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EXHIBIT 10.37
LOGO HERE
GEM Plan
Summary Plan Description
Group Executive Medical
January 1999
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GENERAL AMERICAN
LIFE INSURANCE COMPANY
ST. LOUIS, MISSOURI 63101
CERTIFICATE OF GROUP INSURANCE
This Certificate contains a description of the Benefits Your Employer
provides for Covered Persons under the Group Policy identified below. The
Benefits described are subject to all of the terms and conditions of the Plan.
The Group Policy under which this Certificate is issued may at any time
be amended or ended in accordance with its terms without the consent of the
employee or any other person who claims rights or Benefits under the Group
Policy.
This certifies that General American Life Insurance Company has issued a
Group Insurance Policy numbered MCP-6901 to:
UNOVA, INC.
Policyholder
This Certificate describes the Benefits in effect under the Plan as of
January 1, 1999.
The coverage afforded by the Group Policy is not in place of nor does it
affect any requirements for coverage by Worker's Compensation Insurance nor does
it pay in addition to Worker's Compensation.
GENERAL AMERICAN LIFE INSURANCE COMPANY
President
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COMPLAINT NOTICE
If You have a question about Your Policy or if You need assistance with
a problem, You should first contact Your plan representative. After Your plan
representative's contact with Us, should You feel You are not being treated
fairly with respect to a claim, You may contact the California Department of
Insurance.
To contact the Department, write or call:
Department of Insurance
Consumer Service Division
300 S. Spring Street
Los Angeles, California 90013
213-897-8921
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TABLE OF CONTENTS
SECTION PAGE
Introduction ......................................................................................1
Eligibility .......................................................................................2
When Coverage Begins ..............................................................................4
When Coverage Ends ................................................................................6
Continuation of Coverage in the Event of a Labor Dispute ..........................................7
Special California Continuation for Surviving Spouses, Divorced or Legally Separated Spouses ......8
Special California Continuation of Medical or Health Coverage for Employees Age 60 and Over
and Their Spouses ...............................................................................9
Medicare .........................................................................................10
Plan Replacement .................................................................................11
Health Care Benefits .............................................................................12
Medical Conversion Privilege .....................................................................15
Coordination of Benefits .........................................................................16
Claims and Other General Provisions ..............................................................18
General Definitions ..............................................................................20
ERISA Information ................................................................................28
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INTRODUCTION
Your Employer has chosen the Benefits described in this
Booklet/Certificate for many reasons. The most important of these are to protect
its most valuable assets -- its healthy and productive employees -- and to
provide You (and Your family) with significant financial protection against the
physical, emotional and economic strain Illness or Injury can bring.
Please read this document carefully to familiarize Yourself with the
Benefits it describes and the procedures for filing claims. If You have any
questions about Your coverage, please contact the plan representative.
When used in the Plan, unless otherwise stated, the terms are as defined
in:
1. the General Definitions section, or
2. the specific benefits sections.
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ELIGIBILITY
ELIGIBLE EMPLOYEES
Employees who are classified by the Employer as a) an active Key
Executive employee, b) a retired Key Executive employee, or c) a consultant who
has been designated as a participant by the Employer, or their wholly-owned
subsidiaries, and who is compensated for his/her services by or is under
agreement with the Employer or their wholly-owned subsidiaries.
ELIGIBLE DEPENDENTS
To be eligible for Dependent Coverage under the Plan, Your dependent(s)
must be eligible.
Your Eligible Dependents are:
1. Your lawful spouse;
2. Your unmarried dependent Child:
a. less than age 19; and
b. age 19 to 23 if a full-time student in an accredited school and
dependent on You for main support and care;
3. Your Child with a mental or physical handicap who is over the age limit,
if a) the Child becomes and remains Disabled while covered under the
Plan, or b) was covered under the Prior Plan that this Plan replaces
and, in either case, all of the following conditions are met:
a. the Child has not been married;
b. cannot hold a self-supporting job due to the handicap; and
C. depends on You for main support and care.
First proof of incapacity must be given to Us (at Your expense) within
31 days of the Child's limiting birthday. After two years following the
attainment of the limiting age, subsequent proof may be requested annually.
"Child" means: Your natural Child; Your stepchild; an adopted Child; a
Child who has been Placed For Adoption with You; a Child for whom You have been
appointed legal guardian; a Child who is recognized under a qualified medical
child support order as having a right to enrollment under the Plan (hereafter
"QMCSO-child"); or a Foster Child. With respect to an adopted or placed Child,
dependent coverage will include necessary care and treatment of medical
conditions existing prior to the date of placement. In all cases the Child must
depend upon You for his/her main support and care. However, when a court
recognizes a Child as a QMCSO-child, the Child will be considered Your Eligible
Dependent regardless of whether the Child is living with You or receiving
his/her main support and care from You.
No person may be covered as a dependent of more than one employee. An
employee may not be covered as a dependent.
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ELIGIBILITY - CONTINUED
COVERAGE FOR NEWBORNS - WELL BABY CARE
A newborn Child will become covered from moment of birth provided You
enroll the newborn Child for coverage within 31 days from the date of birth.
Such newborn Child will be eligible for the following Covered Expenses. (a)
Hospital room and board (or nursery) charges; (b) routine Doctor visits while
Hospital confined; and (c) circumcision while Hospital confined.
This coverage will end on the earlier of:
1. the date the newborn Child is discharged or
2. the date the newborn Child is 7 days old.
COVERAGE FOR NEWBORNS - SICK BABY CARE
A newborn Child is eligible from the moment of birth for Covered
Expenses due directly to:
1. Injury;
2. premature birth; or
3. a condition which exists at birth.
If You do not have Dependent Coverage in force, this coverage (including
any Extended Benefits) will end 31 days after the date Your Child is born. If
You Enroll the Child within this 31 day period.
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WHEN COVERAGE BEGINS
FOR ELIGIBLE EMPLOYEES:
Your coverage will be made effective on:
1. Your Eligibility Date if You Enroll on or before that date; or
2. the date You Enroll if You do so within 31 days after Your Eligibility
Date.
If You do not Enroll within 31 days after You are eligible, please refer
to the provision on Late Enrollees within this section.
FOR ELIGIBLE DEPENDENTS:
Dependent Coverage cannot become effective prior to the date Your
coverage is effective. Dependent Coverage will be effective with respect to each
Eligible Dependent You then have on:
1. the date You are eligible for coverage if You Enroll Your dependents
within 31 days; or
2. the date Your dependents are eligible if You Enroll them within 31 days.
If You do not Enroll Your dependents for coverage within 31 days after
they are eligible for coverage, please refer to the provision on Late Enrollees
below.
LATE ENROLLEES
If You do not Enroll within 31 days after You are eligible for Health
Care coverage, You may be a Late Enrollee. If:
1. You do not enroll Your dependents within 31 days after You are eligible
for such coverage or Your dependent was not enrolled within 31 days
after he/she became eligible; or
2. You wish to restore Dependent Health Care coverage which ended because
You did not make required Contributions, Your dependent may be
considered a Late Enrollee. (Please refer to the General Definitions
section.)
- Late Enrollee may Enroll only during the open enrollment period.
- Late Enrollee's coverage will be made effective on the first day of the
calendar month following the open enrollment period.
OTHER ENROLLMENT PERIODS
You or Your Eligible Dependent may only request enrollment under the
Health Care coverage
1. during the initial enrollment period or subsequent open enrollment
periods;
2. during the Special Enrollment Periods;
3. during any state prescribed enrollment periods.
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WHEN COVERAGE BEGINS - CONTINUED
You or an Eligible Dependent may Enroll for coverage during Special
Enrollment Periods without being considered a Late Enrollee under the following
circumstances:
The Special Enrollment Periods exist under the following circumstances:
1. Loss of Other Coverage. If You or an Eligible Dependent
a. was/were covered under another group health plan (including
COBRA continuation) or under no share-of-cost Medi-Cal coverage
or had other medical insurance coverage at the time enrollment
was declined; and
b. stated, in writing, that coverage under another health plan or
under a no share-of-cost Medi-Cal coverage was the reason for
declining enrollment and were provided with a notice of this
requirement and the consequences of such a requirement; and the
Employer can provide Us with a written statement confirming
these facts and
c. have/has lost or will lose coverage under the other plan as a
result of loss of eligibility (due to such reasons as
termination of employment, change of employment status, death of
a spouse, divorce, legal separation) or cessation of the
employer's contributions to such coverage (even if the other
plan is continued) or loss of no share-of-cost Medi-Cal coverage
or have exhausted COBRA continuation coverage, You or an
Eligible Dependent may Enroll within 31 days after loss of
coverage. Coverage will be effective on the first day of the
month following enrollment.
