Teamsters Local 805 Welfare Fund

PLAN BENEFITS

The Fund provides Hospitalization, Major Medical, Dental, Optical, Prescription and Death benefits.

The Fund provides benefits for Injury or Illness, as defined herein. Benefits payable are based upon Reasonable and Customary charges for Covered Expenses resulting from services and supplies that qualify as Medically Necessary care and treatment. How the Fund makes these determinations is discussed below. Note that certain Major Medical benefits are subject to benefit limitations, as set forth below.

A. REASONABLE AND CUSTOMARY AND OTHER RECOGNIZED CHARGES

Many benefits described in this booklet refer to Reasonable and Customary (R&C) charges. The amount of benefits payable depends, in part, on the extent to which a particular charge is determined to be "reasonable and customary". The Local 805 Welfare Fund will not pay more than the Reasonable and Customary charge for services and supplies.

For purposes of this Plan, Reasonable and Customary charges are the fees 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. Accordingly, the Reasonable and Customary charge may differ by geographical area, so that a reasonable and customary charge for a certain services in New York City may differ from the reasonable and customary charge for the same surgery in Connecticut, New Jersey or Pennsylvania.

The Plan, as specified in this booklet, does not use a Reasonable and Customary fee schedule for certain services and supplies. In those instances the Plan will use either the stated amount or the Negotiated Charge as the recognized charges. The Network fee schedule will be less than the generally accepted Reasonable and Customary charges and will result in a balance that you will be responsible to pay. The way to avoid balances of this type is to use the Network providers.

Before incurring medical expenses you may wish to check the Fund's Allowable Expense and ask your Physician about his charge for a particular procedure. Otherwise you may be responsible to pay a large part of the expense out of your own pocket.

B. MEDICALLY NECESSARY CARE

The Plan covers only Medically Necessary care and/or treatment, 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. The Board of Trustees has the discretion to determine medical necessity under the criteria guidelines set out herein. For more information on what is considered Medically Necessary under the Plan, please see the Glossary of Terms section of this SPD.

C. LIFETIME MAXIMUM BENEFIT LIMITATION

All Hospitalization and Major Medical Benefits under this Plan are subject to a lifetime maximum of $1,000,000 per person. Once $1,000,000 in Hospitalization and/or Major Medical benefits have been paid on behalf of a Participant or any Eligible Dependent, no further payments will be made by this Plan.