Teamsters Local 251 Health Services & Insurance Plan

SECTION EIGHT: Life and Dismemberment Insurance and WA&S (Level 1)

Life Insurance

If you die while you're covered under this Plan, your beneficiary is eligible for a benefit of $50,000.

Your eligible dependents are covered for a $20,000 Life Insurance benefit, payable to you, as the member.
When you're no longer eligible for Life Insurance coverage through this Plan, you may convert your insurance to an individual contract by submitting a written application within 31 days of your termination.
If you have a terminal illness, you may be eligible to receive up to 75% of your life insurance benefit prior to your death.
If you become disabled, you will not forfeit your Life Insurance benefit. Your benefit can be extended during your disability.

Accelerated Payment of Life Insurance Benefit

If while covered under this Plan for Life Insurance you become terminally ill; or your spouse becomes terminally ill; you may request that Aetna pay an Accelerated Death Benefit.

“A terminal illness as defined by Aetna means: suffers from an incurable, progressive, and medically recognized disease or condition; and to a reasonable medical probability and based on a generally accepted prognostic protocol, will not survive more than the 24 months.”

You may elect to have up to 75% of your benefit payable to you under the Accelerated Payment Option. The total amount of your Life Insurance benefit that would have been payable upon your death will be reduced. For more information, contact the Fund Office at (401) 467-3323.

What is Totally Disabled?

You are "totally disabled" when you are not working at any job for wage or profit, and you are unable to work in any job that is reasonably suited to you by your education, training or experience.

Extended Life Insurance Benefits During Total Disability

If you become totally disabled while you are covered by this Plan, and you are less than age 60 when your disability starts, and you have been Totally Disabled for at least nine months, your Life Insurance benefit may be extended for successive one-year periods.
You are permanently and totally disabled only if a disease or injury stops you from working at:

your own job; or
any other job for pay or profit; and
it must continue to stop you from working at any reasonable job.

You must meet all of the following to be eligible:

Your Life Insurance must be be in force when you become permanent and totally disabled
You must be under age 60 at the time you are first permanently and totally disabled.
Your permanent and total disability must have lasted for at least 9 consecutive months without interruption.

Aetna must receive your written notice of claim for this extension at its Home Office within 15 months from the date you cease active work. If your written notice is not received by Aetna within 15 months, you will not be eligible for this benefit extension.

This extended insurance will be the amount you were insured for on the date your disability began.
This extension period will end on the first to occur of:

Your total disability ends;
You fail to provide the required proof of your total disability to Aetna; and
The date you are well enough to work in any job that is reasonably suited to you by your education, training or experience.
The date you start to work in any job for pay or profit.

After insurance has been extended continuously for 2 years. Aetna will not request an exam or proof more often than once in a 15 month period.

NOTE: If you retire early before age 60 with a disability you can elect to extend your Life Insurance Benefit, OR you can elect $5,000 Retiree Life Insurance if you are eligible. You cannot have both. If you apply for the extended Life Insurance Benefit and you do not get it, you may be able to get Retiree Life Insurance, if you qualify. See Section 10: Retiree Benefits for more information.

Converting Your Life Insurance

You may convert all or part of your insurance to an individual life insurance contract if you are no longer eligible for life insurance under this Plan because:

Your employment ends or you are transferred out of a covered class; or
Because of age or retirement

You must apply for the individual contract and pay the first premium within 31 days after you cease to be insured for the Employee Term Life Insurance.
The individual contract must conform to the following:

The contract amount must not exceed the amount of your Employee Term Life Insurance coverage you had under this Plan when your insurance ends.
Your premium must be based on Aetna's rate as it applies to the form and amount, and to your class of risk and age at the time.
The effective date is the end of the 31-day period during which you may apply for the individual contract.

Life Insurance for Your Dependents

If your eligible dependent dies while covered by this Plan, you (as the member) are eligible to receive a life insurance benefit of $20,000. You will need to submit a certified death certificate to the Fund Office. If your spouse dies, you will also need to submit your marriage certificate.

