EXHIBIT 10.16
PLAN INSTRUMENT
THE COCA-COLA COMPANY
SPECIAL MEDICAL INSURANCE PLAN
By action of its Board of Directors on May 4, 1982, The
Coca-Cola Company (hereinafter referred to as the Company)
adopted The Coca-Cola Company Special Medical Insurance Plan
for the purpose of providing eligible employees and their
covered dependents with benefits for expenses related to
hospital, surgical, medical, dental and vision care.
Subsidiaries of the Company, whether directly or indirectly
owned, may become Participating Subsidiaries in said Plan
upon approval by Officers of the Company. The Company and
each Participating Subsidiary will be known as an Employer
under said Plan.
In accordance with the provisions of the Employee Retirement
Income Security Act of 1974 (hereinafter referred to as the
Act) the Company does hereby establish the Plan designated
above (hereinafter referred to as the Plan), identified as
Plan Number 549, with Employer Identification Number
58-0628465.
The Company shall be the Plan Administrator as referred to in
the Act.
The Company shall be the named fiduciary with full authority
to control and manage the operation and administration of the
Plan, and shall be the agent for service of legal process in
addition to the Insurance Company named in the Group Policy.
The Plan shall be administered directly by the Plan
Administrator. Benefits provided under the Plan shall be
provided through the purchase and maintenance of one or more
Group Policies which the Officers of the Company are
authorized to enter into with respect to this Plan. The
Officers of the Company may terminate or enter into Group
Policies or agreements with Insurance Companies, or otherwise
provide for payment of benefits under the Plan.
Plan requirements respecting eligibility for participation
and benefits shall be the requirements as to employees to be
insured as set forth in the Group Policy. The persons
entitled to benefits under the Plan are the employees insured
as set forth in the Group Policy and their Qualified
Dependents covered in accordance with the terms, provisions
and conditions of the Group Policy. The benefits under the
Plan are those provided by the Group Policy in accordance
with the terms, provisions and conditions of the Group
Policy. The Group Policy specifies the Employers whose
employees are covered by the Plan.
It is the intent of this Plan Instrument and it is the
funding policy of the that all Plan benefits are to
be provided under and in accordance with the provisions of
the Group Policy, which the Company shall purchase and
maintain on behalf of the Plan; provided, however that any
payments made to or credits to the Company in accordance with
the experience rating provisions, if any, of the Group Policy
shall be the separate property of the Company.
1
Whether or not contributions are to be made by the employees
to the Employer for the benefits and the amount of any such
contribution is subject to change by the Company.
Claims for benefits under the Plan are to be submitted to the
Insurance Company as provided in the Group Policy. Payment
of claims under the Plan will be made by the Insurance
Company as provided in the Group Policy. A claim which is
denied by the Insurance Company shall be reviewed by said
Insurance Company in accordance with the procedure as
provided in the Group Policy which is not inconsistent with
claims procedure regulations in the Act as then in effect,
and the decision of the Insurance Company on any claim shall
be final. With respect to the Act on claims procedure
regulations, the Insurance Company shall be the appropriate
named fiduciary of the Plan for the purpose of such review
and decision thereon. The Insurance Company's decision on
any claim shall be final.
The Plan years coincide with the policy years of the Group
Policy.
The Company, by action of its Officers, shall have the right
to terminate, suspend, withdraw, amend or modify the Plan in
whole or in part at any time, but no amendment to the benefit
or other provisions of the Group Policy may be made without
the approval of the Insurance Company. The Company shall
make any amendments to the Plan which may be needed for
compliance with the Act.
This Plan Instrument shall be effective as of July 1, 1982.
Dated at Atlanta, Georgia THE COCA-COLA COMPANY
This 1st day of August, 1989 By: /s/ D. A. Saarel
Official Title: Senior Vice President
Attest: /s/ G. T. Allan
2
Amendment No. 1
SPECIAL MEDICAL INSURANCE PLAN
Effective January 1, 1989, the above captioned Plan is
amended as follows:
Delete the next to last paragraph in its entirety and insert
the following:
The Company, by action of its
Officers, shall have the right to
terminate, suspend, withdraw, amend
or modify the Plan in whole or in
part at any time, but no amendment to
the benefit or other provisions of
the Agreement may be made without the
approval of the Claims Services
Provider. However, the Company expects
to continue the Plan indefinitely.
The Company shall make any amendments to
the Plan which may be needed for
compliance with the Act.
The Assistant Vice President and Director Compensation and
Benefits or his designee is authorized to perform all
necessary acts to effectuate this amendment.
/s/ D. A. Saarel August 1, 1989
D. A. Saarel Date
Senior Vice President
Human Resources Division
3
56019-08/31/83
Application is Hereby Made to
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
by THE COCA-COLA COMPANY
whose Main Office Address is ATLANTA, GEORGIA
for Group Policy No GO56019
Said Group Policy is hereby approved and the terms thereof
are hereby accepted.
This application is executed in duplicate, one counterpart
being attached to said Policy and the other being
returned to The Prudential Insurance Company of America.
It is agreed that this Application supersedes any previous
application for the said Group Policy.
THE COCA-COLA COMPANY
(Full or Corporate Name
of Applicant)
Dated at Atlanta, Georgia By Senior Vice President
(Signature and Title)
On ----------, 19--
Witness --------------------
To be signed by Resident Agent where required by law)
ORD 18054-A-ED 5-48 THIS COPY IS TO REMAIN ATTACHED TO THE POLICY
New Issue
Printed in U.S.A.
by Prudential Press
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
GROUP POLICY SCHEDULE
POLICY DATE
July 1, 1982.
POLICY ANNIVERSARIES
July 1 of each year, beginning in 1987.
PREMIUM DUE DATES
The Policy Date, and thereafter the first day of each month
beginning with August, 1982.
GOVERNING JURISDICTION
State of Georgia
EMPLOYMENT WAITING PERIOD
The period of continuous service on a full-time basis with
the Employer as specified in the Coverage Schedule.
Policyholder
THE COCA-COLA COMPANY
Group Policy
GO-56019
PARTICIPATING SUBSIDIARIES
The Coca-Cola Export Corporation
Coca-Cola Interamerican Corporation Coca-Cola Enterprises Inc.
Caribbean Refrescos, Inc.
MINIMUM PARTICIPATION NUMBER
25
2
INCLUDED EMPLOYERS PROVISIONS
The Policyholder and any Participating Subsidiary
are Employers included under the Group Policy.
"Participating Subsidiaries" means any subsidiary
owned directly or indirectly by the Policyholder
which has elected to be an included Employer in the
Group Policy with the approval of the Policyholder
and which is listed under "Participating
Subsidiaries", in the Group Policy Schedule.
Any individual employed by more than one included
Employer shall be considered as being employed only
by one Employer, and his service with the other
Employer or Employers shall be considered as
service with that one Employer.
If any Employer ceases to be an included Employer,
the Group Policy will be considered as terminating
on the date of such cessation with respect to all
Employees of that Employer, who on the next day are
not Employees of another included Employer within
the eligible classes under the Group Policy. The
Policyholder shall notify Prudential, in writing,
when a Participating Subsidiary ceases to be owned
directly or indirectly by the Policyholder.
3
DEFINITIONS
ACTIVE WORK REQUIREMENT: A requirement that an Employee be
actively at work on a full-time basis at the business
establishment of the Employer or at other locations to which
the Employer's business requires the Employee to travel.
BENEFIT YEAR: Means a calendar year (January 1 through
December 31).
CLOSE RELATIVE: Means the Employee, his spouse, and a child,
brother, sister or parent of the Employee or his spouse.
COMPANY: When the term "the Company" is used it means The
Coca-Cola Company, One Coca-Cola Plaza, N.W., Atlanta,
Georgia 30313.
