EXTENDED BENEFITS If you or any of your dependents are totally disabled at the time coverage under this plan terminates, benefits may be extended for expenses incurred due to that disability if
the following conditions are met:
(a) the expense would have been covered if the insurance had been continued; (b) you or your dependent remain disabled to the date such expense is incurred; and (c) you or your
dependent are not entitled to similar benefits under any other group plan when each expense is incurred.
Medical benefits will be extended and payable after insurance terminates, but only for treatment of the illness or injury
which caused the disability. Benefits will be payable subject to the limitations and maximums which were in effect under the plan at the time insurance terminated. Benefits will continue until the earliest of:
(a) the date you or your dependent are no longer disabled; (b) the date you or your dependent become covered under another insurance plan which provides similar benefits; or (c) for
Comprehensive Major Medical Benefits, the end of 12 consecutive months from the date of termination.
A special extension applies for an employee or dependent spouse who is pregnant when her insurance terminates. The applicable benefits
will be provided for covered expenses due to that pregnancy even though she may not be totally disabled on the date of termination provided that:
(a) the pregnancy commenced while she was insured under the policy; and (b) she is not eligible for coverage under any other group insurance policy or plan providing similar benefits for the
pregnancy.
MULTIPHASIC PHYSICAL EXAMINATION PLAN The Construction Workers Local No.1 Health & Welfare Trust will pay for a multiphasic physical examination for each eligible member. In addition the spouse of each
eligible member will also be eligible for such examination. The Trust will pay a maximum of $100.00 per
eligible person for each examination each calendar year. Payments under this program will be for physician services, lab tests, xrays and other diagnostic measures involved in conducting such examinations. To submit a claim under this plan, first submit the claim to the claims office as described elsewhere in this
booklet. The claims office will determine whether any portion of the claim is covered by the major medical portion of your coverage. When you receive the explanation of benefits from the claims office,
submit that to Construction Workers Local No. 1 Health & Welfare Trust, Administration Company, 5500 Market Street, San Francisco, CA 94000, together with all itemized medical and hospital bills involved.
COORDINATION OF BENEFITS Members of a family are often covered by more than one group health insurance plan. As a result, two or more plans are paying for the same expense. To avoid this costly problem,
your health plan provides a Coordination of Benefits provision. This provision affects all your health coverages. How Does Coordination WorkIf you or your dependents are also covered under
another group plan, the total amount received from all plans will never be more than 100% of "allowable expenses." Benefits are reduced only to the extent necessary to prevent any person from making a
profit on his insurance. "Allowable Expenses" are any necessary and reasonable expenses for
medical or dental services, treatment or supplies, covered by one of the plans under which you or your dependents are insured. A "Plan" is considered to be any group insurance providing coverage for medical treatments or services on an insured or uninsured basis. This includes group blanket or
franchise insurance, group Blue Cross, group Blue Shield, group practice and any other group prepayment coverage, labormanagement trusteed plans, union welfare plans, employer organization plans, any coverage under
governmental programs and any coverage as required or provided by law, including Mandatory State NoFault Auto Insurance. Which Plan Pays FirstIf both plans have a Coordination of Benefits provision,
the plan that insures you as an employee pays first. If you are insured as an employee under two plans, the plan which has insured you longer is primary, A plan which covers you as other than a laidoff employee or
retiree will pay its benefits before a plan which covers you as a laidoff employee or as a retiree; this does not apply if either plan does not have a provision regarding laidoff or retired employees. If either plan
covers you under its COBRA provision, that plan is secondary unless both plans do not contain this rule. If one plan does not have a Coordination of Benefits provision, that plan is always primary. If a dependent
child is covered under two plans, the plan of the parent whose birthday occurs earliest in the calendar year (excluding year of birth) pays its benefits first. If the parents of a dependent child are divorced or
separated the plan of the parent with custody pays its benefits first, if the parent with custody remarries, the order of payment is as follows: (a) Natural parent with whom the child resides; (b) Stepparent with whom the child resides; and (c) Natural parent not having custody of the child. This order of payment can change if the divorce decree directs one of the parents to be financially responsible for the health care expenses of the child.
Right to Obtain or Release InformationThe insurance company may obtain or release any information necessary to implement these provisions. You must declare your coverage under other plans. The
insurance company can pay to another paying organization amounts warranted to satisfy the intent of this provision, and to the extent of such payment is discharged from liability for any claim. The company can also
recover from the insured, from another insurance company, or from another organization amounts that are overpaid under this provision. MEDICARE COORDINATION OF BENEFITS This plan will pay
benefits before Medicare in the following circumstances: 1) All claims for an active employee who is age 65 or older, 2) all claims for dependents of an active employee over age 65, and 3) the
first 18 months of treatment for end-stage renal disease received by any eligible person who is less than 65 years of age. Medicare will be primary and this plan secondary on claims for eligible employees age 65 or older who do not fall within the above categories with coverage under the active
plan. This would include retired employees age 65 or older with extended coverage due to reserve accumulation or making allowable self-payments. In each case where this Plan continues as primary, the Company will pay first and Medicare will pay second. However, if you are an active employee aged 65 or
over, you have the option of electing Medicare as your primary, coverage under this Plan will cease.
"Active Employee" means any employee working in the industry having contributions remitted to the Plan or employees available for work and on the out-of-work list of the Construction Workers No. 1 and
employees on the out-of-work list of the Construction Workers No. 1 making self-payments for continued coverage.
