| International Union of Operating Engineers Local 891 Welfare Fund | |||||||||||||
| Board of Trustees Robert J Troeller, President/Trustee Kevin J. Gallagher, Chairman Frank Byrne Andrew Samberg Adele McGreal Fund Third-Party Administrator Fund Accountants |
Alternate Trustee to the President Richard Gorgoglione Fund Chairman Fund Counsel |
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Highlights Of Your Benefits This section of your booklet highlights the benefits provided by the Local 891 Welfare Fund. All of the benefits are described in detail in the appropriate sections in this booklet. The following benefits are available to all covered members and their eligible dependents, unless otherwise indicated.
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| Reimbursement Scheduled amount for covered preventive, basic and major dental services Orthodontic Catastrophic Medical Plan Vision Care Plan Indemnity (Plan A) Prescription Drug Reimbursement Plan Hearing Care Plan No-cost option Life Insurance Plan Benefit
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Maximums for each covered person Non-orthodontic $3,000 per calendar year Implants Lifetime maximum Two voucher option (Plan B) Four voucher option (Plan C) Covered services Indemnity Variable Benefit Plan Survivor Continuation Benefit Plan Legal Services Plan |
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| General Information
What benefits are provided by the I.U.O.E. Local 891 Welfare Fund?
The I.U.O.E. Local 891 Welfare Fund (Hereafter referred to asWelfare Funds or as Funds) provides dental, catastrophic medical, vision care, prescription drug, hearing care, life insurance, legal services, and a variable benefit to all active members, retirees and their eligible dependents. The Fund also reimburses the COBRA premiums paid to New York City for the first 12 months of COBRA coverage in the event a surviving spouse and/or eligible dependents lose basic health coverage due to the member’s death. Additionally, the Fund waives the first 12 months of COBRA premiums for the surviving spouse and/or eligible dependents of a deceased member for the continuation of Fund benefits. The benefits provided by the Fund supplement those provided by the City.
To the extent that this booklet describes an insured benefit (e.g., life insurance), the group insurance contract specifies the exact benefits provided, and the language of the insurance contract will govern in the event of inconsistency between it and the language of this booklet. What benefits are provided by the City?
All eligible active members, retirees and their dependents are covered by a City basic health plan of their choice. For a detailed description of the basic health benefits, members should refer to the Summary Program Description distributed by the City, which also describes the optional riders that may be purchased to supplement the basic health plan.
Who is eligible for benefits?
Members
The Welfare Fund covers both active and retired members. Active members are employees of the New York City Board of Education who are covered under collective bargaining agreements with Local 891 International Union of Operating Engineers and for whom the Board makes contributions to the Local 891 Welfare Fund.Retired members are eligible for benefits if they are collecting a pension benefit from the City or Board of Education and the City makes contributions to the Welfare Fund on their behalf. Dependents
Dependents are defined by the Fund as your spouse to whom you are legally married and your unmarried dependent children up to the end of the calendar year in which they turn age 23*.*Note: The Catastrophic Medical Plan covers unmarried dependent full-time students until the end of the calendar year of the student’s 23rd birthday or graduation, whichever occurs first.
The term “children” includes natural children; children for whom a court has accepted a consent to adopt and for the support of whom an active or retired member has entered into an agreement; children for whom a court of law has made an active or retired member legally responsible for support and maintenance; and children who live with an active or retired member in a regular parent/child relationship and who are chiefly dependent for support on the active or retired member. In addition to the dependents covered under the plan definitions, the Fund will also cover physically or mentally disabled children of any age who became so handicapped prior to the limiting age, and who are unmarried, chiefly dependent upon the member for support and incapable of self-sustaining employment because of the handicap. The Fund reserves the right to request documentation, such as a marriage license, birth certificate, court order or tax returns from any member to verify a dependent’s status. How do I enroll?
All members must complete and sign an enrollment form and file the original form with the Fund Chairman. Members that have had a change in dependent status or wish to change their beneficiary should contact the Fund Chairman and complete a new enrollment form. Enrollment is required in order to receive benefits.
When does coverage begin?
Coverage for all Fund benefits, except the Catastrophic Medical Plan, begins on a member’s first day of employment. Catastrophic Medical Plan coverage begins on the day you are eligible for the City health benefit plans*. Dependents become eligible on the same date as the member, or the date they first become eligible dependents, if later.When does coverage end?
