notify her own plan).

FOR MEDICARE-ELIGIBLE PERSONS UNDER 65 – If you or any of your dependents are entitled to Medicare for reasons other than being 65 or older, the following rules will apply:

• If you or a dependent are an End Stage Renal Disease (ESRD) beneficiary under Medicare, this Plan will usually pay its benefits before Medicare pays for a period of up to 30 months unless it is legally permitted to pay second.
• In all other cases, this Plan will pay secondary to Medicare when it is allowed to do so by law.

ENROLLMENT IN MEDICARE – You and your spouse are each responsible for enrolling in Medicare Part A and Part B when eligible to do so. At present, there is no cost to you for Part A, which provides hospital benefits. Part B covers such items as doctors’ services. The government makes a monthly charge for Part B. If you want information about Medicare enrollment, contact your local Social Security office (at least 30 days before your 65th birthday, if possible).

The above rules governing C.O.B. with Medicare do not apply to retirees and their spouses. When an eligible retiree or the spouse of an eligible retiree becomes eligible for Medicare, Retiree Comprehensive Plan coverage for that person will terminate.

SUBROGATION;
CONSTRUCTIVE TRUST OF PLAN ASSETS

“Subrogation” is a legal term which provides that the Fund may sue any party that you or a dependent may sue if you or the dependent are injured by the acts of a third party which causes the Plan to provide benefits for your or the dependent’s injuries. Subrogation applies whenever a covered person has a right to recover payment from a third party (including his own insurance carrier). Subrogation does not apply to work-related conditions which are not covered by the Fund in any circumstance.

The Local 734 Welfare Fund is not obligated to pay benefits or claims in those circumstances where a third party is liable for the injury giving rise to the claim for benefits. The Fund may withhold payment of benefits payable in connection with accidental injuries when any party other than the covered person or this Fund may be liable for expenses, until such liability is legally determined.

The Fund, in its sole discretion, may make payment of benefits before a finding of liability is made, subject to the agreement of the covered person (including a minor) and his or her counsel, if any, to hold any proceeds of litigation, settlement or judgment in trust for the Fund and to acknowledge that the proceeds are a Plan asset. Payment may be conditioned upon receipt of a Subrogation and Constructive Trust Agreement signed by the covered person (or, if the covered person is minor, the legally responsible party) and his or her legal representative. In the event of any payment for services under this Plan, the Fund shall, to the extent of such payment, be subrogated to all the rights of recovery of the covered person, and shall be entitled to immediate payment of amounts due before any distribution to or on behalf of the covered person. The covered person will be required to reimburse this Fund for any and all benefits paid under this Plan out of any monies recovered as the result of:

• Judgment,
• Settlement, or
• Any other cause.

Upon receipt by the covered person or the legal representative, the monies recovered shall become an asset of this Fund. The covered person and the legal representative shall hold the monies recovered as a result of judgment, settlement or any other cause in trust for this Fund. The Fund is entitled to payment in full, without set-off for attorney’s fees, of 100% of the benefits paid, whether or not the covered person is made whole.

The Trustees may, in their sole discretion, compromise the amount due under this provision when, in their judgment, the compromise is more likely to result in a higher recovery for the Fund than if no compromise were made.

The covered person must take such action, furnish such information and assistance, and execute and deliver all necessary instruments as the Fund may require to facilitate the enforcement of its rights. If the covered person fails to cooperate with the Fund in the enforcement of its rights, the Fund may suspend payment of all benefits subject to subrogation, enforce its right to restitution of amounts paid and to equitable enforcement of the Plan, and seek such other legal or equitable relief to which it is entitled. in addition, if the covered person fails to cooperate with the Fund in the enforcement of its rights, the Fund may offset all present and future payments due the covered person under the Plan against amounts paid pursuant to the Agreement.

This Fund has the right to recover against any proceeds from other sources received in connection with the accident or injury. It does not pay for nor is responsible for the covered person’s attorney’s fees. Attorney’s fees are to be paid solely by the covered person.

CIRCUMSTANCES WHICH MAY RESULT IN CLAIM DENIALS OR LOSS OF BENEFITS
The Trustees, or their Fund Administrator, are authorized to deny payment of a claim, and the reasons for denial may include one or more of the following:

1. The person on whose behalf you filed the claim was not eligible for benefits on the date the expenses were incurred.
2. The claim was not filed within the Plan time limits.
3. The expenses that were denied were not actually incurred or are not covered under the Plan.
4. The person for whom the claim was filed had already received the maximum benefit allowed for that type of expense during a stated period of time, for instance a calendar year maximum benefit, a lifetime maximum benefit, etc.
5. Another plan was primarily responsible for paying benefits for the incurred expenses.
6. No payment, or a reduced payment, was made, because some or all of the expenses for which the claim was filed were applied against a deductible.
7. No payment, or a reduced payment, was made because the covered person:
   • Did not follow the procedures of the Medical Care Review Program;
   • Did not get a required second surgical opinion; or
   • Stayed in the hospital longer than the number of days that were precertified.
8. A third party was responsible for paying the incurred medical expenses, and the required subrogation documents which would permit the Plan to process the claim and recover payment from the third party or his insurance company were not submitted.
9. The Trustees amended the eligibility rules or decreased benefits.
10. The Trustees reduced or temporarily suspended future benefit payments for a covered person in order to recover an overpayment of benefits previously made on his behalf.
11. The Plan of Benefits was terminated and there were no further Plan assets available for paying benefits.

