Definitions

Glossary of Terms

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.

ALLOWABLE CHARGE
The maximum covered charge for a service rendered or supply furnished by a health care provider that will be considered for payment.

1. For in-network providers, the allowable charge is the contracted fee.
2. For out-of-network providers, the allowable charge is the lesser of the reasonable and customary charge (as defined on page 59), or the in-network approved amount (the amount an in-network provider could have charged for the same service or procedure in accordance with the PPO fee agreement). You will be responsible for amounts charged by out-of-network providers for any amount in excess of the allowable charge.

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, retiree or 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:

1. The spouse of an eligible employee or eligible retiree provided the employee or retiree is not legally separated from her. Your “spouse” is the person to whom you are legally married.
2. A child of an eligible employee (see “Definition of Child” below):
   • Who is less than 26 years old; or
   • Who is age 26 or older, unmarried, and incapable of engaging in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. In addition, he must meet all of the following conditions: he must meet the definition of a dependent child except for age; he must have become disabled prior to age 26, 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 impairment or continued impairment may be required.

Definition of Child
For purposes of this definition, a “child” means any of the following:

1. A child born of a valid marriage of yours;
2. If you are a female employee, a child born to you;
3. If you are a male employee, a child of yours not born of a valid marriage for whom you may have been determined to be the legal parent;
4. 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;
5. A child for whom you have legal guardianship, or a child legally adopted by you or placed in your home for adoption; or
6. 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.

Dependent Death Benefits are not payable for children under 14 days of age.
 
If your spouse is on active duty with the armed forces of any country, your spouse will not be considered a dependent.
 
Only dependent spouses are covered under the Retiree 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.
 
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 in this booklet.
 
EMERGENCY
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part.
 
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 (page 6), 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.
 
EMPLOYEE

1. 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
2. Any full-time employee of the Union, the Pension Fund, and the Welfare Fund on whose behalf contributions are made to the Fund. “Full-time” means at least 30 hours per week.

EMPLOYER; PARTICIPATING EMPLOYER

1. 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
2. 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:

1. It is not yet generally accepted among experts as accepted medical practice for the patient’s medical condition;
2. 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
3. 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.
 
The Plan excludes experimental and investigative services and supplies except as described in No. 6 on page 15.
 
FUND; TRUST FUND
The entire Trust of the Local 734 Welfare Fund created and administered according to the Trust Agreement.
 
HOME HEALTH AGENCY

1. A hospital possessing a valid operating certificate authorizing the hospital to provide home health services; or
2. A public agency or private organization (or a subdivision thereof) which meets all of the following requirements: (a) it is primarily engaged in providing skilled nursing services and other therapeutic services in the homes of its patients; (b) it has established policies governing the services that it provides; (c) it provides for the supervision of its services by a doctor or a licensed nurse; (d) it maintains clerical records on all of its patients; (e) 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: (1) must be eligible to participate in Medicare; (2) must have an interdisciplinary group of personnel that includes the services of at least one doctor and one R.N.; (3) must meet the standards of the National Hospice Organization; and (4) must provide, either directly or under other arrangements, the services listed as covered hospice expenses in No. 14 on page 16.
 
Benefits will be payable for hospice care only if Med-Care pre-certifies 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:

1. It is a hospital accredited by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations);
2. It is eligible to participate in and to receive payments from Medicare Part A; or
3. It is an institution that: (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.

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: (1) must be consistent with the symptoms, diagnosis and treatment of the condition; (2) must be the standard of care according to acceptable standards of good medical practice; (3) must not be solely for the convenience of the patient, the patient’s care-giver(s) or a provider; (4) must be the most appropriate which can be safely provided to the patient under the circumstances; and (5) 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.
 
Medical necessity is a determination only as to coverage under the Plan. The ultimate decision as to appropriate treatment should be made by you in consultation with your provider.
 
MENTAL OR NERVOUS DISORDER (MENTAL/NERVOUS DISORDER)
A neurosis, psycho-neurosis, 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 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.
 
RESIDENTIAL TREATMENT FACILITY
A licensed institution that meets all of the following criteria: (1) it is primarily engaged in providing medical care and rehabilitation for individuals with physical, mental/nervous or substance abuse disorders; (2) it provides on-the-premises 24-hour-a-day nursing services by or under the supervision of R.N.’s; (3) every patient is under the supervision of a doctor, and it has available at all times a doctor who is a staff member of an acute care hospital; (4) it is part of the BCBSIL PPO network or accredited by The Joint Commission (formerly JCAHO); and (5) it is not, other than incidentally, an institution providing custodial care. Group homes and halfway houses are not residential treatment facilities and are excluded under this Plan.
 
RETIREE COMPREHENSIVE PLAN (RETIREE 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.
 
SKILLED NURSING FACILITY
A licensed institution that meets all of the following criteria: (1) it is primarily engaged in providing inpatient skilled nursing care, physical restoration services and related services for patients who are convalescing from injury or sickness and who require medical or nursing care to assist the patients to reach a degree of body functioning to permit self-care in essential daily living activities; (2) it provides 24-hour-a-day nursing services by licensed nurses under the supervision of an R.N., and it has an R.N. on duty at least eight hours a day; (3) every patient is under the supervision of a doctor, and it has available at all times a doctor who is a staff member of an acute care hospital; (4) is eligible to participate under Medicare Part A as a “skilled nursing facility”; and (5) it is not, other than incidentally, an institution providing custodial care.
 
SUMMARY PLAN DESCRIPTION
This 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.
 
SUBSTANCE ABUSE TREATMENT FACILITY
A residential treatment facility (as defined by the Plan) specializing in providing treatment for substance abuse.
 
TMJ
Temporomandibular joint syndrome, cranio-mandibular 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.