Plan Provisions
Trustee Interpretation and Authority; Decisions Regarding Benefits, Amendment and Termination
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. Any amendment or termination of the Plan must be in writing; oral modifications are not permitted.
Length of Maternity Hospitalizations
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 whether medical child support orders qualify as Qualified Medical Child Support Orders (QMCSOs) under the Employee Retirement Income Security Act (ERISA).
- 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.
- 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.
- 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.
- Within a reasonable period after the Fund’s (or their delegate) shall determine whether the order is a QMCSO and shall notify you and the affected alternate recipient of this determination.
- If the Trustees determine that the order is not a QMCSO, the Trustees or their attorney will 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.
- 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.
- 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 9 U.S.C. §1169(B)(3) and (4), the Notice shall be deemed to be a QMCSO with respect to that child.
- 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, co-payment 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.
If you submit a fraudulent claim to the Fund, or otherwise attempt to mislead or defraud the Fund regarding your eligibility for benefits (or the eligibility of another person) or claim for benefits, your coverage under the Plan as well as coverage for your family members may be terminated.
Circumstances that May Result in Claim Denials
The circumstances that may result in a claim denial or loss of benefits are outlined in this Summary Plan Description booklet. If you have any questions about a claim denial or loss of eligibility, contact the Fund Office.
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 one year 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. All disputes arising under this Plan will be brought in the federal district court for the Northern District of Illinois, or if there is no federal jurisdiction, then the Circuit Court of Cook County.
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.
Prohibition of Retroactive Rescissions
The Plan will not retroactively rescind the coverage of benefits provided under the medical, dental, prescription drug and vision components of the Plan. However, this does not apply if you commit fraud or make an intentional misrepresentation of material fact. For example, failing to timely inform the Fund in the event of a divorce is an intentional misrepresentation of material fact. Coverage that is terminated due to the failure to pay a premium is not considered a rescission.
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 (including payment of Plan administrative expenses), 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.
Notice of Privacy Practices
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.
Your Rights
When it comes to your protected health information (as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)), you have certain rights. This section explains your rights and some of our responsibilities to help you.
For purposes of this Notice, your protected health information includes all individually identifiable information, including demographic information, related to your past, present or future physical or mental health condition or to payment for health care. Protected health information includes information maintained by the Plan in oral, written, or electronic form. It does not include information that has been deidentified. De-identified information is information that does not identify you and with respect to which there is not reasonable basis to believe that the information can be used to identify you.
Get a copy of health and claims records – You have the right to inspect and copy your protected health information. A request to inspect and copy of records containing your protected health information must be made in writing to the Plan’s Privacy Official. If you request a copy of your protected health information, the Plan will charge you $0.25 per page for copying, plus actual mailing costs. If you request that your information be provided to you in electronic form and the information is readily producible in such form, the information will be provided to you electronically.
Ask us to correct health and claims records – If you believe that your protected health information records are inaccurate or incomplete, you may request that the Plan amend the records. That request may be made as long as the information is maintained by the Plan. A request for an amendment of records must be made in writing to the Plan’s Privacy Official.
The Plan may deny the request if it does not include a reason to support the amendment. The request also may be denied if your protected health information records were not created by the Plan, if the protected health information you are requesting to amend is not part of the Plan’s records, if the protected health information you wish to amend falls within an exception to the protected health information you are permitted to inspect and copy, or if the Plan determines the records containing your health information are accurate and complete.
Request confidential communications – You have the right to request that the Plan communicate with you in a certain way. The Plan is not required to honor such requests, but the Plan will do so if it can be done without interfering with the Plan’s normal operations or if you believe that the disclosure of your protected health information could endanger you. If you wish to receive confidential communications, please make your request in writing to the Plan’s Privacy Official.
Ask us to limit what we use or share – You may request restrictions on certain uses and disclosures of your protected health information. The Plan is not required to agree to your request, but the Plan will ordinarily honor any request that the Plan communicate only with you (that is, refrain from disclosing your claim or benefit information to your relatives, friends, or members of your household). If you wish to make a request for restrictions, please contact the Plan’s Privacy Official.
Get a list of those with whom we’ve shared information – You have the right to request a list of certain disclosures of your protected health information that the Plan is required to keep a record of under the Federal privacy rules, such as disclosures for public purposes, disclosures authorized by law or disclosures that are not in accordance with the Plan’s privacy policies or applicable law. The request must be made in writing to the Plan’s Privacy Official. The request should specify the time period for which you are requesting the information but may not start earlier than April 14, 2004. Accounting requests may not be made for periods of time in excess of six years. The Plan will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests will be subject to a reasonable cost-based fee. The Plan will inform you in advance of the fee, if applicable.
Get a copy of this privacy notice – You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you – If you are of legal age, you can exercise the privacy rights explained in this Notice. Your rights can also be exercised by your Personal Representative. A Personal Representative is:
- The parent of a minor child.
- The person designated in a Health Care Power of Attorney (limited to the rights stated in the Power of Attorney).
- The legal guardian of a mentally incompetent adult.
- The administrator or executor of your estate, or your next of kin.
Be notified in case of breach – The Plan must notify you within 60 days of the discovery of a breach of confidentiality of your protected health information.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting our Privacy Official.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/ complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices
For certain protected health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in payment for your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
We never share your information for marketing purposes. We never sell your information.
Our Uses and Disclosures
How do we typically use or share your protected health information?
We typically use or share your protected health information in the following ways.
Help manage the health care treatment you receive – We can use your protected health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization – We can use and disclose your information to run our organization and contact you when necessary.
We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage.
Example: We use health information about you to develop better services for you.
Pay for your health services – We can use and disclose your protected health information as we pay for your health services.
Administer your plan – We may disclose your protected health information to your health plan sponsor (the Trustees) for plan administration.
How else can we use or share your protected health information?
We are allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues – We can share protected health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
Do research – We can, but do not, use or share your information for health research.
Comply with the law – We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- We can share protected health information about you with organ procurement organizations.
- We can share protected health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests – We can use or share protected health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions – We can share protected health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your protected health information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your protected health information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.
Contact Person
The Fund has designated the following as its contact person for all issues regarding patient privacy and your privacy rights:
Mr. Thomas J. Boehm
Fund Administrator, Local 734 Welfare Fund
6643 North Northwest Highway
Chicago, IL 60631-1360
Telephone (773) 594-2810
Fax: (773) 631-3824
Effective Date
This Notice is effective January 1, 2022.