2. Acquisition of Dependents. If You did not Enroll when first eligible and
acquire a dependent through marriage, birth, adoption or Placement For
Adoption, You and the newly acquired dependent(s) may Enroll within 31
days of the date of marriage, birth, adoption or Placement For Adoption.
In the case of the birth, adoption or placement of a Child, Your spouse
may also be enrolled as Your dependent if otherwise eligible for
coverage. Coverage will be effective on the date of birth, adoption or
Placement For Adoption. In the case of marriage, coverage will be made
effective on the first day of the month following enrollment.
3. During any state prescribed enrollment period.
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WHEN COVERAGE ENDS
FOR EMPLOYEES:
Your coverage will end on the date of the first of these events:
1. The end of the month in which You stop Active Work on a Full-Time Basis
in an Eligible Class, except that:
a. if You stop Active Work due to Injury, Illness or Qualified
Leave of Absence for personal Injury or Illness, Your Employer
will continue Your Health coverage subject to payment of
Contributions. Such coverage will continue only while You are
unable to return to work because of the Injury, Illness or
Qualified Leave of Absence. This coverage continuance will be on
a basis precluding individual selection;
b. if You stop Active Work to take a qualified military leave of
absence (pursuant to the Uniformed Services Employment and
Reemployment Rights Act of 1994), You may elect to continue Your
Health coverage subject to payment of premium. Such coverage
will continue only while You are unable to return to work
because of the qualified military leave of absence. Such
continuance will be on a basis precluding individual selection;
c. if You stop Active Work to take a Qualified Leave of Absence
(pursuant to the Family and Medical Leave Act of 1993 or other
applicable state's leave law, if any such law applies to Your
Employer), for reasons other than personal Illness or Injury,
Your Employer will continue coverage subject to payment of
Contributions. Such coverage will continue only while You are
unable to return to work because of the Qualified Leave of
Absence. Such continuance will be on a basis precluding
individual selection;
d. Upon retirement from UNOVA, Inc., coverage for the retired
executive and their dependents will continue until the executive
attains age 72. If the retired executive dies before attainment
of age 72, the surviving dependents will be covered until the
retired executive would have attained age 72.
2. As to any one coverage or class, the date the Plan is amended or changed
to exclude that coverage or class.
3. Your Employer ceases to be an Associated Company of the Policyholder.
4. Your Employer ceases to be a member of the trust to which We issued the
Policy.
5. The Plan ends.
FOR DEPENDENTS:
A dependent's coverage will end on the earlier of:
1. the date Your coverage ends; or
2. the end of the month in which the dependent ceases to be eligible as
defined by the Plan.
Please read the Special California Continuation of Medical or Health
Coverage provisions to determine if Your coverage may extend beyond the time
allowed above.
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CONTINUANCE OF COVERAGE IN THE EVENT
OF A LABOR DISPUTE
Your and Your dependent's coverage under the Group Policy will continue
and Your employment will be considered to continue after the day it would
otherwise end under the Group Policy because You ceased work as a result of a
labor dispute, subject to the following conditions:
1. You are a member of a collective bargaining unit which participates in
the cessation of work resulting from the labor dispute.
2. Your union agrees to collect and remit to Us the required monthly
premium, and Your union agrees that it will:
a. keep required monthly premium collection records in connection
with this continuance of coverage;
b. furnish Us with needed information to administer this
continuance of coverage when We require that information; and
C. permit Us, at any reasonable time, to inspect the union records
which relate to this continuance of coverage.
3. You must remit the required monthly premium to Your union on the date
You stopped work. The union, if it agrees, will remit to Us all such
monthly premium payments. Your required monthly payment will be at the
premium rate applicable to Your and Your dependent's Benefit Class as We
required on the date You stopped work.
We will not discontinue Your coverage if any of Your required premium
which was unpaid on the date You stopped work and was due prior to the
date You stopped work, if paid prior to the date the next premium is due
under the terms of the Plan.
You must remit to Your union subsequent required monthly premium
payments not later then 20 days after the due date for the premium for
that month.
The grace period for payment of premiums will not apply to premiums due
to Us for any coverage continued under this provision. Premiums must be
paid to Us by Your union within 31 days after the due date.
4. In addition to Our right under the Plan to change premium rates, We have
the right to increase the rate charged to You for Your and your
dependent's coverage on the date You stopped work. We may increase this
premium rate by up to twenty percent (20%), or a higher percent if
approved by the Insurance Commissioner of the state of California. An
increase in premium rates will automatically increase Your required
monthly premium.
5. Neither We nor the Policyholder has the right to terminate the Plan with
respect to coverage being continued under this provision.
6. Your continuance of coverage provided by this provision will terminate
on the earliest of the following:
a. the last day of the period for which (a) You paid the required
premium, or (b) Your union last remitted to Us the required
monthly premium for Your coverage;
b. the premium due date on which the number of employees continuing
coverage under this provision is less than 75% of the number of
employees who are entitled to continue their coverage;
c. the day You take full-time employment with another employer;
d. the end of the continuous six-month period beginning on the day
You stopped work as a result of the labor dispute;
e. the end of the labor dispute which resulted in the cessation of
work;
f. as to any one Eligible Dependent, the date he/she no longer
qualifies as an Eligible Dependent as defined in the Plan.
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SPECIAL CALIFORNIA CONTINUATION FOR SURVIVING
SPOUSES, DIVORCED OR LEGALLY SEPARATED SPOUSES
If Your spouse and any dependent Child(ren) lose coverage under Your
Health Care coverage due to Your death, dissolution of marriage or legal
separation or if Your entitlement to Medicare causes loss of Dependent Coverage,
Your spouse may elect to continue the coverage under California's benefit
instead of Federal Continuation Coverage (COBRA) under certain circumstances.
The continued coverage applies to Medical Care, and any Dental Care, Vision Care
and Prescription Drug coverage You may have under this Plan.
The Plan Administrator must be notified within 15 days of Your spouse's
eligibility due to divorce or legal separation and supplied with the spouse's
mailing address. The spouse will be notified within 15 days and provided with
election forms. If the Plan Administrator is not notified within the time
provided, the right to such coverage will be terminated.
In case of Your death, Your Employer will notify the Plan Administrator.
Coverage will not be terminated for up to 31 days after notice and forms
are provided. If the premium for continued coverage is not paid within 31 days
after notice is provided, coverage will be deemed terminated in accordance with
the "When Coverage Ends" provision.
Continuation of coverage for the Covered Person will terminate on the
date:
1. the Covered Person ceases to reside in the State of California;
2. the Covered Person marries or remarries',
3. the Covered Person becomes eligible for a comparable state, federal or
private group medical or health plan", or
4. the Covered Person becomes eligible for medical care coverage under
another employer's group plan, even though such plan may be less
substantial.
The ineligibility of a dependent Child will not invalidate the continuation
provision for any other family member.
The continued coverage of all dependents , will end on the earliest of:
1. 90 days from when coverage would have ended under the "When Coverage
Ends" provision;
2. the date the spouse ceases to reside in the State of California;
3. the date the spouse remarries;
4. the date the spouse becomes eligible for any comparable state, federal
or private group medical plans;
5. the date the spouse becomes eligible for medical coverage under
another's employer's group plan, even though such plan may be less
substantial;
6. the date the Medical Care coverage under the Plan is terminated;
7. the date the Employer through which coverage was obtained ceases to
participate in the Medical Care coverage; or
8. the date the premium is not paid within the time allowed.
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SPECIAL CALIFORNIA CONTINUATION OF MEDICAL OR
HEALTH COVERAGE FOR EMPLOYEES AGE 60 AND OVER
AND THEIR SPOUSES
If You are age 60 years or older, You and Your covered spouse may elect
to continue coverage beyond the expiration of Your Federal Continuation Coverage
under the Consolidated Omnibus Budget Reconciliation Act (COBRA) under certain
circumstances. This extended continuation applies if You have been employed for
at least 5 years prior to termination of employment and You or Your spouse is
not entitled to Medicare when Your COBRA coverage expires. Continuation follows
the same terms and conditions in force under Your COBRA election.