Am I allowed to continue benefits if I lose coverage?
Members and their eligible dependents may be eligible to continue their Welfare Fund benefits under COBRA. Refer to section XI of the booklet for additional information regarding continuation coverage available under COBRA.
Can the benefits be modified or terminated?
Yes. The benefits provided by the Fund may be changed, modified, augmented or discontinued by the Board of Trustees. The Board of Trustees adopts rules and regulations for the payment of benefits and all provisions of this booklet are subject to such rules and regulations and the Trust agreement which established the Fund and governs its operations.* Refer to the Catastrophic Medical Plan section for details about eligibility/coverage requirements
Active member and retiree benefits under this plan have been made available by the Trustees as a privilege and are always subject to modification or termination in the exercise of the prudent discretion of the Trustees. No person acquires a vested right to such benefits either before or after his or her retirement. The Trustees may expand, modify or cancel the benefits for active members and retirees; change eligibility requirements or the amount of participant contributions; and otherwise exercise their prudent discretion at any time without legal right or recourse by an active member, retiree or any other person. If my claim is denied, may I appeal the decision?
Yes. All rules are uniformly applied by the Fund. The actions of the Fund are subject to review and reconsideration only by the Board of Trustees upon written appeal. An appeal must be filed with the Fund within 60 days of denial of the claim by submitting notice in writing to the Fund Chairman. The Trustees shall act on the appeal within a reasonable period of time and render their decision in writing, which shall be final and conclusive and binding on all persons. What happens if I die and don’t name a beneficiary or if any beneficiary pre-deceases me?
With respect to any benefits payable to a deceased member upon their date of death, or with respect to death benefits payable by virtue of the death of the member where the member’s designated beneficiary has predeceased the member and a successor has not been designated, or where the member has not designated a beneficiary, then these benefits will be made payable to the first surviving class of the following classes of successive preference beneficiaries:The covered member’s:
a) Surviving spouse b) If no surviving spouse, to the surviving children equally c) If no surviving children, to the covered member’s estate
Third Party Reimbursement If a member or dependent is injured through the acts or omissions of a third party, the Fund shall be entitled, to the extent it pays out self-insured benefits, to reimbursement from the member or dependent from any recovery obtained from the responsible third party. Alternatively, the Fund shall be subrogated, unless otherwise prohibited by law, to all rights against such third party arising out of its act or omissions that caused the injury. Subrogation means that the Fund becomes substituted in the injured person’s place to pursue a claim for recovery against the third party. Benefits will be provided only on the condition that the member or dependent agrees in writing to: 1. Reimburse the Fund, to the extent of benefits paid by it, out of any monies recovered from such third party, whether by judgment, settlement or otherwise; 2. Provide the Fund with a Subrogation/Third-Party Reimbursement Agreement and Assignment of Proceeds to the extent of benefits paid out by the Fund on the claim and to cooperate and assist the Fund in seeking recovery. The Assignment will be filed with the person whose act caused the injuries, his or her agent, the court and/or the provider of services; and, 3. Take all reasonable steps to effect recovery from the responsible third party and to do nothing after the injury to prejudice the Fund’s right to reimbursement or subrogation, and to execute and deliver to the Fund Chairman all necessary documents as the Fund may require to facilitate enforcement of the Fund’s rights and not to prejudice such rights.
Cobra Coverage The Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that the City and the Local 891 Welfare Fund offer members, retirees and their families the opportunity to continue certain health benefits at 102% of the group rates (or 150% of the group rate for the 19th through 29th months in cases of total disability) whereby the coverage would otherwise terminate. The maximum period of coverage is either 18, 29, or 36 months, depending on the reason for continuation. Eligibility
Local 891 Welfare Fund members are eligible for continuation under COBRA if Welfare Fund coverage was terminated due to a reduction in hours of employment or the termination of employment (for reasons other than gross misconduct).Spouses of members have the right to choose continuation of coverage if they lose coverage for any of the following reasons: 1) death of the member; 2) termination of the member’s employment (for reasons other than gross misconduct); 3) loss of health coverage due to reduction of hours of employment; 4) divorce or legal separation from the member.
