• SPD Table of Contents
  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Other Limitations on Your Benefits

COORDINATION OF BENEFITS (C.O.B.)

Benefits are coordinated when both you and your spouse and/or your dependent children are covered by this Plan as well as by another group health plan. Coordination allows benefits to be paid by two or more plans, up to but not to exceed 100% of the allowable expenses on the claim.

General C.O.B. Information

1. Benefits are coordinated on all employee, retiree and dependent claims. C.O.B. applies to medical, prescription drug, vision, dental/orthodontia and hearing benefits.
2. Benefits are coordinated with other group plans and Medicare. If you are covered under a personal individual plan for which you pay the full premiums, this Plan will not coordinate with that plan but will pay its normal benefits. Benefits are also not coordinated with Medicaid, or, in most cases, TriCare (the health care program provided by the U.S. armed service). Benefits are not coordinated with private insurance plans, or with plans that do not coordinate benefits.
3. You must file a claim for any benefits to which you are entitled from any other source. Whether or not you file a claim with these other sources, your Plan payments will be calculated as though you have received any benefits to which you are entitled.
4. Benefits are coordinated based on “allowable expenses,” which are expenses that are eligible to be considered for reimbursement.
5. If a person is covered by two or more plans that provide benefits on the basis of negotiated fees, any amount in excess of the highest of the primary plan’s negotiated fees is not an allowable expense. If both plans contract with the same provider, and if the provider’s contract has no provision to the contrary, the lower of the two negotiated fees will be the allowable expense.
6. A plan that pays “primary” benefits is the plan that is required to pay its benefits first. The plan that pays “secondary” benefits is the plan that pays its benefits after the other plan has paid its benefits. The plan that is primary will pay benefits as if it were the only existing coverage without regard to the other plans.

When This Plan is Secondary

When this Plan is secondary, the Plan benefits normally payable will be reduced to the extent that the total amount of benefits paid by all plans will not exceed 100% of the allowable amount. The allowable amount is the in-network negotiated fee, or, for out-of-network charges, the reasonable and customary charge, for medical care or treatment that is covered at least in part by either plan.

This Plan will not pay benefits for expenses which would have been covered by another plan but which are either not paid or are subject to a reduction in benefits because the person failed to take the action required under the other plan’s rules. This could occur in a case where the person was required by the other plan to use certain doctors or hospitals under an HMO. Or it could occur in cases where the person failed to comply with the other plan’s required utilization review or cost containment procedures, such as hospital preadmission review, second surgical opinions, certification of other types of treatment, or any other required notification or procedure of the other plan, including failing to file a claim on time, or failure to provide missing information requested by the other plan.

When this Plan pays reduced benefits due to these rules, only the reduced amount will be charged against any applicable payment limits of the Plan.

If the other plan pays benefits that should have been reduced because of coordination of benefits, the amount by which the benefits should have been reduced may be paid to the other plan. Amounts so paid will be considered benefits under this Plan.

Order of Payment

If all plans have a C.O.B. provision, benefits are determined based on the first of the following rules that applies:

1. Non-dependent or dependent - The plan that covers the person other than as a dependent, for example as an employee or retiree, is primary, and the plan that covers the person as a dependent is secondary. (See “If There Is a Third Plan” on page 71 if the claimant is also covered by Medicare.)
2. On claims for children - If a child is covered under two or more plans, the following provisions determine which plan pays first:
   1. When the natural parents are married (and not separated or divorced), or when they are not married but living together, the plan covering the parent whose birthday comes first in the year will pay first and the plan covering the parent whose birthday comes later in the year will pay second (this is known as the “birthday rule”).
   2. When the natural parents are separated or divorced, or are not married and not living together, benefits are payable according to any existing court decree. If there is no court decree stating who is responsible for a child’s health care, the plan covering the parent with custody (if not remarried) pays first and the plan covering the parent without custody pays second. If the parent with custody has remarried, that parent’s plan pays first, the stepparent’s plan pays second and the plan covering the parent without custody pays third.

The birthday rule will apply if a court decree awards joint custody without specifying that one party has the responsibility to provide health coverage, or in any other situation not addressed in the above rules.

3. Married and/or employed child. If no court order applies and the child is employed and/or married, the Plan covering the child as an employee will pay first, the Plan covering the child as a spouse will pay second, and the Plan covering the child as a dependent child will pay third. This rule will not apply if the other plan uses the longer/shorter rule below.

3. Active or inactive employee - The plan that covers a person as an active employee is prime over a plan that covers the person as a laid-off or retired employee. The same order applies to the person’s dependents.
4. Continuation (COBRA) coverage - If a person whose coverage is provided under a right of continuation provided by federal or state law (“COBRA”) also is covered under another plan, the plan covering the person

as an employee or retiree (or as that person’s dependent) is primary, and the COBRA coverage is secondary. However, this rule will not apply if the person is covered as a dependent under one plan and as a nondependent under the other plan. In that case, the plan covering him as a non-dependent is primary, even if the non-dependent coverage is COBRA coverage.