If You meet the qualifications above, You must make an election for this
special continuation at least 30 days prior to the date Your COBRA coverage is
scheduled to terminate. The election is separate from Your COBRA election;
however, You must elect COBRA in order for the special continuation election to
be valid. You may terminate this coverage at any time. A former spouse of an
employer may also elect to continue coverage beyond the expiration of COBRA by
making an election in this same manner.
Continued coverage, effective after COBRA coverage expires, will
automatically terminate whenever any of the following occurs:
1. Failure to pay the premium when due under the Plan;
2. The employer ceases to provide a group health plan to its employees;
3. Becoming covered under another group health plan;
4. Becoming entitled to Medicare;
5. Attainment of the age of 65; or
6. For Your spouse or former spouse only, five years from the date COBRA
coverage ends.
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MEDICARE
This section applies to a Covered Person who is eligible for Medicare
coverage. It provides rules for determining the order of benefit payments
between coverage under this Plan and those of Medicare. The intent of this
section is to conform the Plan to the requirements of the federal Medicare
Secondary Payer law. Accordingly, the section and its stated rules will be
adjusted, if We deem necessary, so that the Plan's liability for Benefit payment
is neither greater nor less than those required under the law.
1. If, pursuant to the rules:
a. this Plan is determined to be secondary to Medicare, it will pay
secondary to and coordinate its Benefits with Medicare;
b. this Plan is determined to be primary to Medicare, it will pay
Benefits without regard to Medicare benefits.
2. The order of benefit payments rules are outlined below.
a. Rules applicable to a person covered under the Plan by virtue of
that person's "Current Employment Status" with an Employer or as
a dependent of such person:
BASIS OF MEDICARE ELIGIBILITY: THIS PLAN WILL:
- Old-Age (attaining age 65)* Be primary.
- Disability (other than ESRD) Be primary.
- End Stage Renal Disease (ESRD) Be primary for the first 30 months of ESRD Medicare
coverage; be secondary thereafter.
- Old-Age or Disability, preceding or beginning
concurrently with ESRD Continue to be primary until the end of the first 30 months of
ESRD Medicare coverage; be secondary thereafter.
*If a Covered Person elects to have Medicare as primary coverage, such
person's Health Care coverage under this Plan will terminate. If the
employee's Health Care coverage terminates in accordance with this
provision, coverage on the employee's covered dependents will cease on
the same date.
b. Rules applicable to a person covered under the Plan as a Retired
Employee, a dependent of such employee, or on any basis other
than those stated in 2.a. above:
BASIS OF MEDICARE ELIGIBILITY: THIS PLAN WILL:
- Old-Age (attaining age 65) Be secondary.
- Disability (other than ESRD) Be secondary.
- End Stage Renal Disease (ESRD) Be primary for the first 30 months of ESRD Medicare
coverage; be secondary thereafter.
- Old-Age or Disability, preceding ESRD Continue to be secondary.
For purposes of this section, "Current Employment Status": a person is
considered to have Current Employment Status with an Employer if the person is
an employee, is the Employer (including self-employed person), or is associated
with the Employer in a business relationship.
REMEMBER: The Medicare section outlined above applies from the date a Covered
Person is first ELIGIBLE for Medicare (either part A or part B), whether or not
the Covered Person is enrolled and is receiving Medicare benefits.
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PLAN REPLACEMENT
If Medical Care coverage under this Plan replaces a group medical plan
(the "Prior Plan") within 60 days after a) the date the Prior Plan ended, or b)
the date the coverage under a plan for an entire employer unit ended, the
following will apply:
1. If You and Your dependents were covered under the "Prior Plan" on the
date such plan ended, You and Your dependents will be covered under this
Plan, if You and Your dependents meet the Eligibility requirements for
coverage under the terms of this Plan.
2. All former employees entitled to "California Special Continuation for
Employees Age 60 and Over and Their Spouses" will be eligible under this
Plan.
3. If You or Your dependent is totally disabled (as defined by the Prior
Plan) and entitled to an extension of benefits under the Prior Plan, this
Plan will not provide coverage for any Expenses Incurred due to any
conditions causing the disability.
a. Any Benefit payable under this Plan will not be lower than the
benefit that would have been provided under the Prior Plan.
b. Any Benefit payable will be reduced by the amount of benefits
payable under the Prior Plan's extension of benefits provision.
4. Your or Your dependent's coverage will continue until the earlier of:
a. the date coverage would terminate in accordance with this Plan's
Termination of Coverage provision; or
b. for a person Disabled on the date the Prior Plan ended, the end
of the extension of benefits period of the Prior Plan. If the
Prior Plan was not required to provide an extension of benefits,
coverage will end not less than 12 months from the date the
person became Disabled.
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HEALTH CARE BENEFITS
The Calendar Year Maximum Benefit for all Covered Expenses is $100,000
per Family Unit.
COVERED EXPENSES
The Plan Will Pay Benefits for Covered Expenses Incurred for medical,
dental and vision care expenses as defined under the Internal Revenue Code
(Section 213(d) as amended and Internal Revenue Service Income Tax Regulation
1.213-1 as amended) except as specifically listed under the Exclusion in this
Benefit. Covered Expenses include services for the diagnosis, care, and
treatment of a physical or mental defect, Illness or Injury and for the
prevention of disease. Covered services include but are not limited to:
1. Acupuncture.
2. Anesthesia and the professional charge for its administration.
3. Hearing tests, hearing aids and their fittings and batteries.
4. Infertility treatment including reversal of an elective sterilization
procedure.
5. Inpatient Hospital charges including residential alcohol treatment
centers, residential drug addiction treatment centers, psychiatric
residential treatment centers, Hospice facilities.
6. Laboratory and x-ray charges by a Hospital, Doctor's office, laboratory
or imaging center and the professional interpretation fee.
7. Medical equipment including:
a. wheelchairs, hospital beds and the attachments thereto;
b. oxygen and equipment to administer oxygen, breathing aids;
c. needles and syringes to administer insulin, allergens and
prescription drugs;
d. dialysis equipment, supplies, upkeep and training on the use of
such equipment;
e. ostomy bags and supplies;
f. glucometers, dextrometers, destrostix;
g. infusion pumps;
h. nerve stimulators.
8. Nursing services provided by a registered nurse (R.N.), licensed
practical nurse (L.P.N.), or licensed vocational nurse (L.V.N.), in or
out of a Hospital, pertaining to the actual care of an Illness or
Injury.
9. Orthopedic and prosthetic devices including:
a. artificial limbs, eyes and teeth and the replacement thereof;
b. casts, splints and crutches;
c. supports and orthotics;
d. post-mastectomy breast prostheses and holding bras.
10. Outpatient Hospital charges including outpatient treatment centers,
non-residential treatment centers for alcoholism and/or substance abuse,
community mental health centers, ambulatory surgical centers, Birthing
Centers.
11. Physiotherapy services by a physiotherapist.
12. Pre-natal and post natal care.
13. Complications of Pregnancy.
14. Prescription drugs including:
a. birth control pills;
b. insulin.
15. Preventive care including:
a. newborn care;
b. child health supervision services;
c. immunizations and vaccines;
d. screening tests for cancer;
e. annual routine physicals.
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HEALTH CARE BENEFITS - CONTINUED
16. Preventive and restorative dental treatment including orthodontia and
dentures and their replacement.
17. Professional charges of a Physician, chiropractor, podiatrist, Dentist,
Christian Science practitioner, psychologist, speech/language therapist,
speech pathologist, audiologist, optometrist, ophthalmologist, nurse
practitioner, licensed midwife, operating within the scope of their
respective licenses.
18. Professional counseling for a mental health condition by a state
licensed counselor.
19. Psychoanalysis, psychotherapy, psychological testing and group therapy.
20. Skilled Nursing Facilities if confined for medical care.
21. Special schools and tutoring for a Child with a learning disability upon
the recommendation of a Physician.
22. Special schools for a mental impaired or physically Disabled person if
its main purpose is teaching to alleviate the disability, for example:
a. teaches Braille to a visually impaired person;
b. teaches lip reading to a hearing impaired person;
c. gives remedial language training to correct a condition caused
by a birth defect.