COVERAGE CLASSES UNDER A COVERAGE SCHEDULE: The Employees of
the Employer who comprise the classes to which the coverage
provided in that Schedule applies.
COVERED INDIVIDUAL UNDER A COVERAGE: An employee who is
covered for Employee Insurance; a Qualified Dependent with
respect to whom an Employee is insured for Dependents
Insurance.
DEPENDENTS INSURANCE: Insurance pertaining to the person of
a dependent. Under such insurance, a charge will be
considered actually made to an Employee if actually made to
his Qualified Dependent.
EMPLOYEE: When the term "Employee" is used, it means an
Executive of the Company as determined by the Policyholder.
EMPLOYEE INSURANCE: Insurance under a coverage pertaining to
the person of an Employee.
EMPLOYER: When the term "the Employer" is used, it means
collectively all Employers included under the Group Policy.
FULL MEDICARE COVERAGE: Means coverage for all the benefits
provided under Medicare including benefits provided under the
voluntary program established by Medicare.
GROUP POLICY: Means the Master Contract between the
Policyholder and Prudential as identified in the Group Policy
Schedules and is the legal instrument governing all benefits.
PARTICIPATING SUBSIDIARY: Any Subsidiary owned directly or
indirectly by the Policyholder which has elected to be an
included Employer in the Group Policy with approval of the
Policyholder and which is listed under "Participating
Subsidiaries" in the Group Policy Schedule.
4
PHYSICIAN: Means a physician licensed to practice medicine
and perform surgery. Services which would be covered if
rendered by a physician, as defined herein, shall also be
covered when rendered by a duly licensed midwife practicing
within an acceptable Birthing Center as defined by the Plan,
doctor of dental surgery (D.D.S.), doctor of chiropractic, or
a duly licensed doctor of surgical chiropody or podiatry
(D.S.C.), within their specialty, or an acupuncturist who is
certified or licensed as required by the jurisdiction in
which he or she performs his or her practice. The definition
is further contingent upon and subject to standards
established by Prudential.
PLAN: When the term "the Plan" is used, it means the
Supplemental Medical Expense Plan of The Coca-Cola Company
and its Participating Subsidiaries.
POLICYHOLDER: The Coca-Cola Company, One Coca-Cola Plaza,
N.W., Atlanta, Georgia 30313.
PRUDENTIAL: The Prudential Insurance Company of America,
Southern Group Operations, 2849 Paces Ferry Road, Suite 400,
Atlanta, Georgia 30339.
QUALIFIED DEPENDENT: An Employee's spouse or unmarried
child, excluding in any case -
(1) a person after that person has ceased to be a
spouse of the Employee by reason of divorce or
annulment;
(2) a child nineteen or more years of age unless
(a) wholly dependent upon the Employee for support,
(b) a registered student in regular, full-time
attendance at an accredited secondary school,
college, university, or vocational or trade school,
(c) less than twenty-four years of age and
(d) enrolled by the Employer with the Employer
under the Plan as a student with the Employee
making any additional required contributions;
(3) a spouse or child on active duty in any military,
naval or air force of any country; and
(4) a spouse or child who is insured for Employee
Insurance under the Group Policy.
An Employee's children include step-children, legally adopted
children and foster children, provided they are dependent
upon the Employee for support and maintenance.
A child shall not be a qualified dependent of more than one
Employee. If more than one Employee would otherwise be
insured under the Group Policy with respect to a child as a
qualified dependent, the child will be considered to be the
qualified dependent only of that one of such Employees with
the lower case deductible under the Major Medical Expense
Insurance of the Plan according to the Policyholder's
records.
5
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
6
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
7
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
8
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
9
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
10
SCHEDULE OF PREMIUM RATES
CLASSES OF EMPLOYEES
TO WHICH THIS SCHEDULE APPLIES:
Employees as specified in the Coverage Classes under the
Coverage Schedules.
APPLICABLE INSURANCE
Employee and Dependent Medical
MONTHLY RATES
EMPLOYEE INSURANCE DEPENDENT INSURANCE
$666.66 per Employee $333.34 per Employee with
one Dependent
$500.00 per Employee with
two or more Dependents
11
ELIGIBILITY
Eligible Classes: All Employees of the Employer who are
within the Coverage Classes under the Coverage Schedules.
BECOMING INSURED FOR EMPLOYEE INSURANCE
This Section applies separately to the Employee Insurance
under each coverage.
The Employee shall be insured from the first day, on or after
his date of eligibility, on which he is included in a
Coverage Class for the insurance and the following
requirements are simultaneously satisfied:
(1) He has requested it of the Employer on a form
satisfactory to Prudential and has agreed to
make the required contributions.
(2) If any evidence of insurability requirement
applies, he has complied with that requirement.
He will be considered as having complied on the
first day of the month next following the month
in which Prudential determines the evidence is
satisfactory.
(3) He is complying with the Active Work Requirement
of the Definitions.
BECOMING INSURED FOR DEPENDENTS INSURANCE
This section (other than requirement (1) below) applies
separately to each Qualified Dependent an Employee has or
acquires.
The Employee shall be insured with respect to a Qualified
Dependent from the first day, on or after the Employee's date
of eligibility, as specified in the Coverage Schedule, on
which the following requirements are simultaneously
satisfied:
(1) The Employee has requested it of the Employer on
a form satisfactory to Prudential and has agreed
to make the required contributions.
(2) The Employee is included in the Coverage Classes.
(3) If any evidence of insurability requirement
applies with respect to the Qualified Dependent,
the Employee has complied with that requirement.
An Employee will be considered as having complied
on the first day of the month next following the
month in which Prudential determines the evidence
to be satisfactory.
12
(4) The insurance with respect to the Qualified
Dependent is not being deferred in accordance
with the section Deferment of Effective Date
of Insurance.
EVIDENCE OF INSURABILITY REQUIREMENTS FOR EMPLOYEE INSURANCE
An Employee must furnish evidence of his insurability
satisfactory to Prudential in order to become insured for
Employee Insurance under a coverage, in any of the following
situations:
(1) LATE PARTICIPATION UNDER CONTRIBUTORY INSURANCE -
He does not satisfy the requirement (1) of Becoming
Insured For Employee Insurance before the end of the
month following his date of eligibility.
(2) FAILURE TO MAKE CONTRIBUTION - He requests the
insurance after previous termination of any
insurance under the Group Policy because of
failure to make a required contribution.
(3) PREVIOUS EVIDENCE REQUIREMENT - He has not
satisfied a previous requirement that evidence of
his insurability be furnished in order for him to
become insured under a coverage of the Group Policy
or any other Prudential group policy which provides
or provided insurance for Employees of the Employer.
EVIDENCE OF INSURABILITY REQUIREMENTS FOR DEPENDENTS
INSURANCE
An Employee must furnish evidence of insurability of a
Qualified Dependent satisfactory to Prudential in order to
become insured with respect to that Dependent, in any of the
situations listed below. These requirements shall not apply
to any Qualified Dependent acquired after the Employee
becomes insured for Dependents Insurance, provided the
Employee is making the required contributions for Dependents
Insurance.
(1) LATE PARTICIPATION - The Employee does not satisfy
requirement (1) of Becoming Insured for Dependents
Insurance before the end of the calendar month
immediately following the first day, on or after his
date of eligibility, on which he has a Qualified
Dependent.
(2) FAILURE TO MAKE CONTRIBUTION - The Employee
requests the insurance after previous termination of
any insurance under the Plan because of failure to
make a required contribution.
(3) PREVIOUS EVIDENCE REQUIREMENT - Neither the
Employee nor the Dependent has satisfied a previous
requirement that evidence of the Dependent's
insurability be furnished in order for the Dependent
to become insured, as a Dependent or Employee, under
a coverage of the Group Policy or any other
Prudential group policy which provides or provided
insurance for Employees of the Employer.