You may cover your:

Wife or husband; and
Unmarried children who are 14 days or older but under 19 years of age
Any other unmarried child who is under age 25 as long as he or she is a full-time student in a post-secondary educational institution as defined in Section 2 of this Summary Plan Description.
Note: Proof of a student’s full-time enrollment in a post-secondary educational institution is required each year.

Your children include:

Your biological children
Your adopted children
Your stepchildren
Your foster child

The following dependents are not eligible

Those in full-time active military service.
Children less than 14 days of age

Handicapped Dependent Children

Life Insurance and Accidental Death and Personal Loss Coverage for your fully handicapped dependent child may be continued past the maximum age for a dependent child. However, such coverage may not be continued if the child has been issued a personal life conversion policy.

Your child is fully handicapped if:

he or she is not able to earn his or her own living because of a mental retardation or a physical handicap which started prior to the date he or she reaches the maximum age for dependent children; and
he or she depends chiefly on you for support and maintenance

Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date your child reaches the maximum age

Coverage will end on the first to occur of:

Cessation of the handicap
Failure to give proof that the handicap continues
Failure to have any required exam
Termination of Dependent Coverage as to your child for any reason other than reaching the maximum age.

Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to examine your child as often as needed while the handicap continues.

An exam will not be required more often than once a year after 2 years from the date your child reached the maximum age.

Vested Death Benefit

(Frozen as of December 31, 1990)

The Vested Death Benefit is frozen as of December 31, 1990. If you qualified for this benefit as of December 31, 1990, you may be entitled to a benefit of $500 or more to use to pay for eligible medical expenses during retirement.

What You Need To Do:

Contact the Fund Office for a claim form if you have eligible expenses.
Submit your claim and receipts to the Fund Office to use the money in your account to pay for your eligible expenses.
In the event of your death, your beneficiary should notify the Fund Office and provide a certified death certificate to receive the balance remaining in your account.

Your Vested Death Benefit

You are only eligible for the Vested Death Benefit if you met the eligibility requirements before benefits stopped accruing on December 31, 1990. The Vested Death Benefit a sum of money (based on your years of service) that is put into an account for you. You may use this money one month after your benefits terminate to pay for certain eligible medical expenses. The remainder will be paid to your designated beneficiary upon your death.

Eligibility

In order to be eligible for the Vested Death Benefit you must:

Have qualified for this benefit as of December 31, 1990;
No longer be working in Covered Employment;
No longer be eligible for the life insurance benefit provided by the Fund;
Be at least age 55;
Have been eligible for benefits under the Fund for at least five years before December 31, 1990.
Apply for this benefit within one year from the date the group life insurance benefit terminates.

If you meet these requirements, you will be credited with $100 in addition to the $500 minimum for every year over the five years you were eligible for benefits from the Fund, up to a maximum of $1,500. This money is kept in an account for you to use when you retire. You may withdraw up to 100% of the money in your account to pay for hospital, surgical, eye care, medical expenses, dental expenses or premiums that are not paid by Medicare. You do not have to be eligible for Medicare to use this money.

How to Receive Reimbursement

Submit a claim form and evidence of the expenses you incur to the Fund Office. Any amount you withdraw from your account will be deducted from the Vested Death Benefit that will be paid to your beneficiary when you die.

If you leave covered employment and are awarded your Vested Death Benefit, but then return to covered employment, your Vested Death Benefit will be suspended until you retire again.

Accidental Death and Dismemberment Benefits

Your Accidental Death and Dismemberment (AD&D) coverage for Level I benefits only pays benefits for the accidental loss of your life, sight, hand or foot. The injury causing the loss must occur while you are covered under this Plan.