Benefits otherwise payable under the Group Policy for Allowable Expenses , shall be reduced so that the sum of benefits payable under the Group Policy and "Medicare" for such expense shall not exceed the total
of such Allowable Expenses. However, Life and Accidental Death and Dismemberment Insurance, shall not be included in determining the sum of benefits payable under the Group Policy. "Allowable Expenses" means reasonable charges as determined by the Medicare Intermediary which are for medical care and treatment of the type and kind
covered under the group policy. If payment has been made by the Company in excess of that permitted by
this Rider, the Company shall have the right to recover such excess from any party acquiring same. In determining
benefits payable under "Medicare" all benefits to which the insured individual is entitled under Medicare shall be included, without regard to whether or not the individual has registered for Part
"A" or enrolled for Part "B" of Medicare. To avoid loss of benefits, be sure to enroll in both
Part A and Part B of Medicare. RIGHT OF REIMBURSEMENT
No benefits are payable for any illness, injury, disease or other condition for which a third party may be liable or
legally responsible. However, the Company will advance benefits to or on behalf of the insured only on the condition that the insured agrees in writing:
1. to reimburse the Company to the extent of the benefits provided, immediately upon collection of the damages from such third party,
whether by judgement, settlement, or otherwise.
2. to provide the Company with a lien, to the extent of benefits provided by the Company. The lien may be filed with the person whose act
caused the injury or condition, his agent, his insurer or the Court or administrative agency.
When you apply for benefits under this plan, you must advise the Company that a third party may be liable and provide
additional information as requested by the Company. If, after applying for benefits, you:
you must advise the Company of those facts within 90 days. INJURY OR SICKNESS GENERAL PROVISIONS
(Not Applicable to Life Insurance) Entire Contract)
ChangesThe Policy including the
application of the Policyholder and the individual applications of the Persons constitutes the entire contract between the parties, and any statement made by the Policyholder or by any Person, shall, in the absence of
fraud, be deemed a representation and not a warranty. No such statement shall be used in defense of a claim hereunder unless it is contained in a written application. No change in the Policy shall be valid unless approved by an Executive Officer of the Company and unless such approval be endorsed hereon or attached hereto. No agent
has authority to change the Policy or to waive any of its provisions. Time Limit on Certain Defenses
After three years from the date of issue of the Policy, no misstatement of the Policyholder, except a fraudulent
misstatement, made in its application shall be used to void the Policy; and after three years from the effective date of the coverage with respect to which any claim is made no misstatement of any Person eligible for
coverage under the Policy, except a fraudulent misstatement, made in an application under the Policy shall be used to deny a claim for loss incurred or disability as defined in the Policy commencing after expiration of
such three years. Notice of ClaimWritten notice of claim must be given to the Company within 90 days after the occurrence or commencement of any loss covered by this Policy, or as soon thereafter
as is reasonably possible. Notice given by or on behalf of the Insured or the Beneficiary to the Company at its Head Office in Washington , D.C., or the Administrative Office of the Fund or to any authorized agent of
the Company, with information sufficient to identify the Insured, shall be deemed notice to the Company.
Claim FormsThe Company, upon receipt of a notice of claim at the Administrative Office of the Fund, will furnish to the
claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after giving of such notice the claimant shall be deemed to have complied with the
requirements of this Policy as to proofs of loss upon submitting, within the time fixed in the Policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which
claim is made. Proofs of LossWritten proof of loss must be furnished to the Company at the Administrative Office of the Fund in case of claim for loss which the Policy provides any periodic
payment contingent upon continuing loss within 90 days after the termination of the period for which the Company is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to
furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and
in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. Time of Payment of ClaimIndemnities payable under the policy for any loss other
than loss for which the Policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which the
Policy provides periodic payment will be paid each week and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof. Legal ActionsNo action at law or
in equity shall be brought to recover on the Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action shall be brought
after the expiration of three years after the time written proof of loss is required to be furnished.
Payment of ClaimsIndemnity for loss of life (if an accidental death benefit is provided by the Policy) will be payable in
accordance with the Beneficiary designation and the provisions respecting such payment which may be prescribed in this booklet and effective at the time of payment. If no such designation or provision is then effective,
such indemnity shall be payable to the estate of the Insured. Any other accrued indemnities unpaid at the Insured's death may, at the option of the Company, be paid either to such Beneficiary or to such estate. All
other indemnities will be payable to the insured. If any indemnity of the Policy shall be payable to the
estate of the Insured, or to an Insured or Beneficiary who is a minor or otherwise not competent to give a valid release, the Company may pay such indemnity, up to an amount not exceeding $1,000.00 to any relative by
blood or connection by marriage of the Insured or Beneficiary who is deemed by the Company to be equitably entitled thereto. Any payment made by the Company in good faith pursuant to this provision shall fully discharge
the Company to the extent of such payment. Subject to any written direction of the Insured in the
application or otherwise all or a portion of any indemnities provided by the Policy on account of hospital, nursing, medical, or surgical services may, at the Company's option and unless the insured requests otherwise
in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or
person. Physical Examination and AutopsyThe Company at its own expense shall have the right and opportunity to examine the Person or dependent of the Person when and as often as it may reasonably require
during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law. Effect on Worker's CompensationThis coverage is not in lieu of and does not
affect any requirement for coverage by state Worker's Compensation Insurance.
Benefits During Labor DisputeIf the Individual's insurance terminates because he ceases active work as the result of a
labor dispute, arrangements may be made by the Policyholder or other responsible entity to continue his insurance in effect under the group policy while unemployed for no longer than six months, but only if certain
conditions of the group policy are met, including payment of the required premium contribution by at least 75% of the Individuals. Inquire of the Policyholder or Union if the need for continuance occurs. |