Dependents of members have the right to continue coverage if coverage is lost for any of the following reasons: 1) death of the member; 2) termination of a member’s employment (for reasons other than gross misconduct); 3) loss of health coverage due to the member’s reduction in hours of employment; 4) the dependent ceases to be a “dependent child” under the Fund’s eligibility rules. A child who is born to, or placed for adoption with, you during a period of COBRA coverage will be eligible to become a qualified beneficiary. These qualified beneficiaries can be added to COBRA coverage upon proper notification to the Fund of the birth or adoption. Periods of COBRA Continuation
Continuation of coverage for the former member and family as a result of termination of employment (for reasons other than gross misconduct) or reduction of work schedule is available for a maximum of 18 months.If either you or an eligible dependent is classified as disabled under Social Security during the first 60 days of COBRA coverage, coverage may be continued for up to a total of 29 months. You must notify the Fund Chairman before the end of the initial 18 months and within 60 days of such disability determination. If any qualified beneficiary becomes eligible for this 11 month disability extension, all covered qualified beneficiaries are also entitled to the 11 month extension of coverage. However, if you or your eligible dependent is no longer classified as disabled by Social Security, that person must notify the Fund Chairman within 30 days of the determination and the 11 month extension will end. The covered person is required to pay 150% of the cost for the 19th through the 29th months.
Continuation of coverage for the spouse or dependent as a result of death, divorce, legal separation, or loss of dependent child status is available for a maximum of 36 months. Continuation of coverage can never exceed 36 months in total, regardless of the number of events which relate to a loss of coverage. Coverage during the continuation period will terminate if the COBRA recipient fails to make timely premium payments or becomes enrolled in another employer-sponsored group health plan (unless the plan contains a pre-existing condition exclusion). Notification Responsibilities
Under the law, the member or eligible dependents have the responsibility to notify either their payroll secretary or the Health & Welfare Division of the Board of Education and the Fund Chairman within 60 days of an address change, divorce, legal separation, or a child losing dependent status. Retirees should notify the NYC Employee Benefits Program and the Fund Chairman.When a qualifying event occurs and provided the Fund has received proper notification, you and your family will be notified of your option to choose continuation coverage.
Election of COBRA Continuation
To elect City COBRA continuation of health coverage, the COBRA eligible person must complete a “COBRA – Continuation of Coverage Application”. Members and/or eligible dependents can obtain an application form from either their payroll secretary or the Health & Welfare Board of Education. Retirees should notify the NYC Employee Benefits Program.To indicate your interest in electing Local 891 Welfare Fund COBRA continuation coverage, you should answer ‘yes’ to the question on the City COBRA application form that asks “Do you wish to purchase benefits from your Welfare Fund?” and notify the Fund Chairman directly. To expedite processing, you should send a copy of the completed City COBRA application form to the Fund Chairman. If you do not purchase City COBRA, but would like to elect Welfare Fund COBRA continuation coverage, write to the Fund Chairman directly.
Eligible persons choosing to elect COBRA continuation coverage must do so within 60 days of the date on which they receive notification of their rights. Note: The election of City COBRA does not automatically enroll you in COBRA for the Local 891 Welfare Fund. You must indicate on the City COBRA form that you wish to enroll in COBRA from your Welfare Fund
Coordination Of Benefits All benefits provided by the Local 891 Welfare Fund are subject to Coordination of Benefits (COB) provisions. COB is applicable when you or your eligible dependents are covered by another group benefit plan. In the event any Welfare Fund benefits are also provided by the patient’s basic health plan, then that plan is primary and the Welfare Fund is secondary. The Fund also provides Coordination of Benefits to members married to members. Benefits are payable under a primary-secondary formula. The primary plan determines its benefits first, and pays its normal benefit. The secondary plan computes its benefit second, and may reduce its benefit payment so that the member does not receive more than 100% reimbursement of expenses. In no event would the Local 891 Welfare Fund’s liability exceed the benefits payable in the absence of COB. The order of payment is determined as follows:
1. If one plan does not have a COB provision it will be Primary.2. If the patient is our (Local 891 Welfare Fund) member, the Local 891 Welfare Fund is the primary payer. However, if the patient is the spouse of our member, and is covered under another group plan, the other group is primary and the Local 891 Welfare Fund is secondary.