What You Need To Do:

If you suffer a loss, contact the Fund Office for a claim form.
Ask your physician to provide a statement (proof of loss) describing your loss.
Send the physician's statement along with the completed claim form within 365 days after the date of loss to:

Teamsters Local 251
Health Services and Insurance Plan
1201 Elmwood Avenue
Providence, RI 02907-3799

Your AD&D Benefit

You are eligible for AD&D benefits if:

You sustain an accidental bodily injury while you're covered by this Plan;
The loss results directly from that injury and from no other cause; and
You suffer the loss within 365 days after the accident.

The following Accidental Death and Dismemberment Benefits are payable to covered participants under this Plan:

	Member Dependent
Type of Loss		Amount Amount
Life		$50,000 $20,000
Both Hands		$50,000 $20,000
Both Feet		$50,000 $20,000
Sight of Both Eyes		$50,000 $20,000
Third Degree Burns covering 75% or more of the body		$50,000 $20,000
Third Degree Burns covering 50% to 74% or more of the body		$25,000 $10,000
Uniplegia		$12,500 $5,000
One Hand		$25,000 $10,000
One Foot		$25,000 $10,000
Sight of One Eye		$25,000 $10,000
Thumb and Index finger of same hand		$12,500 $5,000
Speech and hearing		$50,000 $20,000
Speech or hearing in both ears		$25,000 $10,000
Quadriplegia		$50,000 $20,000
Paraplegia		$25,000 $10,000
Hemiplegia		$25,000 $10,000

Loss of sight means total and permanent loss of sight. Loss of hand or foot means loss by severance at or above the wrist or ankle. The maximum benefit for all losses you sustain from one accident is $50,000 and $20,000 for your eligible dependents.

Payment of Benefits

The Accidental Death benefit is payable to your beneficiary.
The Accidental Dismemberment benefit is payable to you.

What's Not Covered

A loss is not covered if it is a result of:

A bodily or mental infirmity;
A disease, ptomaine, or bacterial infection;*
Medical or surgical treatment;*
Suicide or attempted suicide (while sane or insane);
An intentionally self-inflicted injury;
A war or any act of war (declared or not declared);
Voluntary inhalation of poisonous gases;
Commission of or attempt to commit a criminal act;
Use of alcohol, intoxicants, or drugs, except as prescribed by a physician. An accident in which the blood alcohol level of the operator of a motor vehicle meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred shall be deemed to be caused by the use of alcohol;
Intended or accidental contact with nuclear or atomic energy by explosion and/or release;
Air or space travel. This does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo);
These do not apply if the loss is caused by:
An infection which results directly from the injury.
Surgery needed because of the injury.

The injury must not be one which is excluded by the terms of this section.

Passenger Restraint and Airbag Benefit
(Level 1)

If a covered loss of life occurs solely and as a direct result of an accident involving a motor vehicle while the person;

is an occupant of the motor vehicle; and
at the time of the accident is properly using a passenger restraint; and
if the driver has, at the time of the accident a valid driver’s license;

Passenger Restraint Benefit Maximum for you and each covered dependent is $10,000.

Airbag Benefit Maximum for you and each covered dependent is $5,000.
No Airbag Benefit will be payable unless a Passenger Restraint Benefit is paid.

Educational Benefit for Dependent Child and Spouse

If you or your covered dependent spouse suffer a loss of life solely and as a direct result of an accident an Education Benefit is payable on behalf of each Dependent Child.

Education Benefit Maximum for each dependent child is 5% of your Principal Sum not to exceed $5,000 per year per child for up to 4 years. Your spouse’s benefit is 5% of your Principal Sum not to exceed $5,000 per year for up to 4 years.

Child Care Benefit

The Child Care Benefit is paid at 3% of the member's or spouses principal to a Maximum of $2,000 per child per year. The benefit is payable for a maximum of 4 years from the date of death.

Repatriations of Remains Benefit

$5,000 is payable if repatriation occurs outside of 200 miles from the principal residence.

Coma Benefit

If, while insured, a person suffers a bodily injury caused by an accident and if, within 30 days after the accident, he or she becomes comatose solely and as a direct result of the accident, Aetna will pay a monthly benefit provided the person is continually comatose for at least 30 consecutive days.