5. Longer or shorter length of coverage - The plan that covered the person as an employee or retiree longer is primary.
6. Two Plan employees - If you and your spouse are both covered as employees under this Plan and one of you has a claim, the Plan will pay primary benefits on the claim as the claim of an employee and then pay secondary benefits on the claim as the claim of a dependent. Claims for the dependent children of two Plan employees will be coordinated, subject to rules in No. 2 above.
7. Other situations - If the preceding rules do not determine the primary plan, this plan will follow the guidelines established by the National Association of Insurance Commissioners (NAIC) to determine the order of payment. If the NAIC guidelines do not apply to a particular situation, the allowable expenses will be shared equally between the plans, but in no case will this plan will pay more than it would have paid had it been primary.

Right of Repayment

If a payment of any amount has been made that is in excess of that permitted by coordination of benefits, this Plan has the right to recover such amount from any party that has received such payment.

Right to Receive and Release Necessary Information

The Fund may, without the consent of or notice to any person, release to or obtain from any insurance company or other organization or person any information, with respect to any person, which the Fund deems to be necessary for such purposes of implementing these coordination of benefit rules. Any person claiming benefits under this Plan shall furnish to the Fund Office such information as may be necessary to implement these rules.

Coordination of Benefits with Medicare

Important Information About Medicare

This Plan will pay secondary to Medicare whenever it is allowed to do so by law. The rules governing when the Plan can pay secondary are determined by the Centers for Medicare and Medicaid (CMS), a federal agency. This section summarizes those rules.

If you are retired, Medicare will be primary and this Plan will be secondary. Medicare will also be primary for your spouse if she is also entitled to Medicare.

When this Plan is secondary to Medicare, it will pay its benefits as though you are enrolled in Parts A and B, whether or not you are actually enrolled. The same rule applies to claims incurred by your spouse. When Medicare will be the primary plan (for example, when you retire), you and your spouse are each responsible for enrolling in Medicare Part A and Part B when you are first eligible to do so. If you want information about Medicare enrollment, contact your local Social Security office (at least 30 days before your 65th birthday, if possible).

For Persons With COBRA and Medicare

Under the COBRA coverage rules, your COBRA will terminate when you become eligible for Medicare. However, if you already have Medicare on your COBRA election date, you are allowed to elect COBRA and keep both coverages. If you do have dual coverage (Medicare and COBRA), the rules governing which plan pays first are as follows: • Medicare will be primary if your Medicare entitlement is due to age or disability. This means you must be enrolled in Part B because the Plan will pay claims as if you have Part B. Medicare will also be primary for your spouse if she has Medicare.

• If you have Medicare due to end stage renal disease (ESRD), your COBRA coverage will be primary for the first 30 months of ESRD Medicare entitlement. Medicare becomes primary after that. The same rule applies to a spouse with ESRD Medicare.

If There Is a Third Plan

If a person who is eligible for Medicare due to age is also covered under a plan as a retired worker and under a third plan as a dependent of an actively working spouse, the plan covering the person as a dependent will pay first, Medicare will pay second, and the plan covering the person as a retired worker will pay last. Similarly, if a person who is eligible for Medicare due to age is covered as a retired worker under one plan and as an active worker under another plan, the plan covering the person as an active worker will pay first, Medicare will pay second, and the plan covering the person as a retired worker will pay last.

SUBROGATION

In the event the Fund pays or is obligated to pay benefits on behalf of a participant or his/her dependents for illness or injury to the participant or dependents and the participant or dependents have the right to recover the amounts of such benefits from any other person, corporation, insurance carrier or governmental agency, including uninsured or underinsured insurance coverage, or any other first-party contract or claim, the Trustees of the Fund and the Fund shall be subrogated to all of the participant’s or dependents’ right of recovery against such person, corporation, insurance, carrier, governmental agency or uninsured or underinsured insurance coverage or any other first-party or third- party contract or claim and shall have a right of reimbursement from the participant or dependent to the full extent of payments made by the Fund and for the cost of collection of these amounts, including attorney’s fees. The full amount of benefits paid shall include any Preferred Provider Organization charge or other payment to a medical discount provider paid with respect to the involved benefits which shall be considered part of the amount of benefits paid. The Trustees and the Fund shall have an equitable lien by agreement in the amount set forth in this paragraph and this equitable lien by agreement shall be enforceable as part of an action to enforce plan terms under ERISA Section 502(a)(3), including injunctive action to ensure that these amounts are preserved and not disbursed. The Trustees’ and the Fund’s equitable lien by agreement imposes a constructive trust upon the assets received as a result of a recovery by the participant or dependents, as opposed to the general assets of the participant or dependents, and enforcement of the equitable lien by agreement does not require that any of these particular assets received be “traced” to a specific account or other destination after they are received by the participant or dependents. The Trustees’ and the Fund’s equitable lien by agreement is from the first dollar received and its enforcement does not require that the participant or dependents be “made whole” or that the entire debt be paid to the participant or dependents prior to the lien’s payment. The Trustees’ and the Fund’s equitable lien by agreement is also not reduced by the legal fees incurred by the participant or dependents in recovering the amounts or by any state law doctrine, such as the “common fund” doctrine, which would purport to impose such a reduction.

