Teamsters Local 251 Health Services & Insurance Plan

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

Life Insurance

If you die from any cause 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 you become terminally ill, you may elect to receive a part of your Life Insurance coverage while you are still living. A terminal illness, as defined by Aetna, means that you are believed to have only six months left to live.

You may elect to have up to 75% of your benefit — $37,500 — 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 will be extended for a period of one year while you are totally disabled.

Within the first year of your disability, you may extend your benefits if you provide Aetna with written proof that:

Total Disability began while you were covered by this Plan.
Your disability has continued for at least nine months.

AETNA will then further extend your Life Insurance benefit for successive one-year periods, as long as you continue to provide proof of your continuing total disability each year. If you die while your Life Insurance benefit is being extended, the benefit is payable when Aetna receives written proof that your total disability continued until the date of your death.

Your Extended Life Insurance Benefit protection ends when:

Your total disability ends;
You fail to provide the required proof of your total disability to Aetna; and
You fail to submit to a medical exam by doctors named by Aetna when and as often as Aetna requires.

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

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 from any cause 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.

Your eligible dependent child is covered under the Life Insurance benefit beginning at age 14 days old. No benefit will be payable if your child dies before he or she reaches 14 days old.

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.

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. Written notification of a claim must be provided within 20 days after the date of the 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're 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:


Type of Loss		Amount

Life		$50,000
Both Hands		$50,000
Both Feet		$50,000
Sight of Both Eyes		$50,000
One Hand and One Foot		$50,000
One Hand and Sight of One Eye		$50,000
One Foot and Sight of One Eye		$50,000
One Hand		$25,000
One Foot		$25,000
Sight of One Eye		$25,000
Thumb and Index finger of same hand		$12,500
Speech and hearing		$50,000
Speech or hearing in both ears		$25,000
Quadriplegia		$50,000
Paraplegia		$25,000
Hemiplegia		$25,000

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.

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 infirmary;
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 gasses;
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;
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 9with 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.

Seat Belt Benefit
(Level 1)

AETNA will pay a Seat Belt Benefit if:

The member dies as a result of an automobile accident for which an AD&D benefit is payable; and
the seat belt was in actual use and properly fastened, as certified in the offical police report, at the time of the accident; and
the member was driving or riding in an automobile driven by a licensed driver who was neither;

a. Intoxicated or driving while impaired. Intoxication and impairment shall be determined by the law of the jurisdiction in which the accident occurs, with or without conviction;
nor

b. Under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any other controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended unless as prescribed by a licensed physician. Conviction is not necessary for a determination of being under the influence.

The amount of the Seat Belt benefit is:

If a covered loss of life of the member occurs as a direct result of a motor vehicle accident and the insured is properly using a passenger restraint and (if the driver) is properly licensed, a benefit will be payable. If an airbag is activated as a result of the same accident, an additional benefit will be payable. Passenger restraint and airbag usage will require verification. The benefit provides for $10,000 for use of a passenger restraint and an additional $5,000 if an additional airbag is activated.
If a member dies and they have a seat belt on but cannot prove it with a certified official report, the beneficiary receives $50,000.00 Life, $50,000.00 AD&D.
If a member dies and they do not have a seatbelt on the beneficiary receives $50,000.00 Life and $50,000.00 AD&D.

Educational Benefit for Dependent Child and Spouse

If a loss of life of the member occurs as a direct result of an accident, an education benefit will be payable on behalf of each dependent child and/ or surviving spouse for a maximum of 4 years from the date of death, with verification of continued enrollment. The benefit provides for 5% of Member's principal sum not to exceed $5,000 per year.

Child Care Benefit

3% of the member's or spouses principal sum Maximum $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 if repatriation occurs outside of 200 miles from the principal residence.

Coma Benefit

If a covered member suffers a bodily injury caused by an accident and as a direct result becomes comatose, a monthly benefit of 5% of the Principal Sum less any benefit amount paid or payable because of the same accident will be payable for 11 months after the person has been continually comatose for at least 30 days. After 12 months of continuous coma, the full Principal Sum less any benefit amount paid or payable because of the same accident is payable. Monthly benefit payments terminate on the earliest of the date all monthly payments have been made; the full Principal Sum is paid; the coma ceases; failure to have any required exam or to give proof of continuous coma; the policy terminates.