3. If the patient is an eligible dependent child under both plans, then the plan of the parent whose birthday occurs first within the calendar year will be primary, except that where the parents are separated or divorced, the following rules will apply: a. if a court order establishes that one of the parents is financially responsible for medical, dental or other health care expenses of a child, the plan under which the child is a dependent of that parent shall be primary; b. if financial responsibility has not been established by a court order and the parent with custody of the child has not remarried, the plan under which the child is the dependent of that parent will be primary; or, c. if financial responsibility has not been established by a court order and the parent with custody has remarried and the child is also covered as a dependent of the step-parent, then the order of payment shall be: 1st the plan under which the child is a dependent of the parent with custody; 2nd the plan under which the child is a dependent of the step-parent; or, 3rd the plan under which the child is covered as a dependent of the parent without custody. 4. If none of the above applies, then the plan under which the patient has been enrolled the longest will be primary. However, the plan covering you as a laid- off or retired member, or as a dependent of such a person, shall be secondary and the plan covering you as an active member shall be primary, as long as the other plan has a COB provision similar to this one.
Dental Plan Who is covered?
All eligible members and dependents, as defined in the General Information section, are covered for dental benefits. However, certain services, such as orthodontia and space maintainers, are only available to eligible dependent children up to the age of 19.
What are the benefits?
Members and their eligible dependents will be reimbursed according to a fixed fee schedule, a copy of which can be obtained from the Fund Chairman. This means that the plan reimburses your expenses up to the amount in the fee schedule, but not more than the dentist’s charge*. In addition, if you use one of the dentists in the Preferred Provider Organization (PPO), the fees listed in the dental schedule will be accepted as payment in full for covered services.However, the payment for covered services is subject to the plan provisions, limitations and exclusions specified in this booklet.
What is the Preferred Provider Organization?
A Preferred Provider Organization, or PPO, consists of a panel of dentists who have agreed to accept the Fund’s dental fee schedule as payment-in-full for covered services. Consequently, there is no out-of-pocket cost to Fund members and their eligible dependents when you use a participating dentist. You will only be required to pay for procedures that are not covered by the plan or for procedures performed after you have reached the plan maximums*.
How do I choose a PPO dentist?
A list of participating dentists is available from the Fund Chairman. You may select any dentist from the list. All members and their dependents will be able to receive appointments during usual office hours without restrictions.
What if my dentist is not a PPO dentist?
You always have the choice of going to your own dentist at any time. If your dentist is interested in joining the PPO panel, you or your dentist should contact the Fund Third Party Administrator at (212) 505-5050, ext. 229 or the Fund Chairman for further details.
What services does the plan cover?
Your dental coverage provides a wide variety of services. The following is an outline of commonly-used covered services.
Implants: For replacement of natural teeth. This service is limited to $1,500 per implant with a $2,000* lifetime benefit maximum. This maximum will not be included in the annual dental plan maximum. Reimbursement for dental implants will only be made under the following American Dental Association (ADA) procedure codes: 6010, 6020, 6040, 6050, 6055, 6080, and 6090. Orthodontic Services: For handicapping malocclusion which is abnormal and correctable. This service is limited to a lifetime benefit maximum of $3,000* per eligible dependent child under age 19. * The Variable Benefit may be applied to out-of-pocket expenses incurred above the dental plan scheduled amount. Is pre-treatment review required?
When a dentist’s charges for a course of treatment will amount to $500 or more, dental services must be reviewed by the Fund before treatment is rendered. In such instances, the member’s dentist is required to submit x-rays and treatment recommendations to the Fund for review by the Fund’s Consulting Dentist. The covered member’s dentist may proceed to render dental services as soon as the proposed course of treatment has been reviewed by the Fund. The Fund reserves the right to deny claims amounting to $500 or more which have not been reviewed by the Fund’s Consulting Dentist prior to beginning treatment.The Fund’s Consulting Dentist reviews all proposed courses of treatment which will amount to $500 or more in order to guard against unnecessary pain and inconvenience to covered members and their eligible dependents, and to prevent frivolous or unnecessary charges to the Fund by a dentist. Also, for these reasons, the Consulting Dentist will examine selected members or their eligible dependents prior to reviewing a proposed course of treatment. In such instances, members receive a second professional opinion free of charge.
How am I reimbursed for rendered services?
When you visit a dentist, you should obtain a Dental Claim Form by calling the Fund Trustee designated to distribute forms. When dental work is completed, you must mail the claim form to the address printed on the claim form. The claim form should be submitted within 60 days of completion of treatment. You must submit claims no later than the end of the calendar year following the year in which services were rendered.
Are there different procedures for filing claims under the PPO?
No. The procedures for filing a claim is the same whether or not you use the PPO.
