SECTION TWELVE: Important Information About Your Plan
The Plan is administered by a joint Board of Trustees, consisting
of four (4) Union representatives and four (4) Employer representatives
who serve without pay. Together they manage the overall direction of
the Fund. At their sole discretion, they decide whether to change,
add or delete benefits.
The Fund Office staff carries out the day-to-day operations of the Plan. These
benefit professionals make sure all eligible members are enrolled, monitor Employer
contributions, answer questions about Plan benefits, and refer benefit-related
issues to the Trustees to be resolved.
| Name of Plan | Teamsters Local 251 Health Services and Insurance Plan |
Type of Plan |
Health and Welfare Plan |
Name of Plan Sponsor |
Board of Trustees of the Teamsters Local 251 Health Services and Insurance Plan |
Agent for Legal Process |
The Board of Trustees |
Type of Administration |
Collectively Bargained, jointly Trusteed Labor Management Trust |
Plan Number |
501 |
IRS Employer Identification Number |
05-0367950 |
Plan Year |
July 1 to June 30 |
Sources of Plan Financing |
All contributions to the Plan are made by employers
in accordance with the Collective Bargaining Agreements with
Local Union 251 of the International Brotherhood of Teamsters.
Participants may make contributions as provided by COBRA, the
federal law, for a limited period of time. |
Right to Amend or Terminate the Plan
Nothing in this Summary Plan Description is meant to interpret or extend
or change in any way the provisions expressed in the Plan. The Trustees
reserve the right to amend, modify or discontinue all or part of
this Plan whenever, in their judgment, conditions warrant.
No Local Union Officer, Business Agent, Local Union Employee, Employer
Representative, or Fund Office personnel, consultant or attorney is
authorized to speak for or on behalf of, or to commit the Trustees
of this Plan on any matter relating to that Plan without the express
authority of the Trustees.
Only the Trustees of the Plan have the authority to determine eligibility
for benefits and the right to participate in the Plan. This includes:
- the manner in which hours are credited,
- eligibility for any benefits,
- discontinuance of benefits,
- status as covered or non covered employee, the level of benefits, and
- interpretation and application of rules and regulations to a particular claim or application.
These determinations are final and binding.
Your ERISA Rights
As a participant in the Teamsters Local 251 Health Services
and Insurance 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:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at
other specified locations, such as worksites and union halls, all documents
governing the Plan, including insurance contracts and collective bargaining
agreements, and a copy of the latest annual report (Form 5500 Series)
filed by the Plan with the U.S. Department of Labor and available at
the Public Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the Plan Administrator, copies of documents
governing the operation of the Plan, including insurance contracts
and collective bargaining agreements, and copies of the latest annual
report (Form 5500 Series) and updated summary plan description. 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.
Prudent Actions By Plan Fiduciaries
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, your union, 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.
Continue Group Health Plan Coverage
Continue health care coverage for yourself, spouse or dependents if
there is a loss of coverage under the plan as a result of a qualifying
event. You or your dependents may have to pay for such coverage.
Review this summary plan description and the documents governing the
plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan, if you have creditable coverage
from another plan. You should be provided a certificate of creditable
coverage, free of charge, from your group health plan or health insurance
issuer when you lose coverage under the plan, when you become entitled
to elect COBRA continuation coverage, when your COBRA continuation
coverage ceases, if you request it before losing coverage, or if you
request it up to 24 months after losing coverage. Without evidence
of creditable coverage, you may be subject to a preexisting condition
exclusion for 12 months (18 months for late enrollees) after your enrollment
date in your coverage.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole
or in part, you have a right to know why this was done, to obtain copies
of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights.
For instance, if you request a copy of the Plan documents or the latest
annual report 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 Administrator.
If you have a claim for benefits that is denied or ignored, in whole
or in part, you may file suit in a state or Federal court. In addition,
if you disagree with the Plan's decision or lack thereof concerning
the qualified status of a domestic relations order or a medical child
support order, you may file suit in 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.
Assistance with Your Questions
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, or if you need assistance in obtaining documents
from the Plan Administrator, 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. You may also obtain certain publications about your rights
and responsibilities under ERISA by calling the publications hotline
of the Pension and Welfare Benefits Administration.