23. Specialized equipment for the physically Disabled including:
a. modifications to Your home to accommodate the Disabled person
(prior Company approval required);
b. modifications to a car to enable a Disabled person to drive it;
c. Braille books and magazines for the visually impaired;
d. support dogs or other animals trained to assist the Disabled
person;
e. special telephone equipment for the hearing impaired;
f. special equipment to adapt television for the hearing impaired.
24. Surgery including sterilization, spontaneous abortion, an abortion
necessary to prevent the death of the mother, elective abortion,
improvement of a deformity related to a congenital abnormality, Injury
or disfiguring disease.
25. Transportation for medical care defined as:
a. professional ambulance to and from a Hospital;
b. train or commercial airline to a Hospital for specialized care;
and
c. emergency transportation to a Hospital by helicopter.
26. Vision care including:
a. routine eye examinations;
b. surgery, eyeglasses and contact lenses to improve vision;
c. eye exercises.
EXCLUSIONS
The Policyholder has chosen to provide many Benefits. There are some
things, however, that will not be covered as health expenses. Excluded items
include but are not limited to:
1. Expenses solely for cosmetic reasons including face lifts, hair
transplants, liposuction.
2. Items ordinarily used for personal, living or family purposes, even if
recommended by a Doctor, including:
a. household help;
b. a vacation;
c. smoking cessation program;
d. weight loss program;
e. health club;
f. maternity clothes;
g. nursing services for a normal healthy baby;
h. over-the-counter drugs and medicines.
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HEALTH CARE BENEFITS - CONTINUED
3. Care or supplies for which:
a. no charge is made;
b. You or Your dependent would not have to pay if You did not have
this coverage.
4. Any care or supplies received prior to the Effective Date or after the
Termination Date of the Covered Person's coverage (unless coverage is
continued according to some Plan provision).
5. Injury or Illness arising out of employment, whether or not You or Your
dependent is covered by Worker's Compensation or similar laws.
6. Any service or treatment covered under another plan of Your Employer.
7. Any charge for a service not listed as a Covered Expense.
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MEDICAL CONVERSION PRIVILEGE
If Your coverage with the Plan ends due to:
1. any reason except failure to pay the required premium; or
2. the Plan ending and not being replaced within 60 days by similar
coverage,
You may purchase personal coverage ("Conversion Coverage") for Yourself and each
of Your covered dependents, provided:
1. You (and Your dependents) were covered by this Plan (and under any group
plan providing similar Benefits which it replaces) for at least three
months prior to the date Your employment ends; and
2. You (and Your dependents) are not eligible for Medicare,
You have 31 days from the date Your coverage ends to submit a written
application and the first premium for Conversion Coverage. You are solely
responsible for contacting Us to obtain this coverage. Premium will be based on
the type of coverage and the sex, age and state of residence of the person
purchasing the coverage. Coverages will become effective on the date group
coverage ends.
If purchase of Conversion Coverage will result in over-insurance
according to Our standards, We reserve the right to deny such coverage.
Pregnancy Benefits are included in a conversion policy if they were
provided under the group Plan which the Conversion Policy replaces.
This privilege is also available to a) covered dependents if You die; or
b) to a dependent Child who reaches the limiting age; or c) to Your ex-spouse on
the date a valid decree of divorce is issued (including any Children whose
coverage also ends at the same time), if exercised within 31 days of the date
coverage ends.
THE CONVERSION COVERAGE WILL MEET THE MINIMUM REQUIREMENTS OF THE STATE
IN WHICH IT IS ISSUED. THE BENEFITS PROVIDED BY THE CONVERSION POLICY WILL NOT
DUPLICATE THE BENEFITS PROVIDED UNDER THIS PLAN.
If Your or Your dependents' coverage with the Plan has been continued
according to federally mandated standards, You or they may still be able to
exercise this conversion right. The full term of the available Federal
Continuation Coverage (COBRA) must have been exhausted to receive this
Conversion Privilege.
15
20
COORDINATION OF BENEFITS
If this is not Your only plan coverage, the Benefits payable under this
Plan, and any other group plan for the Allowable Expenses Incurred during any
Benefit Determination Period will be coordinated so that the combined Benefits
paid or provided by all plans will not exceed 100% of such Allowable Expenses.
You must inform Us if You have other coverage (for example, through Your
spouse's employer); and give Your consent to the release of information so that
We may use this provision. You should first file Your claim with the primary
plan (as determined below). When the claim is paid, send a copy of the charges
and a copy of the Explanation of Benefits Statement from the first plan to the
secondary plan (as determined below). This will accelerate the processing of
Your claim.
One of Your Plans will be determined to be primary (using the rules
below). The primary plan pays its full benefits first. The plan paying second
takes the benefits of the primary plan into account when it determines its
benefits.
A plan is primary when:
1. the plan does not have a COB provision;
2. the plan designates itself as an "excess" or "always secondary" plan; or
3. if both plans have a COB provision, under the rules it is determined to
be primary.
When both plans have a COB provision, the order in which the plans
provide benefits is determined using the first of the following rules which
applies:
1. Employee/dependent. The plan which covers the person as an active
employee is primary. If You or Your dependent is also covered by
Medicare, the plan covering the person as an active employee is primary,
the plan covering the person as a dependent of an active employee is
secondary, and then Medicare.
2. Dependent children.
a. If the parents are not separated or divorced, the plan which
covers the parent whose birthday (month and day) falls earlier
in the calendar year is primary. If both parents have the same
birthday (month and day), the plan which covered the parent
longer is primary. If the other plan does not have the "birthday
rule", the rule in the other plan will determine the primary
plan.
b. If the parents are separated or divorced, the plan which covers
the natural parent with custody is primary; followed by the plan
which covers the step-parent who has married the natural parent
with custody; and finally, the plan which covers the natural
parent without custody.
However, if the court decrees one of the parents responsible for
health care expenses, the plan which covers that parent is
primary.
If the decree names the parent other than the natural parent
with custody, We must be notified and have actual knowledge of
those terms. Any Benefits paid prior to actual knowledge will
not be affected. The plan of the other parent and the plan of
the spouse of the parent with custody will be secondary and
third, respectively.
If joint custody is granted by the court, the rules pertaining
to parents who are not separated or divorced apply.
3. Active/inactive employee. The plan covering the employee who is neither
laid off or retired is primary. If the other plan does not have this
rule, this rule is ignored.
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COORDINATION OF BENEFITS - CONTINUED
4. Continuation coverage. Continuation coverage provided under either
federal or state law is secondary. If the other plan does not have this
rule, this rule is ignored.
5. Length of coverage. If the primary plan cannot be determined using any
of the rules above, the plan which has covered the person for the
longest period of time will be considered primary.
If this Plan is determined to be secondary, We will reduce Benefits
payable so that the total benefits provided by all plans during a claim
determination period are not more than the total Allowable Expenses for the
Covered Person.
The actual Benefit amounts available are determined by each plan's
benefit provisions. Benefits payable under this Plan will never exceed the
amount which would have been paid if there were no other plans involved. If
Benefit payments under this Plan are reduced by COB, only the reduced amounts
will be charged against Your Plan maximums.
If during Coordination of Benefits, payments are made in error, the
plans will have the right to adjust payments among themselves. Such payments
satisfy Our liability. If We overpay a claim, We will have the right to recover
such overpayments from any person for, to whom, or with respect to whom such
payments were made, any other insurance company, or any other organization.
DEFINITIONS
An "Allowable Expense" is the Reasonable and Customary cost for any
necessary medical or dental service which is covered (at least in part) by one
of the plans. If a health plan provides services (rather than cash payments) a
dollar value will be assigned in order to use this provision.
When the primary plan penalizes You for not complying with plan
provisions, such as failing to pre-certify, the amount of the reduction is not
considered an Allowable Expense.
A "Benefit Determination Period" means from January 1 of one year to
December 31 of the same year.
A "plan" as used in this provision, is any of the following which
provides health benefits or services:
1. a group, blanket or franchise plan on an insured basis;
2. other plans which cover people as a group;
3. a self-insured or non-insured plan or other plan which is arranged
through an employer, trustee or union;
4. a pre-payment plan which provides medical or dental service;
5. government plans, except Medicaid;
6. group auto insurance, but only to the extent medical benefits are
payable under group auto insurance;
7. no-fault auto insurance on an individual basis, except where not allowed
by the state in which this Plan is issued;
8. single or family subscribed plans issued under a group or blanket type
plan;
but the definition of plan shall not include:
1. hospital indemnity type plans;
2. school accident-type coverage;
3. traditional auto insurance.
