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