Proof that the person is comatose must be submitted to Aetna no later than 60 days after the date he or she become comatose.

The monthly benefit is the Coma Benefit Percentage less any benefit amount paid or payable under this benefit section for any loss the covered person suffers as a direct result of a bodily injury caused by the same accident. The monthly benefit of 5% of the Principal Sum is payable for 11 months. The full Principal Sum less any benefit amount paid or payable under this benefit section because of the same accident will be payable after the covered person has been continually comatose for 12 months.

No more than the full Principal Sum is payable for all losses resulting from the same accident.

The monthly benefit is payable for as long as the coma continues, until the earliest occur of:

failure to have any required exam;
failure to give proof that the coma continues
the date the full Principal Sum is paid under this benefit section;
the date the covered person is no longer comatose, by death, recovery, or any other change of condition, as certified by a physician; or
termination of the group policy

Aetna will have the right to require proof of the continuation of the coma. Aetna will not request an exam more than twice in a 12 month period.

The information contained in this section is a summary of your life insurance benefits.The Certificate of Coverage issued by Aetna is the governing document that contains a complete description of benefits, exclusions, limitations and conditions of coverage. To request the Certificate of Coverage contact Teamsters Local 251 Health Services and Insurance Plan.

Teamsters Local 251 Health Services and Insurance Plan
1201 Elmwood Avenue
Providence, RI 02907

Weekly Accident and Sickness Benefits

If you become temporarily disabled as a result of a non-work related injury or illness and cannot work, you may be eligible for a Weekly Accident and Sickness Benefit of up to $500 per week and a credit of 25 hours per week towards benefits for up to 26 weeks. A W-2 will be issued for any money received from this benefit. In order to qualify for benefits, you must be an active employee at the time of your injury. For example, if you are out on a worker’s compensation injury at the time of your injury, you are not eligible for weekly accident and sickness benefits.

What You Need To Do

You are eligible for weekly accident and sickness benefits only once every 24 months. This means that you may file only one claim for benefits during a 24 month period. For example, if you file a claim on July 1, 2010, and benefits are awarded for that claim, you may not file another claim for benefits until on or after July 1, 2012. The Trustees may, in their sole discretion, permit you to file another claim within the 24 month period if your injury is severe and requires hospitalization.
If you become disabled, you must call the Fund Office for the proper paperwork which includes:

an Accident and Sickness Claim Form,
an Attending Physician's Report (APR),
the Authorization to Release Information and Reimbursement Agreement,
Form W-4S (tax form),
Authorization for Release of Protected Health information, and
a self-addressed envelope.

Fill out the Accident and Sickness Claim form;
Ask your attending physician(s) to complete a statement of evidence of your disability (APR). A faxed copy will not be acceptable.
Read and complete the Authorization to Release Information form; on the back of the form be sure to choose the box that best describes your situation (you must have this form notarized).
Complete and sign form W-4S:
- If you want Federal and Rhode Island income tax withheld, the minimum Federal amount to be withheld is $20 and all withholding must be in whole dollars, no cents.

If you do not want Federal and Rhode Island income taxes withheld from the benefit payments indicate "NONE" in the amount to be withheld box.

Mail all of the completed information to the Fund Office in the envelope provided.
The Fund Office will mail your employer a "13-Week Form" to determine your gross weekly pay during the 13 weeks immediately before your covered incident. Your benefit will be 75% of the average or $500, whichever is less.
If requested by the Fund, you must undergo a physical examination by the Fund's independent doctor at any time while you are seeking or receiving benefits. Your failure to submit to an examination may affect your continued eligibility for benefits.

Note: All of this information must be completed and returned to the Fund Office no later than 45 days from date of the covered incident. If a completed claim form is not filed within that period, you will have no rights to benefits under this Section. (The Trustees may, in their sole discretion, permit you to file documents after the deadline for good cause shown. Good cause will be determined by the Trustees in their sole discretion.)