17
22
CLAIMS AND OTHER GENERAL PROVISIONS
NOTICE AND PROOF OF CLAIM
You must give Us a written notice of claim for a medical or health claim
(including vision and dental claims, if any), within 12 months after a Covered
Expense is incurred.
Within 15 days after We receive the notice of claim, We will send claim
forms (if required) to You for giving proof of claim. If You do not receive
these forms, You will satisfy the proof of claim requirement by giving Us a
written statement of the nature and extent of the loss within the time limit
provided below.
You must give positive proof of claim to Us or Our authorized claim
office for a medical or health claim (including vision and dental claims, if
any) within 15 months after a Covered Expense is Incurred.
You must give Us proper written notice and proof of loss before We will
be liable for any loss. If You send Us proof as soon as reasonably possible, We
will not reduce or deny claims merely because You cannot reasonably give notice
and proof in writing within the time required. However, such proof must be
furnished within one year from the time proof is otherwise required except in
the absence of legal capacity.
We may, as required by law, accept claims submitted by a third-party
custodial parent or a provider (with the custodial parent's approval) for
Covered Expenses Incurred by a covered dependent Child who is also eligible for
a state medical assistance program (i.e., Medicaid).
PAYMENT OF CLAIMS
1. With the receipt of a claim for medical transportation services, any
Benefits due will be paid directly to the provider if the provider has
not received payment for those services from any other source. Except as
provided below, all other Benefits, other than for loss of life, due and
not validly assigned will be paid to You as soon as practical, but no
later than 30 working days after We receive Due Proof. Due Proof is all
information necessary to determine Our liability for the claim and to
determine if services are Medically Necessary. If We have not paid or
denied a claim containing Due Proof within the time allotted, The Plan
Will Pay interest at the rate of 10% per annum beginning the day after
the allotted time period.
2. The Plan may, to the extent required by law, pay Benefits for claims
incurred by a covered dependent Child directly to a custodial parent, a
state agency or a provider.
3. Benefit payments pursuant to a qualified medical child support order
(QMCSO) in reimbursement for expenses paid by a QMCSO-child or his/her
legal representative (custodial parent or legal guardian) will be made
to the QMCSO child or his/her legal representative.
4. If You use a Participating Provider, The Plan Will Pay Benefits, if any,
to the provider of service.
5. The Plan may pay Benefits to the person or institution who gave You
care.
6. Any payments We make under the above, except under 1. will discharge Our
liability to the extent of Our payment. We are not responsible for how
the Benefits We pay are used.
LEGAL ACTIONS
You may not sue Us for Benefits under this Plan:
1. before 60 days following the date You send Us proof of claim;
2. after 3 years following the end of the period required for giving proof
of claim.
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CLAIMS AND OTHER GENERAL PROVISIONS - CONTINUED
ASSIGNMENT OF BENEFITS
You may assign Medical or Health Care Benefits directly to the Doctor,
Hospital or an appropriate state agency. You can either sign the necessary forms
given to You by the provider of services or sign the designated assignment on
Your claim form. Otherwise, Benefits will be paid according to the Payment of
Claims provision. If You use a Participating Provider, The Plan Will Pay
Benefits, if any, to the provider of service. We will not be responsible for the
validity of any assignment. Nor will We be liable for any action, payment or
other settlement made before We receive such assignment.
To the extent permitted by law, neither the Benefits nor payments under
this Plan will be subject to the claim of creditors or to any legal process.
PHYSICAL EXAMINATIONS
We may have a Doctor of Our choice examine You, at Our expense, as often
as is reasonably necessary while Your claim is pending. We may also have an
autopsy performed, at Our expense, except if prohibited by law.
INCONTESTABILITY AND MISSTATEMENT
We cannot contest the Group Policy after it has been in force for two
years unless premiums are not paid. We cannot contest Your or Your dependent's
insurability after the Policy has been in force for two years during Your or
Your dependent's lifetime unless required Contributions are not paid. However,
no provision of this Policy shall make the coverage of an ineligible person
valid.
Any statement about Your health or age made in writing and signed by You
may be used to contest Your coverage.
If You misstate Your age, The Plan Will only Pay Benefits based on Your
correct age. The Plan will a) adjust premium, b) validate, or c) void coverage
as necessary.
REFUND TO US FOR OVERPAYMENT OF BENEFITS
If You or Your dependent recovers money for medical, Hospital, dental,
prescription drug or vision Expenses Incurred due to an Illness or Injury for
which a Benefit has been paid under the Plan, We will have the right to a refund
from You or Your dependent. The amount refunded to Us will be the lesser of:
1. the amount You or Your dependent recovers;
2. the amount of Benefits We have paid.
You or Your dependent (or a parent or legal guardian, if required) will
help Us do whatever else may be reasonably needed to obtain this refund.
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24
GENERAL DEFINITIONS
When these terms are used in the Plan, they will have the following
meanings unless otherwise noted:
1. ACTIVE WORK / ACTIVELY AT WORK: means You work for Your Employer at
his/her place of business (or such other places as required by Your
Employer) in accordance with his/her established employment practices.
2. ASSOCIATED COMPANY: means those under common control through stock
ownership, contract or otherwise with Your Employer as named in this
Plan.
3. AVERAGE SEMIPRIVATE ROOM CHARGE: means a) the standard charge by the
Hospital for semiprivate room and board accommodations, or the average
of such charges where the Hospital has more than one level of such
charges, or b) 80% of the Hospital's lowest charge for single bed room
and board accommodations when the Hospital does not provide any
semiprivate accommodations.
4. BENEFIT(s): means the amount The Plan Will Pay for Covered Expenses
after You or Your covered dependents have met the Deductible, if any.
5. BIRTHING CENTER: means a licensed place with the primary purpose of
providing a place for live births operating within the scope of its
license.
6. CLOSE RELATIVE: means You, Your spouse, and Your or Your spouse's
brother, sister, parent, or Child.
7. COMMUNITY RESIDENTIAL TREATMENT SERVICES: are community-based mental
health programs designed and staffed to deliver a range of treatment and
rehabilitative services which provide an appropriate and cost-effective
alternative to institutional care. Program elements range from crisis
residential to socialization services and are focused upon helping
clients achieve emotional stability and develop skills necessary to move
toward independent living.
8. COMPLICATIONS OF PREGNANCY: means a disease, disorder or condition which
is diagnosed as distinct from normal pregnancy but adversely affected by
or caused by pregnancy. This includes'.
a. inter-abdominal surgery, including caesarean section;
b. pernicious vomiting (hyperemesis gravidarum);
c. toxemia with convulsions (eclampsia);
d. extra-uterine pregnancy (ectopic);
e. postpartum hemorrhage;
f. rupture or prolapse of the uterus;
g. spontaneous termination of pregnancy during a period of
gestation in which a viable birth is not possible;
h. similar medical and surgical conditions of comparable severity.
Complications of Pregnancy will not include:
a. elective abortion;
b. false labor;
c. occasional spotting;
d. Physician prescribed rest;
e. morning sickness;
f. similar conditions associated with the management of a difficult
pregnancy.
Services and supplies rendered at the termination of pregnancy will not
be considered treatment of Complications of Pregnancy.
20
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GENERAL DEFINITIONS - CONTINUED
9. CONTRIBUTIONS: mean the amount You are required to pay for the coverage
provided under the Plan.
10. COVERED EXPENSE: means a listed Covered Expense under a Benefit
description which will be paid under the Plan if it is:
a. prescribed by a Doctor for the therapeutic treatment of Injury,
Illness or pregnancy;
b. Medically Necessary;
c. not more than what We determine as Reasonable and Customary; and
d. not excluded under any exceptions of the Plan.
If You use a Participating Provider, Covered Expense means the agreed
upon rate set between Us and such provider for services which meet all
of the above standards.
11. COVERED PERSON: means an Enrolled person meeting the eligibility
requirements of the Plan.
12. CREDITABLE COVERAGE: means any of the following coverages a Covered
Person had prior to enrollment under the Plan:
a. a group health plan;
b. health insurance coverage, individual and group, including
coverage through a Health Maintenance Organization (HIVIO);
c. Medicare;
d. Medicaid; or any other publicly sponsored program, provided in
California or elsewhere, of medical care;
e. military health care;
f. a medical care program of the Indian Health Service or of a
tribal organization;
g. a state health risk pool;
h. a health plan offered under the Federal Employee Health Benefits
Program;
i. a public health plan established or maintained by a political
subdivision of a state to provide insurance coverage;
j. a health benefit plan established by the Peace Corps Act.