Are there any deductibles under the plan?
There are no deductibles for any covered services.
What is the maximum benefit that the plan will pay?
There is a yearly maximum benefit allowance of $3,000* for each covered person. A separate lifetime maximum of $2,000* is provided for dental implants per eligible person. There is also another separate lifetime maximum for orthodontia of $3,000* for eligible dependent children up to age 19.
What services are not covered by the plan? The plan does not cover the following:
Catastrophic Medical Plan Note: You must purchase the optional rider offered by the City in order for you and your eligible dependents to be covered for the Catastrophic Medical Plan. Who is covered?
What is the Catastrophic Medical Plan?
The Catastrophic Medical Plan supplements the major medical benefits provided under the City’s GHI-CBP, GHI Type C or HIP-Prime POS plans in the event of catastrophic illness. The plan pays 100% of eligible expenses after a $2,000 annual deductible has been reached. Eligible expenses are those medical and hospital charges considered reasonable and customary by GHI and not reimbursed by the City health plan or any other health insurance coverage.If I have medical coverage under the City plan, why do I need catastrophic coverage?
Under the City plan, eligible members and their dependents have the option of receiving medical services from a non-participating medical care provider at a reduced rate of reimbursement. The catastrophic medical coverage is provided to protect those members who select this option from any large out-of-pocket expenses which may occur. Doesn’t GHI cover catastrophic expenses under the basic program as well? Are there any charges that the plan does not cover? Are there any benefit limits or maximums?
Yes, there is a lifetime maximum benefit of $250,000 per person.
What if I don’t have any out-of-pocket expenses until the end of the year?
All out-of-pocket expenses incurred during the last three months of the calendar year (October, November, December) are applicable to both the current calendar year’s deductible and the next calendar year’s deductible. For example, if you incur $1,200 in out-of-pocket expenses in October and November, then you only need incur an additional $800 in the following year before you meet the deductible.
How do I get reimbursed for covered services?
You may obtain a claim form by calling the Fund Chairman. After completing the claim form, submit it to the Fund Chairman. You must submit claims no later than the end of the calendar year following the year in which services were rendered.
Vision Care Plan Who is covered?
All eligible members and dependents, as defined in the General Information section, are covered for vision care benefits.
What does the plan cover?
The vision care plan covers eye examinations, lenses and frames, and/or contact lenses prescribed by a qualified ophthalmologist or optometrist, or filled by an optician.
What are the benefits?
The benefits depend on the option you select. Members can choose between an indemnity plan and two no-cost options. Thus, members have the following three alternatives:Plan A – Indemnity Plan
Plan B – Two vouchers per year Plan C – Four vouchers per year The indemnity plan pays up to $200.00* per family per calendar year and you have the choice of visiting any qualified optical provider. What are the no-cost options?
Under the no-cost options, the Fund issues a voucher that entitles you to receive a comprehensive eye exam and allows you to choose among a wide variety of frames and lenses without incurring any out-of-pocket expenses. We have arrangements with optical companies, each of which has a network of participating providers from which you may choose. A list of participating provider locations will be provided when vouchers are issued. By capitalizing on discounts that are available with these companies, the Fund can offer enhanced benefits to you and your family members.* The Variable Benefit may be applied to out-of-pocket expenses incurred above the indemnity plan maximum.
Can I combine the indemnity plan with the no-cost options?
No. If you select the indemnity plan for any given year, you may not select either voucher option for that same year. However, you may combine either of the voucher plans to a maximum value of $200 per year. Each voucher can only be used for one eye exam and one pair of eyeglasses, pursuant to the plan.
What if I select a pair of frames which is more expensive than those that the no-cost plan allows?
You are responsible for paying the difference between the value of the frame and the amount the plan provides. However, the participating optical care companies have agreed to provide you with a 30% discount on all services that exceed the coverage provided by the plan.
How are benefits obtained?
If you intend to use Plan A, then obtain a claim form by calling the Fund Chairman. After completing the claim form, submit it to the address printed on the claim form within 90 days of treatment. You must submit claims under the indemnity option no later than the end of the calendar year following the year in which services were rendered.You may obtain vouchers by calling the Fund Third Party Administrator at (212) 505-5050, ext 229. Since the vouchers expire 60 days following issuance, we recommend that you only request a voucher shortly before you are ready to use the plan. Vouchers are only valid for no more than 60 days and expire on December 31 if not used in the calendar year in which they were issued. (E.g., a voucher is issued November 15; voucher expires December 31).