13
NEWBORN CHILD PROVISIONS
These provisions modify the Group Policy's provisions for
insurance which provides benefits for expenses of a
dependent's medical care under a coverage, solely with
respect to a child who is born to an Employee while the
Employee is insured for Employee Insurance under a coverage
and while the child is not otherwise a covered individual
under the coverage in accordance with the terms of the Group
Policy other than these Newborn Child Provisions.
Such a child is a covered individual under the coverage from
the moment of birth. However, any coverage that a child has
solely by reason of these Newborn Child Provisions is hereby
modified to provide that no benefits will be payable
thereunder with respect to any charge incurred for a service
or supply furnished for the medical care of the child after
the end of the thirty-one day period immediately following
his birth.
The requirement of the Group Policy that the Employee must
furnish evidence of the insurability of a qualified dependent
satisfactory to the Prudential in order to become insured
with respect to that dependent shall not apply to a child who
becomes a covered individual from the moment of birth by
reason of these Newborn Child Provisions. Nor, shall such
requirement be a condition for any continuance of the child's
coverage beyond the thirty-one day period immediately
following the child's birth, if before the end of that
period, the Employee has requested such dependent's insurance
on a form satisfactory to Prudential and has agreed to make
the contributions required for such insurance. The
Employee's failure to make when due any contribution required
of him for dependents insurance shall in no event effect
termination of the newborn child's coverage under the Group
Policy prior to the end of that thirty-one day period.
CHANGES OF EMPLOYEE BENEFITS
The Employee Insurance benefits for which an Employee is
insured will be those for his classification under the
applicable Coverage Schedule unless otherwise determined in
accordance with this Section.
This Section applies unless the Coverage Schedule indicates
to the contrary.
When an Employee's classification changes or the benefits
applicable to his classification are changed by an amendment
to the Group Policy, the change will not result in an
adjustment of the Employee's benefits (including the amount)
until the first day, on or after the date of the change, on
which he is complying with the active work requirement of the
General Definitions. His benefits will be adjusted on that
day to those then applicable to his classification.
14
CHANGES OF DEPENDENTS BENEFITS
The Dependents Insurance benefits for which an Employee is
insured will be those for his classification under the
applicable Coverage Schedule unless otherwise determined in
accordance with this Section.
This Section applies unless the Coverage Schedule indicated
to the contrary.
When an Employee's classification changes or the benefits
applicable to his classification are changed by an amendment
to the Group Policy, the change will not result in an
adjustment of the Employee's benefits with respect to a
Qualified Dependent (including the amount) until the first
day, on or after the date of the change, on which the
adjustment for that dependent is not being deferred in
accordance with the Section Deferment of Effective Date of
Insurance. Such benefits will be adjusted on that day to
those then applicable to the Employee's classification.
TERMINATION OF EMPLOYEE INSURANCE
The Employee Insurance of an Employee under a coverage will
automatically terminate at the end of the month when:
(1) he ceases to be a member of the Coverage Classes
for the insurance because of termination of
employment (described below) or for any other
reason, or
(2) his class is no longer included in the Coverage
Classes for the insurance, or
(3) the provisions of the Group Policy for the
insurance terminate.
(4) any contribution required of him for any insurance
under the Group Policy is not made when due
Termination of Employment - For insurance purposes, an
Employee's employment will be considered to terminate when he
no longer actively engaged in work on a full-time basis for
the Employer. However, if absence from such full-time work
is then of type set forth in the Coverage Schedule for the
insurance, the Employer may, without discrimination among
persons in like circumstances, consider the Employee as not
having terminated his employment for insurance purposes and,
while such absence is of any such type, as continuing to be a
member of the Coverage Classes for the insurance up to any
applicable time limit in the Coverage Schedule.
TERMINATION OF DEPENDENTS INSURANCE
An Employee's Dependents Coverage will terminate under the
circumstance described in the section "Termination of
Employee Coverage" as though that section's reference to
"Employee Coverage" were a reference to "Dependents
Coverage".
15
Any provision which would continue coverage following the
Employee's death will be specified in the Coverage Schedule.
Payment of benefits under Dependents Coverage continued after
the Employee's death will be made to his spouse if living, to
such spouse's estate if the spouse survived the Employee's
children, and otherwise to the person or institution
appearing to the Employer to have assumed the principal
support of such children.
All of the Dependents Coverage with respect to a particular
Qualified Dependent will automatically terminate at the end
of the month, if that Dependent ceases to be a Qualified
Dependent, when the Employee ceases to be covered for
Employee Coverage, or when the Employee ceases to make the
Employer the payments required hereunder for such coverage.
Anything in these provision to the contrary notwithstanding,
the coverage applicable to any qualified Dependent included
in the Definitions may be continued after age twenty-four for
a period not exceeding the length of his period of service
performed prior to age twenty-four in the Armed Forces of the
United States of America provided he continues to meet the
other provisions as Qualified Dependent.
OPTION TO CONTINUE COVERAGE OF DEPENDENT CHILD INCAPACITATED
WHEN SPECIFIED AGE LIMIT FOR CHILDREN IS ATTAINED - if
dependent child is mentally or physically incapable of
earning of living on the date coverage under the Group Policy
with respect to such child would terminate due to attainment
of the specified age limit for children, and if within
thirty-one days of such date the Employer receives due proof
of such incapacity, then such specified age limit shall not
operate to terminate such coverage under the Plan with
respect to such child so long as such child remains in such
condition. This provision does not waive, alter or extend in
any respect, other than as stated above, any of the
provisions, conditions, limitations and exceptions of the
Plan.
MODIFICATIONS OF TERMINATION PROVISIONS TO
PROVIDE CONTINUATION OF INSURANCE AT THE
EMPLOYEE'S OR THE DEPENDENTS OPTION
INSURANCE TO WHICH THESE MODIFICATIONS APPLY: All health
care expense insurance under the Group Policy.
WHEN APPLICABLE: When such insurance otherwise would have
ended in accordance with "Termination of Employee Insurance"
and/or "Termination of Dependents Insurance" of the Group
Policy.
CONDITIONS FOR CONTINUING EMPLOYEE AND DEPENDENTS INSURANCE:
The Employee has the right to continue insurance if insurance
would have been ended because:
16
(1) the Employee's employment ended for a reason
other than gross misconduct; or
(2) the Employee's work hours were reduced.
CONDITIONS FOR CONTINUING DEPENDENTS INSURANCE: A qualified
dependent has the right to continue insurance if insurance
for that dependent would have ended:
(1) because the Employee's employment ended for a
reason other than gross misconduct; or
(2) because the Employee's work hours were reduced; or
(3) at the Employee's death; or
(4) because the Employee became entitled to Medicare
benefits. "Medicare" means Title XVIII (Health
Insurance for the Aged) of the United States
Social Security Act, as amended from time to
time; or
(5) in the case of an Employee's spouse, when the
spouse ceased to be a qualified dependent as a
result of divorce or legal separation; or
(6) in the case of an Employee's qualified dependent
child, when the child ceased to be a qualified
dependent under the provisions of the Group Policy.
NOTICE: This applies if dependents insurance for a qualified
dependent would have ended due to an event shown in (5) or
(6) above. If a person wants to continue the insurance,
written notice of the event must be given to the Policyholder
within 60 days after the event shown in (5) or (6) above.
CONTINUATION: The Policyholder will give a written election
notice of the right to continue the insurance. Such notice
will state the amount of the payment, if any, required for
the continued insurance. If a person wants to continue the
insurance, the election notice must be completed and returned
to the Policyholder, along with any required first payment,
within 60 days of the later of: (1) the date the insurance
would otherwise have ended; or (2) the date of the notice
informing the person of the right to continue. But in no
event may election be made more than 90 days (150 days if the
insurance is being continued due to an event shown in (5) or
(6) above) after the date the insurance would otherwise have
ended. If this is done, the insurance will be continued from
the date it would have ended until the first of the following
occurs:
(1) If the insurance is being continued due to the
Employee's end of employment or a reduction of
the Employee's work hours, the day 18 months
from the date the insurance would have ended.