The Affordable Care Act
This group health plan believes it is a “grandfathered health
plan” under the Patient Protection and Affordable Care Act (the
Affordable Care Act). As permitted by the Affordable Care Act,
a grandfathered health plan can preserve certain basic health coverage
that was already in effect when that law was enacted. Being a
grandfathered health plan means that your Plan may not include certain
consumer protections of the Affordable Care Act that apply to other
plans, for example, the requirement for the provision of preventive
health services without any cost sharing. However, grandfathered
health plans must comply with certain other consumer protections in
the Affordable Care Act, for example, the elimination of lifetime limits
on benefits.
Questions regarding which protections apply and which protections do
not apply to a grandfathered health plan and what might cause a plan
to change from grandfathered health plan status can be directed to
the plan administrator at [insert contact information]. You may
also contact the Employee Benefits Security Administration, U.S. Department
of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply
to grandfathered health plans.
Rights of Appeal
You possess the right to appeal to the Board of Trustees the loss of
your eligibility status under the Plan. In addition, if you file
a claim for weekly accident and sickness benefits, and then receive
a decision with which you disagree, you possess the right to appeal
the denial of your claim by contacting the Board of Trustees.
The claims filing and appeals procedures described below will apply
to claims and appeals over which the Board of Trustees has discretion. Generally,
except for questions of eligibility to participate in the Plan and
the determination of eligibility for Weekly Accident and Sickness Benefits,
the Board of Trustees does not have any say over benefit determinations
made by another provider or insurance carrier. Claims for benefits
under such arrangements must be pursued using the claims and appeals
procedures provided by such provider or insurance carrier. See Section
Eleven for additional information regarding claims and appeal procedures.
The Board of Trustees has full and absolute discretion, authority and
power to interpret the terms of the SPD, determine all questions of
eligibility and adjudicate weekly accident and sickness benefit claims.
IMPORTANT NOTE: In all cases, provisions under the various
claims procedures require that claims for benefits or reimbursement for medical
services and appeals from the denial of claims must be submitted within a specific
period of time. A failure to meet these time limits may bar the claim or appeal.
Appeal Procedures
If your weekly accident and sickness benefit claim is denied in whole
or in part, or you are informed that you are no longer eligible to
participate in the Plan, you have the right to appeal. If you wish
to appeal a benefit denial or eligibility determination, you must submit
the appeal in writing within 180 days after you receive the denial
of benefits or eligibility determination. Appeals should be sent to
the Board of Trustees at the address below.
Teamsters Local 251 Health Services and Insurance Plan
1201 Elmwood Avenue
Providence, RI 02907
You may submit with your appeal written comments, documents, or other
information in support of your appeal. Inasmuch as the appeal will
be decided by the Trustees, the appeal therefore will be decided by
a person different from the person who made the initial claim decision
and who is not a subordinate of the person who made the initial claim
decision. No deference will be accorded to the initial benefit decision.
If a health care professional is consulted in connection with your
appeal, the Board of Trustees will consult with a health care professional
different from the person who was consulted in the initial claim decision
and who is not a subordinate of the person who was consulted in the
initial claim decision. Upon request, your Fund Administrator will
identify any medical expert whose advice was obtained on behalf of
Trustees in connection with your appeal.
You will be notified of the decision on appeal within a reasonable
period of time, but no later than five days after the monthly Trustee
meeting at which your appeal is decided. If the Trustees receive your
appeal less than 30 days before the next Trustee meeting, your appeal
will be decided at the second Trustee meeting following the date the
Trustees receive your appeal. If the Trustees receive your appeal 30
or more days before the next Trustee meeting, your appeal will be decided
at the next Trustee meeting.
If special circumstances require additional time to process your appeal,
you will be notified in writing of the reason for the extension and
the date the claim will be decided, which will be no later than the
third Trustee meeting following the date the Trustees receives your
appeal.
If your appeal is denied, the notice of adverse benefit decision will-
- state specific reason(s) for the adverse determination;
- refer to specific Plan provision(s) on which the benefit determination is based;
- state that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to your claim for benefits;
- disclose any internal rule, guidelines, or protocol relied on in making the adverse determination (or state that such information will be provided free of charge upon request);
- explain the scientific or clinical judgment for the determination (or state that such information will be provided free of charge upon request), if the denial is based on a Medical Necessity or Experimental treatment or similar limit; and
- include a statement regarding your right to commence a legal action under section 502(a) of ERISA.
You may not bring a lawsuit to recover benefits under the Plan unless you have exhausted your appeal rights under the SPD.
