Summary Plan Description

Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

GLOSSARY OF TERMS

When reading this booklet, you may encounter some terms with which you may not be familiar or which may have a specific meaning for purposes of this booklet. These definitions are being provided to help you understand what these terms mean and how they are applied in the administration of your benefit program.

Accidental means a loss or an injury due solely to unexpected and unintentional means.

Accidental Injury is physical harm or disability, which is the result of a specific unexpected incident caused by an outside force. The physical harm or disability must have occurred at an identifiable time and place. Accidental injury does not include illness or infection, except infection of a cut or wound.

Active Employee (also, “Participant") means an Employee who is actively at work in the industry and for whom Contributions are being paid into the Fund (other than Retiree co-payments) and who is not a Retiree. For the purpose of the Plan, an Employee’s absence from work due to any health factor (such as being absent from work on sick leave) is treated as being “actively at work.” An Employee shall only be considered an Active Employee during a period in which Contributions are actually being paid into the Fund.

Allowable Expense means a necessary, Reasonable and Customary health care service or expense, including deductibles, coinsurance or co-payments, which 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 allowable charge shall be the usual, customary and reasonable amount for that service as determined by the Board of Trustees from time to time.

Beneficiary is a person designated by a Participant or under the terms of this Plan, who is or may become entitled to a benefit.

Board and Room Charges are charges made by an institution for board and room and other necessary services and supplies. They must be regularly made at a daily or weekly rate.
Board of Trustees or Trustees are all of the members of the joint Board of Trustees of the Local 805 Welfare Fund.

COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended from time to time, which governs continuation of coverage.

Collective Bargaining Agreement(s) is (are) the labor agreement(s) between the Union and participating Employers, which provides for the payment of Contributions to the Fund.
Contributions are payments made by employers on behalf of Participants pursuant to Collective Bargaining Agreements or other written agreements requiring that such payments be made. Contributions shall also include payments made by Participants who continue their coverage under the COBRA provisions of the Plan.

Co-payment or Copay is a fee, charged to a Participant, which represents a portion of the applicable Covered Expense.

Cosmetic Surgery includes, but is not limited to, plastic surgery, reconstructive surgery, cosmetic surgery or other services and supplies which improve, alter or enhance appearance, whether or not for psychological or emotional reasons, except to the extent needed (1) to improve the function of a malformed part of the body (a) that is not a tooth or structure that supports the teeth; (b) that is the result of a severe birth defect (including cleft lib, webbed fingers or toes); or (c) that is a direct result of disease or surgery performed to treat a disease or injury, or (2) to repair an injury, in which case surgery must be performed in the calendar year of the accident which causes the injury or in the next calendar year.

Covered Employment means work for which an Employer is required to make Contributions to the Fund on your behalf under the terms of a Collective Bargaining Agreement or any other agreement.

Covered Expense (also Allowable Expense) means any necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part under any part of this welfare plan of benefits.

Covered Dental Expenses included under the Plan are the charges of a dentist which a Participant is required to pay for dental services listed in the Schedule of Covered Dental Services and received while coverage is in effect.

Creditable Coverage is any individual or group plan that provides medical, Hospital and surgical coverage, including continuation or conversion coverage, coverage under a publicly sponsored program such as Medicare or Medicaid, CHAMPUS, the Federal Employees Health Benefits Program, programs of the Indian Health Service or of a tribal organization, a state health benefits risk pool, or coverage through the Peace Corps. Creditable coverage does not include accident only, credit, coverage for on-site medical clinics, disability income, coverage only for a specified disease or condition, Hospital indemnity or other fixed indemnity insurance, Medicare supplement, Workers’ Compensation insurance, long-term care insurance, dental, vision, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.

Custodial Care is defined as all services and supplies, including room and board and other institutional care, which is provided primarily to assist an eligible person in the activities of daily living and which do not require the continuous attention of trained medical or paramedical personnel. Custodial Care may include the preparation of special diets, supervision over medication that can be self-administered, assistance in getting in or out of bed, walking, bathing, dressing, and eating. Services and supplies may be deemed to be for Custodial Care without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed.

Death Benefits are payments of benefits to a designated Beneficiary upon the death of a Participant who dies while covered by this Plan.

Deductible (also Calendar Year Deductible) means the out-of-pocket expense that you must pay each year before a Major Medical is payable under the terms of the Plan.

Dentist means a person who is duly licensed and acting within the scope of a dental license to practice dentistry, including a Physician who may furnish dental care.

Durable Medical Equipment is defined as no more than one item of equipment for the same or similar purpose, and the accessories needed to operate it, which is:

made to withstand prolonged use;
made for and mainly used in the treatment of a disease or injury;
suited for use in the home;
not normally of use to persons who do not have a disease or injury;
not for use in altering air quality or temperature; and
not for exercise or training.

The following are examples of equipment that are not Durable Medical Equipment: whirlpools, portable whirlpool pumps; sauna baths; massage devices; over bed tables; elevators; communication aids; vision aids; and telephone alert systems.

Emergency is a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain), which the person reasonably perceives could permanently endanger health if medical treatment is not received immediately. Final determination as to whether services were rendered in connection with an emergency will rest solely with us.