The preceding is not an all-inclusive listing of the circumstances which may result in claim denials or loss of benefits. It is only representative of the types of circumstances, in addition to failure to meet the regular eligibility requirements, that might cause denial of a claim for benefits. If you have any questions about a claim denial, contact the Fund Office.

CERTIFICATES OF CREDITABLE COVERAGE

When you or a dependent are no longer eligible for Plan benefits, you have a right to request a certificate of creditable coverage from the Fund Office. This certificate provides evidence of your prior health care coverage under the Plan. You may need to furnish this certificate if you become eligible under another group health plan that excludes coverage for preexisting conditions. You may also need this certificate in order to buy an individual insurance policy with a preexisting condition exclusion or limitation. You also have the right to request one for any other reason.

Just call or write the Fund Office to request a certificate. You may request one any time within 24 months of when you were last covered under the Plan.

If your coverage terminates due to termination of employment or reduction in hours, the Fund Office will automatically send a certificate of coverage to you at your last known address. The Fund Office also automatically sends one to your dependent’s last known address if you notify the Fund Office that a dependent’s coverage has terminated.

ADDITIONAL PLAN PROVISIONS

TRUSTEE INTERPRETATION AND AUTHORITY; DECISIONS REGARDING BENEFITS – The Plan is administered by the Trustees in accordance with the Trust Agreement. The Trustees, or their Fund Administrator subject to Trustees’ review, have the right to interpret the Plan, the Plan documents, and the Plan regulations and procedures. Their interpretation is final and binding on all involved persons. All questions or controversies arising in any way in connection with this Plan or the Fund or its operation will be submitted to the Trustees, or their Fund Administrator subject to Trustees’ review, for decision. Benefits under this Plan will be paid only when the Board of Trustees or persons delegated by them decide, in their sole discretion, that the participant or beneficiary is entitled to benefits. The decision of the Trustees, or the Fund Administrator if not appealed on a timely basis, is final and binding on all persons dealing with the Plan or the Fund or claiming any benefit under the Plan.

The Trustees have the authority to amend the eligibility rules or other provisions of the Plan. They may increase, reduce, change or eliminate benefits or terminate the Plan at any time, provided that such changes are not inconsistent with law or with the provisions of the Plan or the Trust Agreement. All benefits of the Plan are conditional and subject to the Trustees’ authority to change or terminate them at any time.

LENGTH OF MATERNITY HOSPITALIZATIONS – A federal law requires that a covered person and her newborn infant are entitled to at least 48 hours of inpatient hospital care following a normal delivery and at least 96 hours of inpatient hospital care following a Caesarean section. Further, a Plan cannot require the provider (hospital or doctor) to obtain authorization from the Plan for prescribing a length of stay not in excess of these periods. (The attending provider may however, after consulting with the mother, discharge the mother and newborn earlier than 48 hours following a vaginal delivery or 96 hours following a Cesarean section.) The Plan will provide benefits for the covered medical expenses incurred by a person eligible for maternity benefits during the prescribed time periods, subject to all applicable Plan benefit provisions, maximums and limitations.

QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) PROCEDURES – The following procedures apply to determinations made by the Plan Administrator (that is, the Trustees of this Fund), with respect to qualification of medical child support orders for approval as Qualified Medical Child Support Orders (QMCSOs) under the Employee Retirement Income Security Act (ERISA).