17
(2) If the insurance is being continued due to:
(a) the Employee's death; or (b) the Employee's
entitlement to Medical benefits; or (c) the
Employee's divorce or legal separation from the
Employee's spouse; or (d) an Employee's qualified
dependent child ceasing to be eligible under the
provisions of the Group Policy, the day 36 months
from the date the insurance would have ended.
(3) The day the person becomes covered under any
other health plan for persons in a group, on an
insured or uninsured basis.
(4) If the next payment is not made when due, the
end of the last period for which any required
payment was made when due.
(5) The day the person becomes entitled to
Medicare benefits.
(6) The provisions of the Group Policy for such
insurance end.
While Employee Insurance is continued according to the above
modifications, all other terms of the Group Policy will
apply, except the "Changes of Employee Benefits" section of
the Insurance Plan Provision shall not apply.
While Dependents Insurance is continued according to the
above modifications, all other terms of the Group Policy will
apply, except that benefits under the health care expense
insurance will be paid to the person who elected the
continuation right. If the person who elected the
continuation right is not living, the following will apply:
(1) If the Employee elected the continuation right,
benefits will be paid to:
(a) the Employee's spouse, if living; or
(b) the estate of the Employee's spouse,
if the Employee's spouse is not living
but survived the qualified dependent
children; or
(c) the person or institution appearing
to Prudential to have assumed the main
support of the Employee's qualified
dependent children, if neither (a)
nor (b) applies.
(2) If the Employee's spouse elected the continuation
right, benefits will be paid to:
(a) estate of the Employee's spouse, if the
Employee's spouse survived the Employee's
qualified dependent children; or
(b) the person or institution appearing to
Prudential to have assumed the main
support of the Employee's qualified
dependent children, if (a) does not apply.
18
(3) If an Employee's qualified dependent child elected
the continuation right, benefits will be paid to
that qualified dependent child's estate.
If an amount is so paid, Prudential will not have to pay that
part of the insurance again.
19
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
20
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
21
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
22
PROVISION FOR COORDINATION
OF BENEFITS UNDER THE PLAN WITH OTHER BENEFITS
A. BENEFITS SUBJECT TO THIS PROVISION - All of the benefits
provided under the Plan with respect to expenses incurred on
or after the effective date of the Plan. The portion of the
Plan which provides such benefits is herein call "this Plan."
B. PLAN - Any of the following providing benefits or
services for, or by reason of, medical or dental care or
treatment - (a) a governmental program or coverage required
or provided by statute, other than any coverage provided
under a motor vehicle insurance contract; (b) group insurance
or other arrangement of coverage for individuals in a group,
including prepayment coverage, group or individual practice
coverage; coverage for students sponsored by or provided
through an educational institution above the high school
level, except a blanket school accident policy and except
that this (b) shall not include any individually underwritten
and individually issued contract or plan of insurance which
provides exclusively for accident and sickness benefits and
for which 100% of the premiums have been paid by the insured
or a member of the insured's family.
"Plan" shall be construed separately with respect to -
(i) Each Policy, contract or other arrangement for
benefits or services.
(ii) That portion of any such policy, contract or other
arrangement which reserves the right to take the
benefits of other Plans into consideration in
determining its benefits and that portion which
does not.
C. ALLOWABLE EXPENSE - Any necessary, reasonable and
customary item of expense at least a portion of which is
covered under at least one of the Plans covering the person
for whom claim is made. If benefits are provided in the form
of services, the reasonable cash value of each service
rendered shall be considered both an Allowable Expense and a
benefit paid.
D. CLAIM DETERMINATION PERIOD - A Calendar Year (January 1
through December 31), but excluding, for any person, any
portion occurring prior to the first day he is covered under
this Plan.
E. EFFECT ON BENEFITS
(1) This Section E applies in determining the benefits
payable under this Plan as to a person for any
Claim Determination Period, when the total
Allowable Expenses incurred as to such person
during such period are less than the sum of
23
(a) the benefits that would be payable for
such expenses under this Plan in the absence
of this Section E, and
(b) the benefits that would be payable for such
expenses under all other Plans in the absence
therein of provisions of similar purpose to
this provision. In such an instance, the
benefits described in (a) shall be reduced to
the extent necessary so that the sum of such
reduced benefits and all the benefits payable
for such Allowable Expenses under all other
Plans, except as provided in item (2) of this
Section E, shall not exceed such total
Allowable Expenses. Benefits payable under
another Plan include the benefits that would
have been payable had claim been duly made
therefor.
(2) The benefits of another Plan will not be included in
"all the benefits payable for such Allowable Expenses
under all other Plans" of the second sentence of item
(a) of the Section E if:
(a) such other Plan contains a provision coordinating
its benefits with those of this Plan and
(b) both the rules of such other Plan and the rules
set forth in item (3) of this Section E would
require this Plan to determine its benefits
before such other Plan.
(3) Rules establishing the order of benefit determination as
to a person on whose expenses claim is based (for the
purposes of item (2) of this Section E):
(a) The benefits of a Plan which covers him other
than as a dependent shall be determined before
the benefits of a Plan which covers him as a
dependent.
(b) Except as stated in subparagraph E.(3)(c) below,
when this Plan and another Plan cover the same
child as a dependent of both his parents:
(i) the benefits of the Plan of the parent
whose birthday falls earlier in a year
are determined before those of the Plan
of the parent whose birthday falls later
in that year; but
(ii) if both parents have the same birthday,
the benefits of the Plan which covered the
parent longer are determined before those
of the Plan which covered the other parent
for a shorter period of time.
24
However, if the other Plan does not have the
rule described in (i), immediately above, and
if, as a result, the Plans do not agree on the
order of benefits, the rule in the other Plan
will determine the order of benefits.
(c) If two or more Plans cover a person who is a
dependent child of divorced or separated parents,
benefits for the child are determined in this order:
(i) first, the Plan of the parent with custody
of the child;
(ii) then, the Plan of the spouse of the parent
with custody of the child; and
(iii) finally, the Plan of the parent not having
custody of the child. However, if the
specific terms of a court decree state that
one of the parents is responsible for the
health care expenses of the child, and the
entity obligated to pay or provide the
benefits of the Plan of that parent has
actual knowledge of those terms, the
benefits of that Plan are determined first.
This paragraph does not apply when any
benefits are actually paid or provided
before the entity has that actual knowledge.
(d) The benefits of a Plan which covers a person as an
employee who is neither laid off nor retired, or as
that employee's dependent, are determined before
those of a Plan which covers that person as a
laid off or retired employee or as that employee's
dependent. If the other Plan does not have this
rule, and if, as a result, the Plans do not agree
on the order of benefits, this rule (d) is ignored.
(e) When rules (a), (b), (c) or (d) do not establish
an order of benefit determination, the benefits
of a Plan which has covered him the shorter
period of time.
(4) When this Section E operates to reduce the total amount
of benefits otherwise payable under this Plan as to a
person for any Claim Determination Period, each benefit
that would be payable in the absence of the Section E
shall be reduced proportionately, and such reduced
benefit shall be charged against any applicable benefit
limit of this Plan.
F. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION - For
the purposes of determining the applicability of and
implementing the terms of this provision of this Plan or any
provision of similar purpose of any other Plan, Prudential
may, without the consent of or notice to any person, release
to or obtain from any other insurance companies or other
25
organization or person any information, with respect to any
person, which Prudential deems to be necessary for such
purposes. Any person claiming benefits under this Plan shall
furnish to Prudential such information as may be necessary to
implement this provision.