Emergency Care: This means the treatment given in a hospital’s emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

placing the person’s health in serious jeopardy; or
serious impairment to bodily function; or
serious dysfunction of a body part or organ; or
in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Employee is a person employed by an Employer in work covered under a Collective Bargaining Agreement on whose behalf Contributions are required to be made to the Fund.

Employer is any Employer that is obligated, under a Collective Bargaining Agreement or other written agreement, to make Contributions to the Fund on behalf of its covered employees.

Employer also includes the Union, Teamsters Local 805 Welfare Fund and the Teamsters Local 805 Pension Fund.

ERISA means the Employee Retirement Income Security Act of 1974, as amended from time to time.

Experimental or Investigational means treatment that, for the particular diagnosis or treatment of the enrolled person’s condition, is not of proven benefit and not generally recognized by the medical or dental community (as reflected in published literature).

Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of an enrolled person’s condition. A claims administrator may require that any or all of the following criteria be met to determine whether a technology, treatment, procedure, biological product, medical device or drug is experimental, investigative, obsolete or ineffective:

there is final market approval by the U.S. Food and Drug Administration (FDA) for the patient’s particular diagnosis or condition, except for certain drugs prescribed for the treatment of cancer. Once the FDA approves use of a medical device, drug or biological product for a particular diagnosis or condition, use for another diagnosis or condition may require that additional criteria be met;

published peer-review medical literature must conclude that the technology has a definite positive effect on health outcomes;

published evidence must show that over time the treatment improves health outcomes (i.e., the beneficial effects outweigh any harmful effects);

published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used. Published proof must show that the treatment improves health outcomes in standard medical practice, not just in an experimental laboratory setting.

FMLA means the Family Medical Leave Act of 1993, as amended from time to time.

Fund Office means the office of the Plan Administrator (The Board of Trustees) of the Local 805 Welfare Fund, 44-61 11th St, 3rd Floor, Long Island City, NY 11101.

Generic Drug is a prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name.

HIPAA means the Health Insurance Portability and Accountability Act of 1996, as amended.

Home Health Care Agency is an agency that:

Mainly provides skilled nursing and other therapeutic services; and
Is associated with a professional group which makes policy; this group must have at least one physician and one R.N.; and
Has full-time supervision by a physician or R.N.; and
Keeps complete medical records on each person; and
Has a full-time administrator; and
meets licensing standards.

Home Health Care Plan is a plan that provides for care and treatment of a disease or injury. The care and treatment must be: prescribed in writing by the attending physician; and an alternative to confinement in a hospital or convalescent facility.

Hospice is a licensed public or private health care organization primarily engaged in providing a coordinated program of home and inpatient care for a terminally ill individual and which provides a coordinated set of services on a 24-hour basis as follows:

nursing care by or under the supervision of a registered nurse;
physical or occupational therapy or speech language pathology services;
medical social services under the direction of a Physician;
home health care by a trained aide;
medical supplies, including drugs and biologicals and the use of medical appliances;
physician services;
short-term inpatient care for acute pain control, symptom management, or to provide respite periods for family members. Such respite care should only be provided on an intermittent, non-routine and occasional basis for a period of not longer than 5 consecutive days; and
counseling, including dietary, with respect to care and adjustment to the patient's death.

Benefits are provided to terminally ill patients no longer receiving curative treatment, whose life expectancy is 6 months or less, as certified by their attending Physician.

Hospice Care is care given to a terminally ill person by or under arrangements with a Hospice Care Agency. The care must be part of a Hospice Care Program.

Hospice Care Agency is an agency or organization which: Has Hospice Care available 24 hours a day, meets any licensing or certification standards set forth by the jurisdiction where it is, provides skilled nursing services, medical social services and psychological and dietary counseling.

Hospice Care Facility is a facility, or distinct part of one, which:

Mainly provides inpatient Hospice Care to terminally ill persons.
Charges its patients.
Meets any licensing or certification standards set forth by the jurisdiction where it is.
Keeps a medical record on each patient.
Provides an ongoing quality assurance program; this includes reviews by physicians other than those who own or direct the facility.
Is run by a staff of physicians; at least one such physician must be on call at all times.
Provides, 24 hours a day, nursing services under the direction of a R.N.
Has a full-time administrator.

Hospice Care Program is a written plan of Hospice Care, which is established and reviewed by a physician attending the person and appropriate personnel of a Hospice. It is designed to provide palliative and supportive care to terminally ill persons; and supportive care to their families. It includes an assessment of the person’s medical and social needs; and a description of the care to be given to meet those needs.

Hospital is defined as an institution that:

is duly licensed as a Hospital (if licensing is required in the state in which the Hospital operates);
operates primarily for the diagnosis, treatment and rehabilitation of sick, injured or disabled persons as in-patients;
provides 24-hour nursing services by registered- or graduate nurses on duty or;
has a staff of one or more licensed physicians available at all times;
provides organized facilities for diagnosis and surgery either on its premises or at an institution with which the establishment has a formal arrangement for the provision of such facilities;
is not primarily a clinic, nursing, rest or convalescent home or an extended care facility or a similar establishment and is not (other than incidentally) a place for treatment of alcoholism or drug addiction; and
has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.