Eligibility

To qualify for Weekly Accident and Sickness Benefits, you must:

Be covered for Level I medical benefits;
Work at least one hour of covered employment after the effective date of your Level I coverage;
Be unable to perform work for at least 8 days due to an illness, non-work related injury or accident;
Not be receiving a pension. As of the date of your retirement, you are no longer eligible for this benefit;
Not be collecting unemployment benefits or workers compensation benefits;
At any time you request the WA&S forms, you may be required to see the Fund's doctor;
Submit all of the completed forms to the Fund Office within forty-five days of the date of the covered incident;
Return to work one day before you can be entitled to a claim on Weekly accident and sickness benefits claim.
There is a maximum benefit of 26 weeks in a twenty four month period.

The “date of the covered incident” is the first date on which you are unable to perform work due to an illness, non-work related injury or accident.

You will need to apply for TDI, and submit your approval or denial to the Fund Office before any benefits will be paid. You can apply for TDI by calling (401) 462-8420.

How Benefits Are Paid

The Weekly Accident and Sickness Benefit is designed to help you maintain your health coverage. It may provide income as a supplement to Temporary disability insurance (TDI) or supplement any short-term disability income you may receive from another source, such as TDI. The maximum weekly disability income you can receive from both sources combined is $500 or 75% of your weekly earnings, whichever is less. The 75% is calculated based on your average 13 week gross pay immediately before your covered incident.

For example, Jason earns $800 per week. Through TDI, he receives a weekly short-term disability benefit of $250. If he applies for a disability benefit through this Plan, the maximum weekly benefit he could receive is $250 so that the total benefit he receives from both sources is $500 per week.

Maximum Weekly Benefit

If you do not have other disability income, the Fund's benefit provides up to $500 per week or 75% of your weekly earnings, whichever is less, and contribution credit of 25 hours per week for up to 26 weeks.

However, Brian earns $600 per week. Through TDI he also receives a weekly short-term disability benefit of $250. If he applies for a disability benefit through this Plan, the maximum amount he could receive is $450 per week, because $450 is 75% of his regular weekly earnings. Through this Plan he would be eligible to receive a weekly benefit of $200

Mental Injuries

The Fund will pay weekly accident and sickness benefits for mental injury claims only in the following situations: If you become disabled as a result of a mental injury caused or accompanied by identifiable physical trauma or from a mental injury caused by emotional stress resulting from a situation of substantially greater dimensions than the day-to-day emotional strain and tension which employees typically encounter on a daily basis without serious mental injury, you may be eligible for benefits. In addition, the Fund will provide weekly accident and sickness benefits where the mental injury results in hospitalization.

For the purposes of this section, mental injury means an observable and substantial impairment in your ability to function within the normal range of performance and behavior.

The Fund's Trustees have final, discretionary authority to determine whether a mental injury may result in eligibility for weekly accident and sickness benefits.

Receiving Your Benefit

Your weekly benefit payments will begin on the eighth day of your disability and may continue as long as you are disabled, up to 26 weeks. You will receive a benefit for the first seven days of your disability after you have been out on disability for a full 30 days.

You will receive 25 hours per week credit toward your ongoing eligibility requirements, after your employer has met their obligation, for a maximum of 26 weeks. No pension contributions will be made on your behalf for Weekly Accident and Sickness benefits.

If you retire, your Weekly Accident and Sickness benefits end as of your retirement date.

Notify the Fund Office immediately when:

You recover from your disability;
You return to work;
There is a change in the amount of benefits you receive from other sources.
You retire

Please notify the Fund Office as soon you apply for your Pension.

Disabilities that result from a work-related illness or injury are not covered. In addition, any period of disability that exists at the same time as a work-related illness or injury is not covered. If you have applied and been denied by Workers' Compensation, upon proof of your denial, you may apply for this benefit subject to the reimbursement agreement.

If you receive any payment from a third party relating to your disability claim, you will be required to reimburse the Fund Office for any and all of the Weekly Accident and Sickness benefit that you received based on the reimbursement agreement.