G. FACILITY OF PAYMENT - Whenever payments which should
have been made under this Plan in accordance with this
provision have been made under any other Plans, Prudential
shall have the right, exercisable alone and in its sole
discretion, to pay over to any organizations making such
other payments any amounts it shall determine to be warranted
in order to satisfy the intent of this provision. Amounts so
paid by Prudential shall be deemed to be benefits paid under
this Plan and to the extent of such payments, shall be fully
discharged from liability under this Plan.
H. RIGHT OF RECOVERY - Whenever payments have been made by
Prudential with respect to Allowable Expenses in a total
amount, at any time, in excess of the maximum amount of
payment necessary at that time to satisfy the intent of this
provision, Prudential shall have the right to recover such
payments, to the extent of such excess, from among one or
more of the following, as Prudential shall determine: any
persons to or for or with respect to whom such payments were
made, any other insurance companies, any other organizations.
GENERAL PROVISIONS
A. PAYMENT OF PREMIUMS -- GRACE PERIOD
Premiums under the Group Policy are payable by the
Policyholder to Prudential, at an office of Prudential or to
its authorized representative. There is a premium due and
payable on each premium due date specified in the Group
Policy Schedule. A grace period if thirty-one days, without
interest charge, is allowed for the payment of each premium
other than the first. The Policyholder is liable to
Prudential for the payment of premiums for the time the Group
Policy is in force.
B. PREMIUM COMPUTATION -- CHANGE OF PREMIUM RATES
The premium due on each premium due date is the sum of the
premium charges for the insurance then provided under the
coverages of the Group Policy, determined from the applicable
premium rates then in effect and the Employees insured at the
periodic intervals established by Prudential. Premiums may
be computed by any other method mutually agreeable to the
Policyholder and Prudential which produces approximately the
same total amount.
Prudential shall have the right to change premium rates as of
(1) any premium due date, (2) any date an Employer becomes or
ceases to be included under the Group Policy, and (3) for a
26
coverage, any date the extent or nature of the risk under
that coverage, or under any other coverage considered in
determining the premium rate for that coverage, is changed by
amendment or termination or by reason of any provision of law
or any governmental program or regulation. However, the
premium rates for insurance under a coverage, or portion
separately rated, will not be changed under (1) above before
the first policy anniversary. The Policyholder will be
notified whenever a change in the premium rates is made.
C. DIVIDENDS
The portion, if any, of the divisible surplus of Prudential
allocable to the Group Policy at each policy anniversary will
be determined annually by Prudential's Board of Directors and
will be credited to the Group Policy as a dividend on such
anniversary, provided the Group Policy is continued in force
by the payment of all premiums to such anniversary.
Any such dividend will be (1) paid to the Policyholder in
cash, or at the Policyholder's option, (2) applied to the
reduction of the premium then due.
If the aggregate dividends under the Group Policy and any
other group policy or policies issued to the Policyholder
should be in excess of the aggregate contributions toward
their cost made by the Employer from its own funds, an amount
equal to such excess will be applied for the sole benefit of
insured persons. Payment of any dividend to the Policyholder
will completely discharge the liability of Prudential with
respect to that dividend.
D. TERMINATION OF GROUP POLICY OR OF INSURANCE PROVISIONS
By Failure to Pay Premium: If any premium is not paid within
its grace period (as provided in Section A of these General
Provisions), the Group Policy will terminate at the end of
the grace period. However, if the Policyholder makes written
request in advance for termination to take effect at the end
of the period for which premiums have been paid or at any
time during the grace period, the Group Policy will terminate
on the date requested.
By Failure to Maintain Insuring Conditions: Prudential may
terminate the provisions of the Group Policy for any
insurance under a coverage on any premium due date, if the
Employees insured total less than the Minimum Participation
Number or are contributing for such insurance and notice of
intention to terminate has been given to the Policyholder at
least thirty-one days in advance.
By Termination of Associated Protection: If the Coverage
Schedule for any insurance defines an Associated Protection,
the provisions for such insurance will terminate upon
termination of the Associated Protection.
27
E. ASSIGNMENT LIMITATIONS
Insurance under a coverage is not assignable unless the
Coverage Schedule indicates that it is assignable. No
responsibility of the validity or sufficiency of any
assignment is assumed by Prudential. Prudential shall not be
considered to have knowledge of any assignment unless the
original or a duplicate is filed with Prudential through the
Employer.
F. EMPLOYEE'S CERTIFICATE
Prudential will issue to the Policyholder, for delivery to
each insured Employee, an individual certificate stating to
whom benefits are payable and the essential features of his
insurance protection, including any protection and rights
upon termination of his insurance and the rights and
requirements for establishment and payment of claim.
G. RECORDS -- INFORMATION TO BE FURNISHED
Either the Policyholder or Prudential, as mutually agreed,
shall keep a record of the insured Employees containing the
essential particulars of the insurance. The Policyholder
shall forward the information periodically required by
Prudential in connection with the administration of the Group
Policy and the determination of the premium rates. All
records of the Policyholder and of the Employer which have a
bearing on the insurance shall be open for inspection by
Prudential at any reasonable time.
Prudential shall not be liable for the fulfillment of any
obligation dependent upon such information prior to its
receipt in a form satisfactory to Prudential. Incorrect
information furnished may be corrected, if Prudential shall
not have acted to its prejudice by relying on it. An
Employee's insurance under a coverage shall in no event be
invalidated by failure of the Policyholder or the Employer,
due to clerical error, to record or report the Employee for
such insurance.
H. THE CONTRACT -- INCONTESTABILITY OF POLICY
The Group Policy, together with the Application of the
Policyholder, a copy of which is attached hereto and made a
part hereof and the individual applications, if any, of the
persons insured hereunder constitute the entire contract.
All statements made by the Policyholder shall be deemed
representations and not warranties, and no such statement
shall be used in any contest of the insurance hereunder
unless it is contained in the Policyholder's Application.
The validity of the Group Policy shall not be contested,
except for non-payment of premiums, after it has been in
force for one year from its date of issue.
The Group Policy may be amended at any time, without the
consent of the insured Employees or any other person
having a beneficial interest in it, upon written request
made by the Policyholder and agreed to by Prudential. Any
such amendment shall be without prejudice to any claim
28
arising prior to the date of change. No agent or other
person, except the President, a Vice President, the
Secretary, an Actuary, an Associate Actuary, and Assistant
Secretary or an Assistant Actuary of Prudential has authority
to waive any conditions or restrictions of the Group Policy;
to extend the time for paying a premium; to make or modify a
contract; or to bind Prudential by making any promise or
representation or by giving or receiving any information. No
change to the Group Policy shall be valid unless evidenced by
an endorsement on it signed by one of the aforesaid officers
or by an amendment to it signed by the Policyholder and by
one of the aforesaid officers.
CLAIM PROVISIONS
These provisions apply to each coverage under the Group
Policy which contains a specific provision subjecting the
payment of benefits under the coverage to the Group Policy's
Claim Provisions.
Written proof of the loss under a coverage upon which claim
may be based must be furnished to Prudential within ninety
days after --
(1) the end of each month or lesser period for
which Prudential is liable under the coverage,
if the coverage provides for payment at such
periodic intervals,
(2) the end of each Calendar Year for which Prudential
is liable, if the coverage is one under which
payment is made for charges incurred during a
"Calendar Year" as defined in such coverage; and
(3) the date of the loss, in the case of any other
coverage.
Failure to furnish such proof within the required time shall
not invalidate nor reduce any claim if it was not reasonably
possible to give proof within such time, provided such proof
is furnished as soon as reasonably possible.
All benefits will be paid upon receipt of written proof
covering the occurrence, character and extent of the event
for which claim is made; except that if any coverage provides
for payment at monthly or at more frequent periodic
intervals, Prudential shall not be required to make payment
of benefits thereunder more often than so provided.
