Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

COVERAGE UNDER MORE THAN ONE GROUP HEALTH PLAN: COORDINATION OF BENEFITS (COB)

This Fund operates under rules that prevent it from paying benefits which, together with the benefits from any other group health care plan, Medicare, workers' compensation, coverage provided by a federal, state or local government or agency, coverage under any motor vehicle no- fault coverage (or any other coverage) for medical expenses or loss of earnings that is required by law, or recovery you may receive from a negligent or wrongful third party, would allow you to recover more that 100% of medical and/or dental expenses you incur. In many instances, you may recover less that 100% of those medical and/or dental expenses from the duplicate sources of coverage or recovery. In some instances, this Fund will not provide coverage if you can recover from some other resource. In other instances, this Fund will advance its benefits, but only subject to its right to recover them if and when you or your covered Dependent actually recover some or all of your losses from a third party.

A. WHEN AND HOW COORDINATION OF BENEFITS (COB) APPLIES

For the purposes of this subsection A, the word "plan" refers to any group medical or dental policy, contract or plan, whether insured or self-insured, that provided benefits that are available under this Plan for expenses incurred by the covered person. A "group plan" provides its benefits or services to employees, retirees or members of a group who are eligible for and have elected coverage.

Many families with more than one person working are covered by more than one medical or dental plan. If this is the case with your family, you must let the Fund (or its insurer) know about all your coverage’s when you submit a claim.

Coordination of Benefits (or “COB”, as it is usually called) operates so that one of the plans (called the primary plan) will pay its benefits first, as if the other plan (called the secondary plan) did not exist. The secondary plan may then pay additional benefits. In no event will the combined benefits of the primary and secondary plans exceed 100% of the medical or dental expenses incurred and which are covered by the plans. As a result, sometimes, the combined benefits that are paid will be less than the total expenses.

B. WHICH PLAN PAYS FIRST: ORDER OF BENEFIT DETERMINATION RULES

Group plans determine the sequence in which they pay benefits, or which plan pays first, by applying order of benefit determination rules in a specific sequence. This Fund uses the order of benefit determination rules established by the National Association of Insurance Commissioners (NAIC) and which are commonly used by insured and self-insured plans. Any group plan that does not have COB rules or does not use these same rules always pays its benefits first.

If all the plans have COB rules that are the same as the Fund's rules, payment is determined in accordance with the following rules. If the first rule does not establish a sequence or order of benefits, the next rule applies, and so on, until an order of benefits is established. The rules are:

i. Rule 1: Non-Dependent/Dependent
The plan that covers a person as an employee, retiree, member or subscriber (that is, other than as a dependent) pays first; and the plan that covers the same person as a dependent pays second.

ii. Rule 2: Dependent Child Covered Under More Than One Plan
a. When a plan and another plan cover the same child as a dependent of different parents (who are not divorced or separated), the plan that covers the parent whose birthday falls earlier in the year pays first; and the plan that covers the parent whose birthday falls later in the year pays second.

b. If both parents have the same birthday, the plan that has covered one of the parents for a longer period of time pays first; and the plan that has covered the other parent for the shorter period of time pays second.

c. The word "birthday" refers only to the month and day in a calendar year; not the year in which the person was born.

d. If the other plan does not have this rule but instead has a rule based on the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits.

e. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage, and the plan of that parent has actual knowledge of the terms of that court decree, that plan pays first. However, this provision does not apply during any Plan Year during which any benefits were actually paid or provided before the plan had actual knowledge of the specific terms of that court decree.

f. If the parents are divorced or separated and there is no court decree allocating responsibility for the child's health care services or expenses, the order of benefit determination among the plans of the parents and their spouses (if any) is:

i. The plan of the custodial parent pays first;
ii. The plan of the spouse of the custodial parent pays second; and
iii. The plan of the non-custodial parent pays third.

iii. Rule 3: Active/Laid-Off or Retired Employee
a. The plan that covers a person either as an employee who is neither laid-off nor retired (i.e., an active employee) (or as that active employee's dependent), pays first; and the plan that covers the same person as a laid- off or retired employee (or as that laid-off or retired employee's dependent) pays second. For the purposes of this rule, an employee who is no longer working for an employer is deemed to be a laid-off or retired employee (and not an active employee).

b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

c. If a person is covered as a laid-off or retired employee under one plan and as a dependent of an active employee under another plan, the order of benefits is determined by Rule 1 rather than by this rule.

iv. Rule 4: Longer/Shorter Length of Coverage
a. If none of the previous rules determines the order of benefits, the plan that covered an employee, member or subscriber for the longer period of time pays first; and the plan that covered that person for the shorter period of time pays second.

b. To determine how long a person was covered by a plan, two plans are treated as one if the person was eligible for coverage under the second plan within 24 hours after the first plan ended.

c. The start of a new plan does not include a change:

• in the amount or scope of a plan's benefits;
• in the entity that pays, provides or administers the plan's benefits; or
• from one type of plan to another (such as from a single-employer plan to a multiple-employer plan).

d. The length of time a person is covered under a plan is measured from the date the person was first covered under that plan. If that date is not readily available, the date the person first became a member of the group will be used to determine the length of time that person was covered under the plan presently in force.

C. HOW MUCH THIS FUND PAYS WHEN IT IS SECONDARY

When this Fund pays second, it will pay, with respect to the total benefits under each claim submitted for payment, no more than 100% of "Allowable Expenses" less whatever payments were actually made by the plan (or plans) that paid first.

"Allowable Expense" means a necessary, Reasonable and Customary health care service or expense, including deductibles, coinsurance or co-payments, that is covered in full or in part by any of the plans covering the person, except as provided below or where a statute applicable to this Fund requires a different definition. This means that an expense or service (or any portion of an expense or service) that is not covered by any of the plans is not an Allowable Expense.

The following are examples of expenses or services that are not Allowable Expenses:

• The difference between the cost of a semi-private room in a Hospital or other health care facility and a private room, unless the patient's stay in a private Hospital room is Medically Necessary.
• Amounts charged by a health-care provider that exceed the highest of the "usual and customary charges" allowed by any of the plans. This means that, among the plans, the highest of the "usual and customary charges" is the amount that all plans will use for COB purposes as such term may be defined under the plans in question.
• Amounts charged by a health care provider that exceed the price, charge, or fee set by agreement with the Fund, if the health care provider has contracted to provide the service for the covered person for a specific fee or payment.

When benefits are reduced by a primary plan because a covered person did not comply with the primary plan's provisions, such as the provisions related to utilization management in this Fund and similar provisions in other plans, the amount of those reductions will not be considered an Allowable Expense by this Fund when it pays second.

Allowable Expenses do not include expenses for services received because of an occupational Sickness or Injury, or expenses for services that are excluded or not covered through this Fund.

D. ADMINISTRATION OF COB

To administer COB, the Fund reserves the right to:

• exchange information with other plans involved in paying claims;
• require that you or your health care provider furnish any necessary information;
• reimburse any plan that made payments that this Fund should have made; or
• recover any overpayment from your Hospital, Physician, Dentist, other health care provider, other insurance company, you or your Dependent.

If this Fund should have paid benefits that were paid by any other plan, this Fund may pay the party that made the other payments in the amount the Board of Trustees (or its designee) determines to be proper under this provision. Any amounts so paid will be considered to benefits through this Fund, and this Fund will be fully discharged from any liability it may have to the extent of such payment.

To obtain all the benefits available to you, you should file a claim under each plan that covers the person for the medical and/or dental expenses that were incurred. However, any person who claims benefits through this Fund must provide the Fund with all the information the Fund needs to apply the COB rules.