The term includes continuation and conversion coverage, but does not
include:
a. coverages designated to supplement other private or governmental
plans such as supplements to Medicare or liability insurance;
b. accident only plans;
c. credit plans;
d. coverage for onsite medical clinics;
e. disability income plans;
f. long term care insurance;
g. dental plans;
h. vision plans;
i. insurance arising out of a workers' compensation or similar law;
j. automobile medical payment insurance; or
k. no fault insurance.
21
26
GENERAL DEFINITIONS - CONTINUED
13. CUSTODIAL CARE: means services, provided by a licensed, skilled nurse or
a non-skilled person, for:
a. a person with a chronic medical condition; or
b. a convalescent person.
This care basically provides assistance to a person in daily living; it
does not require technical skills or qualifications. This care is not
reasonably expected to improve the underlying medical condition of a
person even though it may relieve symptoms or pain.
Custodial Care includes, but is not limited to:
a. help in grooming, bathing, dressing, walking;
b. help in getting in and out of bed;
c. help in housekeeping, preparing meals, and eating;
d. giving or helping to use or apply medications, creams and
ointments;
e. administering medical gasses after a therapy program has been
set up;
f. changing dressings, diapers and protective sheets;
g. periodic turning and positioning in bed;
h. routine care of casts, braces and other like devices;
i. routine care of colostomy and ileostomy bags;
j. routine tracheostomy care;
k. routine care of catheters and other like equipment; and
l. supervising exercise programs that do not need the skills of a
therapist.
Care that does require the technical skills of a licensed medical
professional, who is acting within the scope of his/her license, is not
considered to be Custodial Care.
14. DISABLED: means that due to Illness or Injury You cannot perform work
for pay or profit or Your covered dependent cannot perform normal
activities of a person of the same sex and age who is in good health;
except as provided elsewhere in the Plan.
15. DOCTOR: means a medical practitioner licensed to perform surgery and
administer drugs acting in the scope of that license. It will also
include any other licensed practitioner of the healing arts required to
be recognized by law, when that person is acting within the scope of
his/her license and is performing a service for which Benefits are
provided under the Plan.
16. EMERGENCY CARE: means covered services rendered after the sudden onset
of a medical condition manifested by acute symptoms of sufficient
severity, including severe pain, such that the absence of immediate
medical attention could reasonably be expected to result in:
a. placing the patient's health in serious jeopardy;
b. serious impairment of bodily functions; or
c. serious dysfunction of any bodily organ or part.
17. EMPLOYER: means the entity to which the Plan is issued and includes any
affiliated entities or subsidiaries or Associated Companies shown in the
Eligible Class or Classes section of the Group Policy.
22
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GENERAL DEFINITIONS - CONTINUED
18. ENROLL: means completion of all forms required for coverage under the
Plan and agreement to make any required Contribution.
19. ENROLLMENT DATE: means the first day of coverage or, if there is a
Waiting Period, the first day of the Waiting Period.
20. EXPENSE INCURRED: means each expense is considered to be incurred on the
date the care, service or supply is received.
21. EXPERIMENTAL, INVESTIGATIONAL OR UNPROVEN: means care and treatment for
which We determine that one or more of the following is true:
a. The service or supply is under study or in a clinical trial to
evaluate its toxicity, safety or efficacy for a particular
diagnosis or set of indicators. Clinical trials include but are
not limited to phase 1, 11 and III clinical trials.
b. The prevailing opinion within the appropriate specialty of the
United States medical profession is that the service or supply
needs further evaluation for the particular diagnosis or set of
indications before it is used outside clinical trials or other
research settings. We determine if this item b. is true based
on:
i. published reports in authoritative medical literature;
and
ii. regulations, reports, publications and evaluations
issued by government agencies such as the Agency for
Health Care Policy and Research, the National Institutes
of Health, the federal Food and Drug Administration
(FDA), the Health Care Financing Administration (HCFA),
or any other appropriate technological assessment body.
C. In the case of a drug, a device or other supply that is subject
to FDA approval:
i. it does not have FDA approval; or
ii. it has FDA approval only under its Treatment
Investigational New Drug regulation or a similar
regulation; or
iii. it has FDA approval, but it is being used for an
indication or at a dosage that is not an Accepted Off-
Label Use. An "Accepted Off-Label Use" is a use that is:
a) included and favorably recognized for treatment
of the indication in one or more of the
following medical compendia: The American
Medical Association Drug Evaluations, the
American Hospital Formulary Service Drug
Information, and The United States Pharmacopoeia
Information; or
b) established based on supportive clinical
evidence in peer-reviewed medical publications.
d. The providers institutional review board acknowledges that the
use of the service or supply is Experimental, Investigational,
or Unproven and subject to that board's approval.
e. Research protocols indicate that the service or supply is
Experimental, Investigational, or Unproven. This item e. applies
for protocols used by the Covered Person's provider as well as
for protocols used by other providers studying substantially the
same service or supply.]
22. FAMILY UNIT: means You and all of Your dependents who are covered under
the Plan.
23. FOSTER CHILD: means a Child for whom You have assumed a legal obligation
when all the following are met:
a. You are raising the Child as Your own and have assumed full
parental responsibility for the Child;
b. the Child lives in Your home and depends on You for primary
support;
C. You may legally claim the Child as a federal income tax
deduction.
23
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GENERAL DEFINITIONS - CONTINUED
A Foster Child is not a Child:
a. temporarily living in Your home;
b. placed with You in Your home by a social service agency which
retains control of the Child; or
c. whose natural parent may exercise or share parental
responsibility and control.
24. GROUP POLICY: means the Policy contract as shown and numbered on the
cover Page of this Certificate.
25. HEALTH BENEFIT PLAN: means any group or individual policy or contract
that provides medical, Hospital and surgical Benefits. It does not mean
coverage under the following types of insurance:
a. accident only;
b. credit;
c. disability income;
d. Medicare services pursuant to contracts with the U.S.
government;
e. Medicare supplement;
f. long-term care;
g. dental;
h. vision;
i. supplemental liability;
j. Workers' Compensation or similar law;
k. automobile medical payment, or;
l. no-fault liability or equivalent self-insurance.
26. HIRED: means the first day You are scheduled to work for Your Employer.
27. HOSPICE: means an agency that provides counseling and incidental medical
services and may provide room and board to a terminally ill person and
meets all of the following tests:
a. it has obtained any required governmental Certificate of Need
approval;
b. it provides service for a period of 24 hours per day on every
day of the week;
c. it is operated under the direct supervision of a duly qualified
Doctor;
d. it has a nurse coordinator who is a registered graduate nurse
with four years of full-time clinical experience, at least two
of which involved caring for terminally ill patients;
e. it has a social service coordinator who is licensed in the
jurisdiction in which it is located;
f. it is an agency that has as its primary purpose the provision of
Hospice services;
g. it has a full-time administrator;
h. it maintains written records of services provided;
i. its employees are bonded, and it provides malpractice and
malplacement insurance;
j. it is established and operated in accordance with the applicable
laws in the jurisdiction in which it is located and, where
licensing is required, has been licensed and approved by the
regulatory authority having responsibility for licensing under
the law.
28. HOSPITAL: means a place which meets all of the standards below:
a. has permanent and full-time care for bed patients;
b. has a Doctor in regular attendance;
c. has an R.N. on duty or call 24 hours a day;
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29
GENERAL DEFINITIONS - CONTINUED
d. is mainly engaged in giving medical care and services for
Injuries or Illness but not including:
i. rest homes;
ii. nursing homes;
iii. convalescent homes;
iv. homes for the aged;
e. has surgical facilities except that this standard does not apply
to such place operated mainly for treatment of the chronically
ill;
f. is operated lawfully in its area.
"Hospital" also means such place which is mainly engaged in treating
alcoholism, drug addiction or abuse if it meets the standards below:
a. has permanent and full-time care for at least 15 bed patients;
b. has a Doctor in regular attendance;
c. provides 24 hour per day care by R.N.s;
d. has a full-time psychiatrist or psychologist on the staff.