Prudential at its own expense shall have the right and
opportunity to examine the person whose sickness or injury is
the basis of claim when and so often as it may reasonably
require during pendency of claim.
29
No action at law or in equity shall be brought to recover
under the Group Policy prior to the expiration of ninety days
after written proof of the loss upon which claim is based has
been furnished as required above. No such action shall be
brought more than three years after the expiration of the
time within which proof of such loss is required.
CLAIMS PROCESSING -- APPEALS FROM DENIED CLAIMS
1. Prudential will process all claims and shall determine,
in accordance with the provisions of the Group Policy,
the amount of benefits, if any, payable for each such
claim received.
2. Prudential will make its determination whether to pay
the claim within ninety days from the date the claim is
filed. If more time is required for a special case,
Prudential may take up to an additional ninety days, but
the Covered Individual or Beneficiary must be notified
of the special circumstances which require more time, as
well as the date by which a final decision is expected.
3. In the event a claim is denied, Prudential will provide
the Covered Individual or Beneficiary with a written
notice of the denial. The notice will provide the reason
for the denial; specify the Group Policy provisions on
which the denial is based; itemize any additional
information required by Prudential to pursue the claim
further; and outline the following claim appeal and
review procedures:
a. The Covered Individual or Beneficiary will have
the right to ask for a review if he feels that
the claim has not been handled properly. Or, if
he wishes to further pursue a denied claim, he
may send a written appeal through his Employee
Benefits Administrative Office to Prudential.
b. The appeal must be sent within sixty days of
receipt of the claim denial, and it must state
the reason for appealing the denied claim with
supporting evidence attached. The Covered
Individual or Beneficiary will then have the
right to have representation, to review
pertinent documents, and to submit issues and
comments in writing.
c. Within sixty days after receiving an appeal,
Prudential will review it and give the Covered
Individual or Beneficiary written notice of its
decision. If more time is required, Prudential
may take up to an additional sixty days but will
notify the Covered Individual or Beneficiary of
the delay and the special circumstances
requiring the delay.
30
4. The Policyholder and Prudential agree that, with respect
to the Employee Retirement Income Security Act of 1974
(ERISA), Prudential shall be the "appropriate named
fiduciary" of the Plan for the purpose of such review and
decision thereon. Prudential's decision on any claim
shall be final.
INDIVIDUAL'S STATEMENTS AS TO COVERAGE SUBJECTED TO CLAIM
PROVISIONS
All statements with respect to the insurance under such
coverage which are made by a person insured therefor shall be
deemed representations and not warranties. With respect to
each amount of such insurance for which a person is insured,
no such statement made for the purpose of effecting such
insurance of the person shall be used in any contest to avoid
the insurance with respect to which such statement was made
or to reduce benefits thereunder after such insurance has
been in force prior to the contest for a period of two years
during his lifetime, nor unless such statement is contained
in a written instrument signed by him and a copy of that
instrument is or has been furnished to him.
SUPPLEMENTAL MEDICAL EXPENSE INSURANCE
(These benefits are in addition to the Uniform Health Benefit
Plan and Dental Assistance Plan provided under the
Administrative Services Agreement No. 59981 between The
Coca-Cola Company and The Prudential Insurance Company of
America.)
A. ELIGIBLE CHARGES
Subject to Section C (Charges Not Covered), these are the
charges actually made to the Employee for services and
supplies furnished for or in connection with the diagnosis,
cure, mitigation, treatment or prevention of disease of a
person who is a Covered Individual, for the purpose of
affecting any structure or function of the Covered
Individual's body, or for costs incurred for transportation
which is primarily for and essential to medical care. A
charge is considered to be incurred on the date of the
service or purchase for which the charge is made.
B. BENEFITS
PAYABLE FOR: the eligible charges described in Section A.
CONDITION FOR BENEFIT: The charges are incurred while the
person is a Covered Individual.
AMOUNT PAYABLE: The Supplemental Medical Benefit Percentage
(see Coverage Schedule) of the Eligible Charges up to the
Maximum Supplemental Medical Expense Benefit.
31
C. CHARGES NOT COVERED
(1) Any charges incurred in connection with a bodily or
mental disorder due to war or any act of war while
the person is a Covered Individual ("war" means
declared or undeclared war and includes resistance
to armed aggression).
(2) Any charges for services and supplies furnished by
the Employee, the Employee's spouse, or a child,
brother, sister, or parent of the Employee or such
spouse.
(3) Government Plan Charge - any charge (a) for a
service or supply furnished by or on behalf of the
United States Government or any other government
unless payment of the charge is legally required,
or (b) for a service or supply to the extent to
which any benefit in connection with such a
service, supply or charge is provided by any law or
governmental program under which the individual is
or could be covered.
(4) Charges for Services or Supplies that are Not
Needed or Not Appropriately Provided: A charge for
a service or supply is not covered to the extent
that it is not needed or not appropriately
provided. Charges for services or supplies
furnished in connection with a service or supply
that is not needed or not appropriately provided
are also not covered.
For the purpose of this exclusion a service or
supply will be considered both "needed and
appropriately provided" if Prudential determines
that it meets each of these requirements:
(a) It is ordered by a Doctor for the diagnosis or
the treatment of a Sickness or Injury.
(b) The prevailing opinion within the appropriate
specialty of the United States medical
profession is that it is safe and effective
for its intended use, and that its omission
would adversely affect the person's medical
condition.
(c) It is furnished by a provider with appropriate
training, experience, staff and facilities to
furnish that particular service or supply.
Prudential will determine whether these
requirements have been met based on:
32
-- Published reports in authoritative
medical literature;
-- Regulations, reports, publications, or
evaluations issued by government agencies
such as the Agency for Health Care Policy
and Research, the National Institutes of
Health, and the Food and Drug
Administration (FDA);
-- Listings in the following drug compendia:
The American Medical Association Drug
Evaluations, The American Hospital
Formulary Service Drug Information and
The United States Pharmacopeia Dispensing
Information; and
-- Other authoritative medical sources to
the extent that Prudential determines
them to be necessary.
(d) The provider's institutional review board
acknowledges that the use of the service or
supply is experimental or investigational and
subject to that board's approval.
(e) The provider's institutional review board
requires that the patient, parent or guardian
give an informed consent stating that the
service or supply is experimental or
investigational or part of a research project
or study; or federal law requires such a
consent.
(f) Research protocols indicate that the service
or supply is experimental or investigational.
This item (f) applies for protocols used by
the patient's provider as well as for
protocols used by other providers studying
substantially the same service or supply.
Charges for Educational Services or Supplies: A
charge for a service or supply is not covered to
the extent that it is determined by Prudential to
be educational. Charges for services or supplies
furnished in connection with a service or supply
that is educational are also not covered.
"Educational" means:
(a) That the primary purpose of the service or
supply is to provide the person with any of
the following: training in the activities of
daily living; instruction in scholastic skills
such as reading and writing; preparation for
an occupation; or treatment for learning
disabilities; or
(b) That the service or supply is being provided
to promote development beyond any level of
function previously demonstrated.
"Training in the activities of daily living" does
not include training directly related to treatment
of a Sickness or Injury that resulted in a loss of
a previously demonstrated ability to perform those
activities.
33
In the case of a Hospital stay, the length of the
stay and Hospital services and supplies are not
covered to the extent that they are determined to
be allocable to the scholastic education or
vocational training of the patient.
(5) Charge in Excess of Usual and Prevailing Charge -
the portion of any charge for any service or supply
in excess of the usual and prevailing charge as
determined by Prudential. The usual and prevailing
charge for any service or supply is the usual
charge of the provider for the service or supply in
the absence of the insurance, but not more than the
prevailing charge in the area for a like service or
supply. A like service is of the same nature and
duration, requires the same skill, and is performed
by a provider of similar training and experience.