1. You, the “alternate recipient” (the child) or an attorney for any of the preceding individuals, may submit for the Trustees’ approval as a QMCSO either a draft of a medical child support order or an entered medical child support order. Because changes are frequently necessary in order to comply with ERISA, it is recommended that a draft order be submitted prior to entry.
2. The draft or entered medical child support order for which QMCSO status is desired should be submitted to the Trustees by mailing or faxing the order to the Fund Office.
3. Upon receipt of the draft or entered medical child support order for which QMCSO status is desired, either the Trustees or the Trustees’ attorney, on behalf of the Trustees, will promptly notify you, and the affected alternate recipient, together with any other person designated as receiving a benefit under the order, or the attorneys for any of these individuals, of the Trustees’ receipt of the draft or entered medical child support order. A copy of these procedures will be enclosed with the notification.
4. The draft or entered order will be referred to the Trustees’ attorney for purposes of determining its qualified status. Within a reasonable period after the Fund’s receipt of the draft or entered order, the Trustees’ attorney on behalf of the Trustees shall determine whether the order is a QMCSO and shall notify you and the affected alternate recipient of this determination.
5. If the Trustees determine that the order is not a QMCSO, the Trustees’ attorney will ordinarily inform you and the affected alternate recipient of the changes necessary for the order to be accorded QMCSO status. The Trustees’ attorney will ordinarily request that a revised order incorporating the suggested changes be submitted.
6. If the Trustees determine that the order is a QMCSO, you and the affected alternate recipient will be asked to forward a certified copy of the QMCSO for purposes of inclusion in the Trustees records.
7. If the order submitted is with respect to a child of a noncustodial parent who is an employee for whom an employer contributes to the Fund and an appropriately completed National Medical Support Notice promulgated pursuant to section 401(b) of the Child Support Performance and Incentive Act of 1998 is received and complies with the requirements of 29 U.S.C. $1169(B)(3) and (4), the Notice shall be deemed to be a QMCSO with respect to that child.
8. You, the affected alternate recipient, or any other person designated as receiving a benefit under the order, may designate a representative for receipt of copies of notices that are sent with respect to the proposed or entered medical child support order. A designation of a representative will be considered to have been made by an affected person when correspondence regarding the draft or entered medical child support order is received from an attorney or other representative acting on behalf of that person.

WOMEN’S HEALTH AND CANCER RIGHTS ACT – This Plan covers services provided to a covered person for a medically necessary mastectomy and for the post-surgical reconstruction of the affected breast. It also considers charges for the following services and supplies to be covered medical expenses when the charges are incurred by a covered person who is receiving Plan benefits for a mastectomy, and when the person elects (in consultation with her physician) breast reconstruction in connection with the mastectomy:

• Reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications relating to all stages of the mastectomy, including lymphedemas.

Plan benefits payable for these services and supplies are subject to all applicable deductibles, copayment percentages and maximum benefit limitations.

ALTERED OR FORGED CLAIMS – Any claim form or bill submitted by or on behalf of covered person that contains a material alteration or forged information, including signatures, shall be rejected. The Trustees reserve the right to forward the altered or forged document to the local law enforcement agency for whatever legal action such agency deems to be appropriate.

If a provider alters any information on a previously submitted claim, it must be accompanied by written documentation satisfactory to the Trustees that explains the reason for the alteration.

LEGAL ACTIONS – You may not file legal action against the Plan or the Trustees to recover loss until all of the proper claim procedures and claim review procedures have been followed. No legal action for benefits under the Plan may be commenced or maintained against the Plan and/or Trust more than 120 days after receipt of the decision of the Trustees on a matter appealed to them.

RELEASE OF INFORMATION – When you file a claim for benefits, you must provide the Fund Office with any required authorizations for release of necessary information relating to the claim.

EXAMINATIONS – The Trustees have the right to have a doctor examine a person for whom benefits are being claimed, and to ask for an autopsy in the case of a death. They also have the right to examine any and all hospital or medical records relating to a claim.

FREE CHOICE OF DOCTOR – You will have free choice of any doctor who meets this Plan’s definition of a doctor. However, no payment will be made for a doctor’s charges beyond the coverage specifically provided under this Plan.

GOVERNING LAW – This Plan is created and accepted in the State of Illinois. All questions regarding the validity or interpretation of the Trust Agreement or the Plan or any questions concerning the acts and transactions of the Trustees or any other matter that affects the Plan will be determined under federal law, where applicable federal law exists. If there is no applicable federal law, then the laws of the State of Illinois will apply.

WORKERS’ COMPENSATION NOT AFFECTED – This Plan is not in place of and does not affect any requirement for coverage under any Workers’ Compensation Law, Occupational Diseases Law, or similar law. Benefits which would otherwise be payable under the provisions of these laws will not be paid by the Plan merely because you fail or neglect to file a claim for benefits under the provisions of these laws.

PLAN DISCONTINUATION OR TERMINATION – This Plan of Benefits may be discontinued or terminated under certain circumstances-for example, if future collective bargaining agreements don’t require employer contributions to the Fund. In such event, benefits for covered expenses incurred before the termination date fixed by the Trustees will be paid on behalf of covered persons as long as the Plan’s assets are more than the Plan’s liabilities. Full benefits may not be paid if the Plan’s liabilities are more than its assets, and benefit payments will be limited to the monies available in the Trust Fund for such purposes. The Trustees will not be liable for the adequacy or inadequacy of such funds.

If there are any assets remaining after payment of all Plan liabilities, those assets will be used for purposes determined by the Trustees in accordance with the Trust Agreement, provided that any such disposition of assets will be made only for the benefit of former Plan participants and for the purposes set forth in the Plan.