Hospital also means and will include an "Ambulatory Surgical Center"
which meets all of the standards below:
a. is a licensed public or private place;
b. has an organized medical staff of Doctors;
c. has permanent facilities that are equipped and operated mainly
for doing surgery and giving skilled nursing care;
d. has R.N. services when a patient is in the facility; and
e. does not provide services or beds for patients to stay
overnight.
A "Psychiatric Health Facility" is an acute 24-hour, nonhospital
facility which serves as an alternative to acute Hospital psychiatric
services. As such, it provides short term psychiatric, psychological and
nursing services to patients with major acute mental illness.
29. ILLNESS: means sickness, a covered bodily or mental infirmity or
pregnancy.
30. INJURY: means a covered accidental bodily Injury.
31. INPATIENT HOSPITAL CONFINEMENT: means a confinement in a Hospital as a
bedpatient for which room and board charges are made by the Hospital to
the Covered Person.
32. LATE ENROLLEE: means an Eligible Employee or Dependent who requests
Enrollment in the Employer's Health Benefit Plan other than during the
initial enrollment period, during an open enrollment period or during
the Special Enrollment Periods provided under the terms of the Plan,
unless any of the following apply:
a. The person is employed by an Employer who offers multiple Health
Benefit Plans and the person elects a different Health Benefit
Plan during an open enrollment period.
b. A court has ordered coverage to be provided for a spouse or
minor Child and a request for enrollment is made within 31 days
after issuance of the court order.
33. L.P.N.: means a licensed practical nurse acting in the scope of his/her
license.
34. L.V.N.: means a licensed vocational nurse acting in the scope of his/her
license.
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GENERAL DEFINITIONS - CONTINUED
35. MANAGED CARE: means the determination of availability of coverage
through the use of clinical standards to determine the Medical Necessity
of an admission or treatment, and the level and type of treatment, and
Appropriate setting for treatment, with required authorization on a
prospective, concurrent or retrospective basis, sometimes involving case
management.
36. MEDICALLY NECESSARY: means that We determine that the care and treatment
given meets all of the following conditions:
a. it is Appropriate care and consistent with the diagnosis and
symptoms. "Appropriate" means the type, level and length of
service and setting are needed to provide safe and adequate care
and treatment and are provided by the Appropriate provider
acting within the scope of his/her license;
b. it is generally accepted medical practice and meets
professionally recognized standards;
c. it is not deemed to be Experimental, Investigational or Unproven
as defined herein;
d. it is not furnished in connection with medical or other
research;
e. it is specifically allowed by the licensing statutes which apply
to the provider who renders the service; and
f. it is at least as medically effective as any standard care and
treatment.
We will use Our programs, or one established by Our authorized
representative to determine whether care is needed and Appropriate. The
program may include but is not limited to:
a. Pre-Admission Review;
b. Concurrent Review; Continued stay review;
c. Retrospective review; and
d. Pre-Surgery Review and Second Surgical Opinion review.
37. Medicare: means the plan of benefits provided by Title XVIII of the U.S.
Social Security Act of 1965 as amended from time to time.
38. PARTICIPATING PROVIDER: means a Doctor or a Hospital that agrees with Us
to provide Medically Necessary care and treatment at set rates.
39. PHYSICIAN: means a person licensed to practice medicine.
40. PLACED FOR ADOPTION: means the assumption and retention of a legal
obligation for the total or partial support of a child in anticipation
of the adoption of such child. The child's placement with You is
considered terminated upon the termination of such legal obligation.
41. Plan: means the Benefits described in this Certificate as provided by
the Group Policy including all endorsements and amendments.
42. QUALIFIED LEAVE OF ABSENCE: means leave of absence period approved by
the Employer pursuant to the Family and Medical Leave Act of 1993 or
other applicable state's leave law that applies to the Employer. With
Our prior approval, the term also includes the Employer's approved leave
of absence period taken to substantially perform political, public or
civic functions.
43. R.N.: means a licensed registered nurse acting in the scope of his/her
license.
26
31
GENERAL DEFINITIONS - CONTINUED
44. REGULAR EMPLOYEE: means You work Your full number of hours for Your full
rate of pay as required by Your Employer. The amount of required work
time per week may never be less than 20 hours.
45. SKILLED NURSING FACILITY: means a place other than a Hospital that:
a. can provide permanent full-time care for 10 or more resident
patients;
b. has a Doctor available at all times;
c. has an R.N. or Doctor on full-time duty in charge of patient
care;
d. has one or more R.N.s, L.P.N.s or L.V.N.s on duty at all times;
e. keeps a daily medical record for each patient;
f. is not mainly a rest home or a home for Custodial Care of the
aged;
g. is not mainly engaged in treatment of drug addicts or
alcoholics;
h. is operating lawfully as a nursing home.
46. THE PLAN WILL PAY: means that when You send Us proof of claim, We will
determine the Benefits payable and make payment, if any, according to
the Payment of Claims provision.
47. WE, US AND OUR: means General American Life Insurance Company.
48. YOU AND YOUR: means an employee covered under the Plan.
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YOUR RIGHTS UNDER ERISA
As a participant in the Plan, You are entitled to certain rights and
protections under the Employee Retirement Income Security Act of 1974 (ERISA).
ERISA provides that all plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and upon
written request at other specified locations, such as work establishments, all
plan documents, including insurance contracts and copies of all documents filed
by the plan with the U.S. Department of Labor, such as detailed annual reports
and plan descriptions.
Obtain copies of all plan documents and other Plan information upon
written request to the Plan Administrator. The administrator may make a
reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan
Administrator is required by law to furnish each participant with a copy of this
summary annual report.
In addition to creating rights for plan participants, ERISA imposes
duties upon the people who are responsible for the operation of the employee
benefit plan. The people who operate Your Plan, called "Fiduciaries" of the
plan, have a duty to do so prudently and in the interest of You and other plan
participants and beneficiaries. No one, including Your Employer, or any other
person, may fire You or otherwise discriminate against You in any way to prevent
You from obtaining a welfare benefit or exercising Your rights under ERISA.
If Your claim is denied in whole or in part, You must receive a written
explanation of the reason for the denial. You have the right to have the Plan
review and reconsider Your claim. Under ERISA, there are steps You can take to
enforce the above rights. For instance, if You request materials from the Plan
and do not receive them within 30 days, You may file suit in a federal court. In
such a case, the court may require the Plan Administrator to provide the
materials and pay You up to $110 a day until You receive the materials, unless
the materials were not sent because of reasons beyond the control of the Plan
Administrator. If You have a claim for Benefits which is denied or ignored, in
whole or in part, You may file suit in a state or federal court. If it should
happen that plan Fiduciaries misuse the Plan's money, or if You are
discriminated against for asserting Your rights, You may seek assistance from
the U.S. Department of Labor, or You may file suit in a federal court. The court
will decide who should pay court costs and legal fees. If You are successful,
the court may order the person You have sued to pay these costs and fees. If You
lose, the court may order You to pay these costs and fees for example, if it
finds Your claim is frivolous.
If You have any questions about Your Plan, You should contact the Plan
Administrator. If You have any questions about this statement or about Your
rights under ERISA, You should contact the nearest office of the Pension and
Welfare Benefits Administration, U. S. Department of Labor, listed in Your
telephone directory or the Division of Technical Assistance and Inquiries,
Pension and Welfare Benefits Administration, U. S. Department of Labor, 200
Constitution Avenue N. W., Washington, D. C. 20210.
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YOUR RIGHTS UNDER ERISA - CONTINUED
SUPPLEMENTAL ERISA INFORMATION
PLAN NAME:
UNOVA, Inc. Employees' Welfare Benefits Plan
PLAN SPONSOR:
UNOVA, Inc. Employees' Welfare Benefits Plan
21900 Burbank Blvd.
Woodland Hills, CA 91367-7418
EMPLOYER IDENTIFICATION: 95-4647021
PN: 506
TYPE OF PLAN:
Welfare Benefit Plan providing Health Care Benefits for employees and
dependents.
TYPE OF ADMINISTRATION:
The Benefits for Health Care coverage for employees and dependents are
guaranteed under a group insurance policy issued by General American Life
Insurance Company, 13045 Tesson Ferry Road, St. Louis, MO 63128.
PLAN ADMINISTRATOR:
Director of Benefits and Risk Management
LINOVA, Inc.
21900 Burbank Blvd.
Woodland Hills, CA 91367-7418
AGENT FOR LEGAL SERVICES:
UNOVA, Inc.