Death and Dismemberment Benefits for Dependents

Accidental Death and Dismemberment coverage pays benefits for the accidental loss of your dependent's life, sight, hand or foot. The injury causing the loss must occur while your eligible dependent is covered under this Plan.

What You Need To Do:

If your eligible dependent suffers a loss, contact the Fund Office for a claim form.
Ask the physician to provide a statement (proof of loss) describing the loss your eligible dependent is claiming. Written notification of a claim must be provided within 365 days after the date of the loss.

Send the physician's statement along with the completed claim form within 365 days after the date of loss to the Fund Office at:

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

Dismemberment Coverage Eligibility

Your eligible Dependent(s) are eligible for the Dismemberment Coverage Benefit if:

He or she sustains an accidental bodily injury while covered by this Plan;
The loss results directly from that injury and from no other cause; and
He or she suffers the loss within one year after the accident.

The following Personal Accident Coverage Benefits are payable:

Type of Loss	Benefit
Life	$20,000
Both Hands	$20,000
Both Feet	$20,000
Sight of Both Eyes	$20,000
One Hand and One Foot	$20,000
One Hand and Sight of One Eye	$20,000
One Foot and Sight of One Eye	$20,000
Speech and Hearing (by reason of quadriplegia)	$20,000
One Hand	$10,000
One Foot	$10,000
Sight of One Eye	$10,000
Speech	$10,000
Hearing	$10,000
Paraplegia	$10,000
Hemiplegia	$10,000
Thumb and Index Finger of the Same Hand	$2,500

What's Not Covered

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

A bodily or mental infirmary;
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 gasses;
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;
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 9with 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.

Seat Belt Benefit

AETNA will pay a Seat Belt Benefit if:

The eligible dependent dies as a result of an automobile accident for which an AD&D benefit is payable; and
the seat belt was in actual use and properly fastened, as certified in the official police report, at the time of the accident; and
the dependent was driving or riding in an automobile driven by a licensed driver who was neither;

a. Intoxicated of driving while impaired. Intoxication and impairment shall be determined by the
law of the jurisdiction in which the accident occurs, with or without conviction; nor

b. Under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any other controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended unless as prescribed by a licensed physician. Conviction is not necessary for a determination of being under the influence.

The amount of the Seat Belt benefit for a dependent is:

If a covered loss of life of the member occurs as a direct result of a motor vehicle accident and the insured is properly using a passenger restraint and (if the driver) is properly licend=seded, a benefit will be payable. If an airbag is activated as a result of the same accident, an additional benefit will be payable. Passenger restraint and airbag usage will require verification. Thebenefit provides for $10,000 for use of a passenger restraint and an additional $5,000 if an additional airbag is activated.
If a dependent dies and they have a seat belt on but cannot prove it with the certified official police report, the members receives $20,000.00 Life, $20,000.00 AD&D; and
If a dependent dies and they do not have a seat belt on the member receives $20,000.00 Life, and $20,000.00 AD&D.

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.

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, 2006, you may not file another claim for benefits until on or after July 1, 2008.
If you become disabled, you must call the Fund Office within six weeks from the date of your disability 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.

Note: All of this information must be completed and returned to the Fund Office within six weeks of the date they were sent to you for a claim to be processed. (There is an expiration date on the claim forms.)

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;
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 six weeks of the date they were sent to you. The expiration date appears on the Accident and Sickness Claim Forms;
Return to work one day before you can be entitled to another claim on Weekly accident and sickness benefits claim.
There is a maximum benefit of 26 weeks in a twenty four month period.

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

Stress-related claims.

The weekly accident and sickness benefit does not provide coverage for stress-related claims, including claims associated with the day to day stress of daily life. The weekly accident and sickness benefit does provide benefits where the stress-related claim is a result of an unusual, dramatic, stressful incident, or where the stress-related claim results in hospitalization. The Fund's Trustees have final, discretionary authority to determine whether a stress-related claim 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 will 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.