Prescription Drug Reimbursement Plan Who is covered?
All eligible members and dependents, as defined in the General Information section, are covered for prescription drug reimbursement benefits.
What does the plan cover?
The plan covers up to $300* per family per year in out-of-pocket prescription drug expenses. The plan covers expenses incurred by members and their eligible dependents that are not reimbursed by your City health plan or any other health insurance plan, such as expenses applied to a deductible, copayment, or coinsurance requirement. The plan also covers certain prescription drugs that may be excluded under the City’s basic plan, such as birth control pills.
Is the copayment under my prescription drug card covered?
Yes. The plan covers copayments required by the pharmacy at the point-of-sale or under a mail-order program. Be sure to get a receipt from the pharmacist to substantiate your out-of-pocket payment.
Do I need to purchase the optional rider under the City’s basic health plan in order to be eligible for the Fund’s Prescription Drug Reimbursement Plan?
No.
How am I reimbursed for covered services?
You must file a claim for reimbursement after the claim has been submitted for payment under the City’s prescription drug plan. You may obtain a prescription drug reimbursement claim form by calling the Fund Third Party Administrator at (212) 505-5050, ext 229. Submit your completed claim form with the appropriate medical receipts or other evidence of payment to the address on the claim form. Pharmacy drug printouts may be used in lieu of filling out individual prescription lines providing that the patient’s name, date of purchase, prescription number, name of drug, prescribing doctor’s name, dispensing pharmacy and the cost of the prescription to the patient is entered. Claims should only be submitted once a member reaches the $300* maximum or no later than the calendar year following the year expenses were incurred.* The Variable Benefit may be applied to out-of-pocket expenses incurred above the $300 maximum.
What services are not covered by the plan?
The plan does not cover expenses that are excluded under the City’s prescription drug plan for the following reasons:· Prescriptions exceeding the plan’s supply limit;
· Drugs purchased without a prescription; or · Drugs purchased from a laboratory or physician.
Hearing Care Plan Who is covered?
All eligible members and dependents, as defined in the General Information section, are covered for hearing care benefits.
What services does the plan cover?
The hearing care plan covers otologic (hearing) examinations performed by a licensed physician, surgeon or audiologist; and hearing aid appliances prescribed by a licensed physician or audiologist once every 36 months, per ear.
What are the benefits?
The benefits depend on the option you select. Members can choose between an indemnity plan and a no-cost voucher option. Thus, members may elect one of the following plans:Indemnity Plan – reimburses you up to $35 per calendar year for one hearing examination. The plan will also reimburse you up to $600* per ear in each consecutive 36-month period for hearing aid appliances.
No-Cost Voucher Plan – When you use a participating provider, you receive a basic comprehensive hearing examination. In addition, you will be eligible for a covered hearing aid appliance per ear in each consecutive 36-month period without incurring any out-of-pocket expenses. How am I reimbursed for covered services under the indemnity plan?
Contact the Fund Third Party Administrator at (212) 505-5050, ext 229 to obtain a claim form. Send a copy of the completed claim form along with corresponding proof of payment to the address printed on the claim form.
How do I obtain benefits under the no-cost plan?
To receive benefits under the no-cost plan, contact the Fund Administrator at (212) 505-5050, ext 229 to obtain a voucher and a list of participating provider locations. Present the voucher when visiting a participating provider to obtain benefits. Participating providers have agreed to accept the voucher as payment in full for covered services and appliances.* The Variable Benefit may be applied to out-of-pocket expenses incurred above the indemnity plan maximums.
What if I select a hearing aid appliance which is more expensive than those allowed under the no-cost plan?
You are responsible for paying the difference between the cost of the hearing aid and the amount the plan provides.
Are there any deductibles under the plan?
There are no deductibles for any covered services.
What services are not covered by the plan?
The plan does not cover the following:
Life Insurance Plan Who is covered?
All eligible members, as defined in the General Information section, are covered for this benefit.
What are the life insurance benefits?
In the event of a member’s death, the plan pays to the named beneficiary designated on the enrollment form on file with the
How do I designate a beneficiary?