The participant or his or her dependents or the participant acting on behalf of a minor dependent shall execute and deliver such documents and papers, including but not limited to an assignment of the claim against the other party or parties, assignment to the minor child or any parental claim to recover medical expenses of the minor child, and/or a Subrogation or Reimbursement Agreement to the Fund, as the Trustees may require. The participant or dependents shall do whatever else is necessary to secure the rights of the Trustees and the Fund including allowing the intervention by the Trustees or the Fund or the joinder of the Trustees or the Fund in any claim or action against the responsible party or parties or any uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim.

If the participant or dependents do not attempt a recovery of the benefits paid by the Fund or for which the Fund may be obligated, the Trustees or the Fund shall, if in the Fund’s best interest and at the Trustees’ sole discretion, be entitled to institute legal action or claim against the responsible party or parties, against any uninsured or underinsured insurance coverage, or against any other first-party or third-party contract or claim in the name of the Fund or Trustees in order that the Fund may recover all benefit amounts paid to the participant or dependents or paid on their behalf, together with the costs of collection, including attorney’s fees.

In the event of any recovery by judgment or settlement against the responsible party or parties or by payment by an uninsured or underinsured insurance coverage or any other first-party or third-party contract or claim, payment of the lien from the proceeds of the recovery shall take place in the following fashion. Initially, the reasonable costs of collection of the equitable lien by agreement, including the Fund’s attorney’s fees, shall be distributed to the Fund. Next, the amount of benefits paid from the Fund to and on behalf of the participant or dependents, to the full extent of benefits paid or due as a result of the occurrence causing the injury or illness, shall be distributed to the Fund. The remainder or balance of any recovery shall then be paid to the participant or dependents and their attorneys if applicable.

In the event of any failure or refusal by the participant or dependents to execute any document requested by the Trustees or the Fund or to take other action requested by the Trustees or the Fund to protect the interests of the Trustees or the Fund, the Trustees may withhold payment of benefits from the Fund or deduct the amount of any payments from amounts otherwise payable form the Fund for future claims of the participants or dependents. After making claim for benefits from the Fund, the participant or dependents shall take no action which might or could prejudice the rights of the Trustees or the Fund.

In the event the participant or dependents recover any amount by settlement or judgment from or against another party or by payment from any uninsured or underinsured insurance coverage or any other first-party or thirdparty contract or claim the Fund will request repayment of the amount of its equitable lien for the full amount of benefits paid by the Fund. If the participant and/or dependents refuses or fails to repay such amount, then in that event, the Fund shall be entitled to recover such amounts from participant and/or dependents by instituting legal action against the participant and/or dependents and/or by deducing such amounts as may be due on future claims submitted by the participant and dependents. Once a settlement or judgment is reached on the claim additional bills cannot be submitted with respect to the same injury.

The participant or dependents shall be required to pay their own legal fees and costs and to hire only attorneys who agree to waive the common fund doctrine and to remit the gross rather than the net proceeds from litigation.

The Trustees shall pay no legal costs or fees from the Fund without receiving a recovery and then only, in their sole discretion, within the terms of this provision. In the event that an attorney is hired by or on behalf of the participant or his/her dependents and the Fund is given notice and an opportunity to pursue its own subrogation recovery, the Fund shall not be required to hire such attorney. If the attorney representing the eligible individual nevertheless wishes to proceed, and creates a common fund from which the Trustees can recover pursuant to their equitable lien by agreement for subrogation and reimbursement, the Trustees, on behalf of the Fund, may agree to pay up to 10% of its recovery to include the attorney’s legal fees. This 10% shall also include any prorated portion of the cost of recovery. If the attorney agrees to proceed, he will be considered to have waived the common fund doctrine.

These provisions shall apply to any case in which the Fund or Trustees have not been repaid the full amount of benefits made for and on behalf of a participant or beneficiary, together with cost of collection, as of the date of this provision, and any subrogation and reimbursement claim or lien presented by the Fund or Trustees, where the Fund or Trustees have not been repaid the full amount of benefits made for and on behalf of a participant or beneficiary, together with cost of collection, as of the date of these provisions, shall be construed to involve an equitable lien by agreement under these provisions.

(If you want more information about Subrogation, contact the Fund Office.)

Note About Asbestosis Treatment - If you seek services and/or treatment for asbestosis, the Plan will cover your care as if it were not the result of a job-related exposure except that the Fund will be subrogated to any judgment settlement or payment based on a Workers’ Compensation claim or suit.

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