A like supply is one which is identical or
substantially equivalent. "Area" means the
municipality (or, in the case of a large city, the
subdivision thereof) in which the service or supply
is actually provided or such greater area as is
necessary to obtain a representative cross-section
of charges for a like service or supply.
(6) Any cost for coverage under (a) group insurance,
(b) individual insurance or (c) any other
arrangement on an insured or uninsured basis,
including pre-payment coverage, which provides
benefits or services for, or by reason of medical
or dental care or treatment.
(7) Charges incurred for services or supplies to the
extent benefits are provided under The Uniform
Health Benefit Plan and Dental Assistance Plan
provided under the Administrative Services
Agreement No. 59981 between The Coca-Cola Company
and The Prudential Insurance Company of America.
(8) Any reduction in benefit resulting from not using
the Pre-Admission and Concurrent Review Service
Program under The Uniform Health Benefit Plan.
(9) Any reduction in benefit resulting from not using
the Second Surgical Opinion Program under The
Uniform Health Benefit Plan.
34
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
35
PRIVILEGE OF OBTAINING AN INDIVIDUAL INSURANCE
POLICY UNDER CERTAIN CONDITIONS
If an Employee's hospital or surgical expense insurance under
this Policy terminates by reason of termination of the
Employee's employment or of the Employee's transfer out of
the classes eligible for such insurance under this Policy,
the Employee may, subject to the conditions hereinafter
stated, obtain from Prudential, without furnishing evidence
of insurability, an individual insurance policy renewable at
the option of Prudential and affording coverage to the extent
stated below by making written application and the first
premium payment therefor to Prudential at any of its Home or
Head Offices not later than thirty-one days from the date of
such termination of insurance. The availability of the
individual insurance policy, the coverage thereunder, the
person or persons covered under the policy, the initial
premium payable under the policy, the form and all terms and
conditions thereof shall be such as provided by the rules of
Prudential pertaining to insurance obtainable under the
provisions of this section, determined on a basis precluding
individual selection, which are in effect at the time the
application for such individual insurance policy is made to
Prudential. The effective date of an individual insurance
policy issued pursuant to the foregoing provisions shall be
the later of (i) the day on which the application for such
individual insurance policy is received by Prudential at any
of its Home or Head Offices, and (ii) the day following the
termination of the Employee's hospital or surgical expense
insurance under this Policy.
If an Employee's hospital or surgical expense insurance under
this Policy terminates as a result of the Employee's death
and on the date of such termination such Employee is insured
under this Policy for hospital or surgical expense insurance
with respect to a spouse, the privilege of obtaining an
individual insurance policy under the conditions stated above
may be exercised by the Employee's surviving spouse.
If an Employee's hospital or surgical expense insurance under
this Policy terminates for any reason specified in the
preceding paragraphs and on the date of such termination such
Employee is insured for hospital or surgical expense
insurance under this Policy with respect to a child, such
child shall also have the privilege of obtaining an
individual insurance policy under the conditions stated
above, provided such Employee or spouse, if surviving,
exercises the privilege of obtaining an individual insurance
policy which is available to such person under the conditions
stated above.
In the event hospital or surgical expense insurance under
this Policy with respect to an Employee's child terminates
solely because such child marries or attains the limiting age
for Qualified Dependent children with respect to whom
insurance is provided under such hospital or surgical expense
insurance provisions, such child shall have the privilege of
obtaining an individual insurance policy under the same
conditions as would apply to the Employee were he then
terminating employment.
36
An Employee's spouse shall also have the privilege of
obtaining an individual insurance policy under the conditions
stated above upon termination of the hospital or surgical
expense insurance with respect to such spouse by reason of
ceasing to be a Qualified Dependent.
General Provisions of Obtaining an Individual Insurance
Policy:
1. No such individual policy shall be issued to any such
person who becomes eligible for insurance under the
Group Policy in a different status during such thirty-
one day period.
2. No such individual policy shall cover the Dependents of
any person except the Employee or former Employee, or
the wife or husband of a deceased Employee, and then
only if such Employee or deceased Employee, as the case
may be, was covered for Dependents Coverage under the
Group Policy at the time of termination of his insurance
thereunder.
3. If the benefits applicable to any person under the Group
Policy are less than the benefits provided under the
individual policy, issuance of such individual policy
shall be subject to the underwriting rules of Prudential
for the issue of individual policies.
4. If any other insurance (group or otherwise) for hospital
expenses or services is in force or has been requested
or applied for with respect to any person for whom
coverage under such individual policy is requested,
Prudential may (a) decline to issue such individual
policy if such other insurance was not in force prior to
the termination of the Employee's insurance under the
Group Policy, or (b) limit the benefits under such
individual policy if such other insurance was force
prior to the termination of the Employee's insurance
under the Group Policy.
5. The availability of individual insurance policies
referred to herein is subject to approval of forms by
state insurance departments.
6. No such individual policy shall be issued until the end
of the periods for which an individual was continuously
covered as described in Modifications of Termination
Provisions to provide Continuation of Insurance of the
Employee's or Dependents Option.
PROVISIONS FOR NON-DUPLICATION OF BENEFITS UNDER MEDICARE
(1) The aggregate benefits payable under the Plan for services,
treatments and supplies incurred as to a Subject Person, as
determined prior to the application of the Provision
37
for Coordination of Benefits Under the Plan with Other
Benefits, will be the excess, if any, of
(a) Such aggregate benefits determined as if such
charges included Medical Charges with respect to
those treatments, services and supplies which are
within the scope of the Plan, over
(b) the aggregate benefits which, in accordance with
provision (2), are considered to be paid under
Medicare with respect to the same services,
treatments and supplies.
(2) For the purpose of these Provisions, the amount of
benefits considered to be paid under Medicare with
respect to those services, treatments and supplies
furnished a Subject Person as are within the scope of
full Medicare coverage shall be equal to the amount of
the Medical Charges for such services, treatments and
supplies, exclusive of coinsurance and other amounts
which are directly chargeable to that person in
accordance with Medicare or would be so chargeable if
that person had full Medicare coverage.
(3) Any provision of the Plan, other than these Provisions,
which excludes any charges for services, treatments or
supplies to the extent to which any benefits are
provided under a governmental plan or law shall not be
considered to refer to Medicare.
(4) The Provision for Coordination of Benefits Under the
Plan with Other Benefits is modified in the following
respects:
(a) The term "Plan" as used in said provision does not
include any coverage provided under Medicare.
(b) When the Allowable Expenses incurred as to a
Subject Person during any Claim Determination
Period include any expenses for services,
treatments and supplies which are covered in whole
or in part by that person's Medicare coverage, the
aggregate amount of Allowable Expenses shall be
reduced by an amount equal to the Medical Charges
for such services, treatments and supplies,
exclusive of coinsurance and other amounts which
are directly chargeable to that person in
accordance with Medicare.
38
COVERAGE SCHEDULE
SUPPLEMENTAL MEDICAL EXPENSE PLAN
(These benefits are in addition to the Uniform Health Benefit
Plan and Dental Assistance Plan provided under the
Administrative Services Agreement No. 59981 between The
Coca-Cola Company and The Prudential Insurance Company of
America.)
COVERAGE CLASSES
Employees Eligible
All Executives as reported to Prudential by the Policyholder.
Determination of Coverage Class and Classification
The Employer shall determine each individual's coverage class
and classification. Such determinations shall be made on
those dates which are established by the practices of the
Employer. Any such determination shall be made without
discrimination among persons in like circumstance, and shall
be final and conclusive.
EFFECTIVE DATE OF INSURANCE
Employee Insurance
All Employee Insurance is effective on the day the Employee
becomes a full-time Employee, subject to the section Becoming
Insured for Employee Insurance.
An Employee is considered full-time if he works for the
Employer at least the number of hours in the normal work week
established by the Employer, but not less than twenty hours
per week.