Obtain a form from the Fund Chairman to designate a beneficiary. You may name anyone you wish as your beneficiary on a form provided for that purpose. Payment will be made in a lump sum to your designated beneficiary or beneficiaries in equal shares unless you request otherwise when you file your beneficiary form. You may name a contingent beneficiary that will receive your life insurance if all primary beneficiaries die before you.
How do I change my beneficiary?
You may change your beneficiary at any time by filing a new beneficiary designation on the enrollment form. It is very important to keep your beneficiary designation up to date. Should you have a change in marital status or should the beneficiary die, a new beneficiary designation card should be completed.
How are benefits obtained?
A member of the family or the named beneficiary of the deceased should notify the Fund Chairman in writing of the death of the member and include a certified copy of the member’s death certificate. The Fund Chairman will send a claim form to the beneficiary to be completed, signed, and returned to the insurer. The insurer will then process the claim.
What happens if I don’t name a beneficiary or if any beneficiary pre-deceases me?
With respect to any benefits payable to a deceased member upon their date of death, or with respect to death benefits payable by virtue of the death of the member where the member’s designated beneficiary has predeceased the member and a successor has not been designated, or where the member has not designated a beneficiary, then these benefits will be made payable to the first surviving class of the following classes of successive preference beneficiaries:The covered member’s:
a) Surviving spouse b) If no surviving spouse, to the surviving children equally c) If no surviving children, to the covered member’s estate.
Variable benefit Plan Who is covered?
All eligible members and dependents, as defined in the General Information section, are covered for the Variable Benefit plan.
What services does the plan cover?
The Variable Benefit plan was implemented to further minimize out-of-pocket expenses to you and your family. The plan covers out-of-pocket expenses that exceed the maximums of certain Fund benefits, which are the following:Prescription drug expenses in excess of the $300 maximum under the Fund’s Prescription Drug Reimbursement Plan
Hearing aids and services in excess of the maximums under Fund’s Hearing Care Plan indemnity option Vision care expenses and services in excess of the $200 maximum under the Fund’s Vision Care Plan’s indemnity option (Plan “A”) Charges in excess of the dental plan fee schedule for covered expenses (non-PPO panel dentists only) Charges in excess of the dental plan maximums ($3,000 annual maximum; $3,000 lifetime maximum for orthodontia; $2,000 lifetime for dental implants). What are the benefits?
The Variable Benefit Plan provides up to $100 per calendar year per family for eligible expenses incurred in any one of the above benefits.
How are benefits obtained?
If you intend to use the Variable Benefit Plan, obtain a claim form by calling the Fund Third Party Administrator at (212) 505-5050, ext 229. After completing the claim form, submit it to the address printed on the claim form. You must submit claims no later than the end of the calendar year following the year in which services were rendered.
What services are not covered by the plan?
The Variable Benefit Plan applies only to those covered expenses eligible for reimbursement under the rules and regulations of each individual plan that this plan supplements.The Variable Benefit Plan does not supplement the Fund’s Catastrophic Medical Plan; the Fund’s Life Insurance Plan; the Fund’s Survivor Continuation Benefit Plan or the Fund’s Legal Services Plan.
Survivor Continuation Benefit Plan Who is covered?
The Fund protects your survivors if you should die. If you die while a member, your eligible survivors, which are your spouse who has not remarried, and dependent children, as defined in the General Information section, are covered for this benefit.
What are the benefits?
City Health Plan COBRA Premium Reimbursement – In the event of a member’s death, the Fund will reimburse the member’s eligible survivors for the first twelve months of COBRA premiums for the medical coverage that the member’s family was receiving from the City at the time of his or her death.Waiver of Welfare Fund COBRA Payment – COBRA coverage for the Fund’s health-related benefits (catastrophic medical, hearing, variable, dental and vision plans) will be extended to the eligible survivors at no cost for the first twelve months, depending upon what benefits were elected under COBRA.
How are benefits obtained?
A member of the family or the named beneficiary of the deceased should notify the Fund Chairman in writing of the death of the member and include a certified copy of the member’s death certificate. The Fund will reimburse the eligible survivors for COBRA payments once evidence is furnished that the payments have been made for continuation under the City health plan.In order to obtain a waiver of Welfare Fund COBRA payments, the eligible survivors must elect COBRA as set forth on page 7 of this booklet.
Note: The election of City COBRA does not automatically enroll you in COBRA for the Local 891 Welfare Fund. You must indicate on the City COBRA form that you wish to enroll in COBRA from your Welfare Fund. |
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