Confinement in a special unit of a Hospital used primarily as a nursing, rest or convalescent home or extended care facility is deemed to be confinement in an institution other than a Hospital.

Illness means a sickness, disease or disorder resulting in an unsound condition of the mind or body, including but not limited to pregnancy, childbirth and related conditions.

Injury means a wound or damage sustained accidentally and or by external force.
Loss of Hands and Loss of Feet shall mean dismemberment by severance at or above the wrist or ankle joint.

Loss of Sight shall mean total and irrecoverable loss of sight.

Mail Order Pharmacy is an establishment where prescription drugs are legally dispensed by mail.

Maintenance Drugs are drugs prescribed for an extended period of time and necessary to sustain good health. Examples include drugs used to treat high blood pressure, diabetes and arthritis.

Medical Emergency is defined as the need for services to treat a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

placing the health of the afflicted person in serious jeopardy;
or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; or
serious impairment to the person's bodily functions; or
serious dysfunctions of any bodily organ or part of such person; or
serious disfigurement.

Medically Necessary is defined as any service, treatment or supply including a Hospital confinement furnished or prescribed by a Physician or other licensed provider to identify or treat an illness or injury that is:

consistent with the diagnosis and treatment of the patient's condition;
in accordance with good medical practice;
required for reasons other than the convenience of the patient or provider;
the most appropriate level of service or supply that can safely be provided for the patient, and
no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above criteria.

The fact that services or supplies are furnished or prescribed by a Physician or other licensed provider does not necessarily mean that they are Medically Necessary. In no event will the following services or supplies be considered Medically Necessary:

those that do not require the technical skills of a medical, a mental health or a dental professional; or
those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any healthcare provider or healthcare facility; or
those furnished solely because the person is an inpatient on any day on which the person’s disease or injury could safely and adequately be diagnosed or treated while not confined; or
those furnished solely because of the setting if the service or supply could safely and adequately be furnished in a physician’s or a dentist’s office or other less costly setting.

The Board of Trustees has the discretion to determine medical necessity under the criteria and guidelines above.

Medicare means any health insurance benefits provided under Title XVIII of the Social Security Act of 1965, as amended.

Mental or Nervous or Behavioral Disorder is a condition which manifests signs and/or symptoms which are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication, regardless of any underlying physical or medical cause. Mental or behavioral disorders and conditions include, but are not limited to, psychosis, effective disorders, anxiety disorders, personality disorders, obsessive-compulsive disorders, attention disorders with or without hyperactivity, and other psychological, emotional, nervous, behavioral, or stress-related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition, and not including alcoholism or drug addiction.

Negotiated Charge is the maximum charge a Preferred Care Provider (also referred to as a Network Provider) has agreed to make as to any service, treatment or supply for the purpose of the benefits under this Plan.

Participant (also, “Active Employee”) means an employee who is actively at work in the industry and for whom Contributions are being paid into the Fund (other than Retiree co-payments) and who is not a Retiree.

Physician (also doctor) means a duly licensed doctor of medicine (MD) or a doctor of osteopathy (DO) acting within the scope of his or her license. The term may also apply to a Dentist, Podiatrist, Optometrist, Ophthalmologist, Psychologist, Psychiatrist, Chiropractor, Nurse-Midwife, Professional Counselor and Social Worker, any of whom provide Medically Necessary covered services or supplies lawfully rendered within the scope of their respective licenses.

Preferred Care Provider is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but only if the provider is included in the Directory as a Preferred Care Provider for:

the service or supply involved; and
the class of employees of which you are a member.

Preferred Provider Organization (PPO) means a group of select physicians, specialists, hospitals, and other treatment centers which have agreed to provide their services to Fund participants and dependents at a Negotiated Charge under the terms of an agreement. These medical providers are sometimes referred to as Preferred Care Providers and Network Providers throughout this SPD.

Reasonable and Customary (R&C) means the fee regularly charged and received by a person, group or entity for services, treatments or supplies covered under the Plan to the extent such fee does not exceed the general level of charges by others who render or furnish such services, treatments or supplies in the locality where the charge is incurred, for Illness or injury comparable in nature and severity. The term "locality" means a county or such greater geographically significant area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made.

Schedule of Covered Dental Expenses is the list of the Covered Dental Expenses included under the Plan for which a Participant is required to pay for dental services. For each service, however, the Covered Dental Expense will not be more than the amount set forth in the Schedule for the particular dental service. If the charges are less than the Schedule amount for a particular service, the amount included as a Covered Dental Expense will equal the actual charges. A copy of the Schedule is available upon request from the Fund Office.

Second Surgical Opinion is an opinion that may be obtained from another surgeon or doctor of internal medicine, or other specialist unassociated with the surgeon who first recommended surgery.

Total Disability and Totally Disabled means a Participant's complete inability to engage in substantial, gainful employment because of a medically determinable physical or mental impairment that is expected to last permanently or indefinitely, or the complete inability to perform the normal activities of a person of like age and sex.

Union is Local 805, I.B.T.

USERRA means the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended from time to time.