21900 Burbank Blvd.
Woodland Hills, CA 91367-7418
Service of legal process may also be made on the Trustee.
PLAN YEAR ENDS: December 31
CONTRIBUTIONS: Your Employer pays all costs of the Plan.
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YOUR RIGHTS UNDER ERISA - CONTINUED
TERMINATION OR AMENDMENT OF PLAN
The Plan Sponsor intends that this Plan will continue indefinitely, but
reserves the right to amend, modify, revoke or terminate the Plan, in whole or
in part, at any time.
CLAIM DENIAL
In the event a claim is denied You will be notified in writing within 90
days after We receive the claim (unless special circumstances require a longer
time). You will be advised of the following:
1. the reason for denial;
2. specific reference to the Plan provisions on which the denial was based;
3. any additional material or information needed for further review of the
claim;
4. an explanation of the Plan's review procedure.
If Your claim is denied, You may appeal the denial by making a written
request for review to Us within 60 days of the time You received the notice of
denial. In connection with review, You have the right to 1) see the Plan and
other papers affecting the claim, 2) argue against the denial in writing, 3)
have a representative act on Your behalf in the appeal.
The decision on the review shall be in writing, and shall be made within
60 days of the day We receive the request for review. It shall include specific
reasons for the denial, written in a manner understandable to You and contain
specific reference to the pertinent Plan provisions on which the decision was
based.
INSURER'S DISCRETIONARY AUTHORITY
General American Life Insurance Company, being the claims administrator
for the Health Care Benefits shall have the discretionary authority to determine
eligibility for insurance Benefits, construe the terms of the insurance plan and
resolve any disputes which may arise with regard to the rights of any persons
under the terms of the insurance plan, including, but not limited to,
eligibility for participation and claims for Benefits.
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YOUR RIGHTS UNDER ERISA - CONTINUED
FEDERAL CONTINUATION COVERAGE
(also known as COBRA)
In some circumstances, federal law requires that persons who lose group
health plan coverage be given the chance to continue that coverage for a period
of time.
RIGHT TO COBRA CONTINUATION COVERAGE
1. You have a right to choose COBRA continuation coverage if You lose group
health plan coverage because of:
a. a reduction in Your hours of employment; or
b. the voluntary or involuntary termination of Your employment (for
any reason except Your gross misconduct).
2. Your spouse has the right to choose COBRA continuation coverage if
he/she loses group health plan coverage for any of the following
reasons:
a. Your death;
b. the termination of Your employment (except as a result of Your
gross misconduct) or Your reduction in hours;
c. Your divorce or legal separation;
d. Your becoming entitled to Medicare.
3. Your dependent Child has the right to continuation coverage if he/she
loses his/her group health plan coverage due to one of the four reasons
described in 2. above or if he/she ceases to be an Eligible Dependent
under the terms of the Plan's Health Care coverage.
A dependent child born to or placed for adoption with You during Your
COBRA continuation coverage period has the right to COBRA continuation
coverage if You notify the plan administrator of the child's birth or
placement for adoption within the time frame as prescribed by law.
LENGTH OF COBRA CONTINUATION COVERAGE
1. Generally
a. If, as a result of termination of Your employment or reduction
in Your hours, You, Your spouse and/or Your dependents lose the
Plan's Health Care coverage, those who do lose coverage may
elect continuation coverage for up TO 18 MONTHS after the date
Your employment terminates or hours reduce.
b. If Your spouse or dependents lose the Plan's Health Care
coverage due to any of the other events described in 2. or 3.
above (other than Your employment termination or hours
reduction), they may elect continuation coverage for up to 36
MONTHS from the date they experience such event.
c. If Your spouse or dependents become entitled to continuation
coverage because of termination of Your employment or reduction
in Your hours and Your spouse or dependent then experiences
another of the events which would entitle such person to
continued coverage, he/she may extend the 18 month continuation
period to 36 MONTHS from the date of the event that first made
him/her eligible for continuation coverage.
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YOUR RIGHTS UNDER ERISA - CONTINUED
2. Extensions of COBRA Continuation Coverage
a. Disability Extension
If You, Your spouse or Your dependents lose coverage because of
termination of Your employment or reduction of hours and any of
You are determined under Title 11 or XVI of the Social Security
Act to have been Disabled at any time during the first 60 days
of COBRA continuation coverage, then the Disabled person and
such person's family members who are entitled to COBRA
continuation coverage may extend the continuation coverage
period for 11 ADDITIONAL MONTHS, provided:
A notice of a Social Security determination is given to the plan
administrator before the end of the initial 18month period and
within 60 days after the date of such determination.
An Employer may require payments of up to 150 percent of the
applicable group rate for the cost of coverage for these 11
additional months.
b. Employee's Medicare Entitlement Prior to COBRA Event
If You become entitled to Medicare within 18 months prior to
Your employment termination (or work hours reduction), Your
spouse and dependents who are entitled to COBRA continuation
coverage will become eligible for a continuation period of not
shorter than 36 months from the date You become entitled to
Medicare. This continuation period is measured from the time You
are entitled to Medicare. The maximum continuation period for
Your spouse or dependents will not exceed 36 months.
However, unless You are entitled to an extended continuation
period as described in 2.a. above, You yourself will only be
eligible for a continuation period of up to 18 months from the
date of Your employment termination (or work hours reduction).
3. If, after the occurrence of any event described in Right to COBRA
Continuation Coverage above, You, Your spouse and/or Your dependents are
allowed to continue Health Care coverage under the Plan (whether or not
premium payment(s) are required) beyond the Plan's Termination of
Coverage provision for any reason other than to comply with the federal
law (i.e., state laws mandating continuation coverage, or the Plan's
special provisions), such continuation period(s) will be used to reduce
the maximum length of COBRA continuation coverage period otherwise
available to such person under this section.
NOTIFICATION REQUIREMENTS
1. If Your spouse or dependent becomes eligible for continuation coverage
due to divorce, legal separation or the end of dependency status, the
Plan Administrator must be notified within 60 days after Your spouse or
dependent becomes eligible. That person will distribute necessary forms
and explain this continuation in more detail.
If the Plan Administrator is not notified within 60 days of the event
that makes Your spouse or dependent eligible for continuation coverage,
Your spouse or dependent will lose the right to such coverage.
In order for a child born to or placed for adoption with You during Your
COBRA continuation coverage to have the right to COBRA continuation
coverage, You must notify the plan administrator of the child's birth or
placement for adoption within the time frame as prescribed by law.
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YOUR RIGHTS UNDER ERISA - CONTINUED
2. In order for a Disabled person and such person's family members
continuing under the 18-month continuation coverage to be entitled to an
extended continuation period of 11 additional months, such person must
meet the notice requirements and all other conditions described under
Extensions of Continuation Coverage in 2.a. above.
A person continuing under the 11 -month extended continuation coverage
must notify the Plan Administrator within 30 days if the Social Security
Administration determines that the disability ceases to exist.
TERMINATION OF COBRA CONTINUATION COVERAGE
Your Employer may require You, Your spouse and Your dependents to pay
for the cost of the continuation coverage. If these amounts are not paid
within the time allowed, the continuation coverage will end.
Four other reasons that this continuation coverage may terminate before
the full maximum continuation period runs out are:
1. the continued person first becomes, after the date of COBRA continuation
coverage election, entitled to Medicare benefits;
2. the Employer stops providing any group health plan benefits program for
employees;
3. the continued person first becomes, after the date of COBRA continuation
coverage election, covered under another group health plan, and any
preexisting conditions exclusions or limitations of that plan do not
apply to or are satisfied by such person;
4. with respect to any person continuing under the 11-month extended
continuation coverage (as described under Extensions of Continuation
Coverage in 2.a. above), when the Social Security Administration
determines that the disability ceases to exist (the termination becomes
effective as of the first day of the month which is at least 31 days
after the Social Security determination).
CONVERSION PRIVILEGE
Persons who have exhausted their maximum continuation coverage period
will be eligible for the Conversion Privilege described in the group health
plan.
GENERAL INFORMATION
This Federal Continuation Coverage section does not amend or change the
Plan's Termination of Coverage provision. It simply provides a continuation of
coverage right Your Employer is required to offer by law. If We, the
Policyholder or Your Employer terminates this Plan before or during a
continuation period, continuation coverage, if any, will not be under this Plan
and may not be through Us.
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