Dependents Insurance
Dependents Insurance is effective at the time the Employee's
Insurance is effective, subject to the section Becoming
Insured for Dependents Insurance.
DEFERMENT OF EFFECTIVE DATE OF INSURANCE
Employee Insurance
If the Employee does not comply with the Active Work
Requirement when he would otherwise become covered for
Employee Insurance or when any adjustment in the benefits
under such insurance would take effect, the effective date of
such insurance or adjustment will be deferred until the first
day thereafter on which he does comply with that requirement.
39
Dependents Insurance
If any Qualified Dependent is confined for medical care or
treatment in a hospital or other institution on the date any
Dependents Insurance, or adjustment thereof, would otherwise
become effective with respect to that Dependent, such
insurance or adjustment will be deferred until the
termination of a period of thirty days during which such
Dependent shall not have been so confined, or Prudential is
furnished with evidence satisfactory to it that such
Dependent has completely recovered from all injuries and
sicknesses, whichever first occurs, and then only subject to
the further provisions of the Group Policy.
This Section will not operate to defer the effective date of
an Employee's Insurance with respect to a child who is born
to the Employee, and becomes a Qualified Dependent under the
insurance at birth, while the Employee is insured for
Dependents Insurance with respect to one or more other
Dependents.
INSURANCE PROVIDED
Employee Medical Insurance on the following basis-
Employee Insurance -- contributory
Dependents Insurance -- contributory
SUPPLEMENTAL MEDICAL EXPENSE INSURANCE -- Employees and
Dependents -- Insurance Assignable.
Maximum Supplemental Medical Benefit -- 100% of the covered
charges, but not more than $30,000 during a calendar year.
As defined in this section, covered charges means the charges
actually made to the Employee for Medical and Dental services
and supplies which are eligible as deductions for income tax
purposes.
CONTINUANCE IN COVERAGE CLASSES DURING ABSENCE FROM FULL-TIME
WORK:
The types of absences and time limits referred to in the
Termination of Employee Coverage section for considering an
Employee as continuing to be a member of the Coverage Classes
are:
(1) LEAVE OF ABSENCE FOR DISABILITY -- The Employee
Coverage will continue during a Leave of Absence
for Disability. The Employee may continue the
Dependent Coverage by making the contributions for
his or her share of this cost.
(2) PERSONAL LEAVE OF ABSENCE -- The Employee Coverage
will continue during a Personal Leave of Absence for
up to six months following the month in which the
40
Personal Leave of Absence begins. Dependent Coverage
may also continue during this time provided the
Employee continues his or her share of contributions.
(3) MILITARY LEAVE OF ABSENCE -- The Employee Coverage
will continue during a Military Leave of Absence
for up to six months following the month in which
the Military Leave of Absence begins. Dependent
Coverage may also continue during this time
provided the Employee continues his or her share of
contributions.
(4) LAY OFF -- The Employee coverages will continue
during a Lay off for up to twelve months following
the month in which the Lay off begins. Dependent
Coverage may also continue during this time
provided the Employee continues his or her share of
contributions.
(5) RETIREMENT -- The Employee and Dependent Coverage
will terminate at the end of the month following
termination of employment.
41
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
42
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
43
This page is intentionally blank. See the section "The
Contract-Incontestability of Policy" of the General
Provisions of the Group Policy.
44
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
A Mutual Life Insurance Company
RIDER TO BE ATTACHED TO AND MADE A PART OF
GROUP POLICY NO. GO-56019
The Policyholder and the Insurance Company hereby agree that,
effective July 1, 1982, the Policy is modified by the
addition of the following section:
ADDITIONAL PREMIUMS
Premiums under the Policy, exclusive of any additional
premiums required by the provisions of this Rider, are
referred to herein as regular premiums.
An additional premium for insurance under the Policy shall be
determined as hereinafter provided at the end of each policy
year following the effective date of this Rider and, should
the Policy terminate during a policy year, upon such
termination. Each such additional premium shall be payable
upon demand by the Insurance Company.
The additional premium for each policy year shall be equal to
the excess, if any, of (a) the sum of the benefit charges
under the Policy, as defined below, and the Basic Factor
Charge over (b) 100% of the regular premiums for such policy
year. In no event, however, shall such additional premium
for a policy year exceed the Maximum Factor Charge.
The factor charges to be used in computation of an additional
premium for a policy year shall be determined as follows:
The Basic Factor Charge shall be determined by applying
twenty-two percent to the regular premiums for such
policy year.
The Maximum Factor Charge shall be determined by
applying ninety-one and one-tenth percent to the regular
premiums for such policy year.
provided that on each policy anniversary and at such other
times as the regular premium rates for insurance under the
Policy may be changed, the Insurance Company may, by
notifying the Policyholder, change any or all of the above
percentages.
The "benefit charges" shall, with respect to any policy year,
be the sum of (1) the amount of claims paid during such
policy year, plus, as determined by the Insurance Company,
the estimated amount of claims unpaid but chargeable to the
experience of the Policy as of the end of such policy year,
less the estimated amount of unpaid claims, as previously
determined by the Insurance Company, chargeable to the
experience of the Policy at the end of the preceding policy
year, and (2) the amount of any other charges on account of
benefits, as determined by the Insurance Company, for such
policy year.
45
If any of the percentages in effect shall be changed during a
policy year by the Insurance Company, pursuant to the
foregoing provisions, on a date which is not a policy
anniversary, the additional premium for such policy year
shall be the sum of the amounts determined by applying, in a
manner consistent with the foregoing provisions, the factor
percentages in effect during each portion of such policy year
to the regular premiums for the portion of such policy year
during which such percentages were in effect. If any
additional premium is to be determined for a period less than
a policy year, either because the effective date of this
Rider is not a policy anniversary or because the Policy
terminates on a day other than the last day of the policy
year, such determination shall be made in accordance with the
principles of the foregoing provisions, taking the shorter
duration of the period into account.
The Insurance Company has caused this Rider to be executed
this 29th day of December, 1983.
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA
By: /s/ Isabelle L. Kirchner
Secretary
46
Group Policy No. GO-56019
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
A Mutual Life Insurance Company
(Herein Called The Insurance Company)
Rider To Be Attached To and Made A Part Of Group Policy
No. GO-56019
The Insurance Company and the Policyholder agree that,
effective June 30, 1983, the Policy is amended by the
addition of the following provision:
SPECIAL RESERVE
The Insurance Company may maintain a special reserve to be
applied by it from time to time toward stabilizing experience
under the Policy. Such reserve shall be established from
premiums paid under the Policy, and the amount of such
reserve shall be determined by the Insurance Company from
time to time. Such reserve shall be credited with interest
at the end of each policy year, or in the event of
termination of the Policy, at the time of such termination.
The interest for the policy year or portion thereof, as the
case may be, shall be determined at the rate of not less than
5% per annum and on the average amount of the reserve during
the period with respect to which the interest is being
computed, except that after this Rider has been in effect for
a period extending from the effective date of this Rider to
the next policy anniversary and from time to time thereafter
the Insurance Company may change the rate to be used in the
computation of the interest on the reserve.
If at any time the Insurance Company shall determined that
the amount of the special reserve is then in excess of that
required, the Insurance Company shall pay such excess to the
Policyholder as a return of premium.
In the event of termination of the Policy, any balance
remaining in the special reserve after final application of
the reserve by the Insurance Company in accordance with the
above provisions shall be paid to the Policyholder as a
return of premium.
Any return to the Policyholder of the balance of the special
reserve, or any portion thereof, in accordance with the
provisions of this Rider, shall be applied by the
Policyholder solely for the benefit of retired employees or
active employees, or both.
The Insurance Company has caused this Rider to be executed
this first day of March, 1983.
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA
By: /s/ Isabelle L. Kirchner
Secretary
47