Category: Members

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.

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.

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 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.

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.

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?

• When you no longer meet the definition of eligibility (see page 3);
• When the Fund no longer receives contributions on your behalf; or,
• When the Fund terminates or no longer provides benefits for you and your dependents.

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.

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.

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.

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

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.

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).

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.

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

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.

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.

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.

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*.

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.

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.

Your dental coverage provides a wide variety of services. The following is an outline of commonly-used covered services.

• Diagnostic and Preventive Services: Includes oral exams, cleanings, scaling and polishing, fluoride treatment (dependents only up to 19th birthday) and X-rays.
• Palliative Services: Emergency treatment for relief of pain.
• Restorative Services: Fillings, amalgams, and non-abutting crowns
• Oral Surgery: Extractions, fractures, and other oral surgery procedures.
• Endodontic Services: Root canal treatment.
• Space Maintainers: Simple
• Periodontic Services: Gum surgery and maintenance procedures.
• Repair – Dentures and Bridges: Repairs of broken dentures and bridgework.
• Prosthetic Services: Consists of full or partial dentures, abutting crowns, pontics and inlays. (Limited to once every five years.)

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.

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.

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.

No. The procedures for filing a claim is the same whether or not you use the PPO.

There are no deductibles for any covered services.

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.

The plan does not cover the following:

• Charges in excess of the schedule;
• Procedures not listed in the fee schedule as covered expenses;
• Charges performed more frequently than the plan allows, such as more than once every five years for dentures, crowns and bridges;
• Cosmetic dentistry;
• Charges that do not meet professionally recognized standards of quality, are not necessary for treatment of existing disease or injury, or are not appropriate treatment based on the person’s total oral condition.
• Treatment from anyone other than a licensed dentist or physician, except routine cleaning of teeth and fluoride application, which is performed by a licensed dental hygienist under the direct supervision of, and billed by, a dentist or physician;
• Facings, veneers, or similar material placed on molar crown or pontics;
• Any service or supplies incurred, installed, or delivered before you or your dependents become eligible for benefits under this Plan;
• Replacing a lost, missing or stolen prosthetic appliance;
• A broken appointment;
• Any services received from a medical department, clinic or any facility provided or furnished by your or your dependent’s employer;
• Any service that is not necessary or is not normally performed for proper dental care of the condition, or any service that is not approved by the attending dentist;
• Services or supplies that do not meet accepted standards of dental practice including experimental services or supplies;
• * The Variable Benefit may be applied to out-of-pocket expenses incurred above the dental plan maximums.
•  Services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared;
• Any duplicate prosthetic appliance except as specifically provided;
• Completing claim forms;
• Oral hygiene or dietary instruction or plaque control programs;
• Wiring or bonding teeth or crowns to act as a splint for any reason;
• An injury arising from employment;
• An injury covered by Workers’ Compensation;
• An injury covered by No Fault or any similar insurance law;
• Services or supplies for which you are not required to pay; or
• Appliances, restorations, or any procedure to alter vertical dimension or restore occlusion.

• Eligible members, who participate in the City’s basic plans (GHI-CBP or HIP- Prime POS), and purchase the optional rider offered by the City, and their spouses;
• Retired members under the GHI Type C plan who purchase the optional rider offered by the City, and their spouses;
• Unmarried dependent children under age 19
• Effective July 1, 1996, unmarried dependent children who are full-time students until the end of the calendar year of the students’ 23rd birthday or graduation, whichever occurs first.

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?
The catastrophic coverage provided under the basic program is limited to in-hospital care, such as expenses relating to surgery, anesthesia, maternity care, and in-hospital lab and X-ray. The catastrophic coverage under the City’s GHI-CBP excludes non-hospital expenses. Since non-hospital expenses can be substantial when acute care is required, the Fund’s catastrophic coverage provides you with added protection.

Are there any charges that the plan does not cover?
The plan does not cover any charges that are covered under the City’s optional rider. For instance, psychiatric and prescription drug charges are excluded. Any charges that are excluded under the basic plan are also excluded under the Catastrophic Medical Plan.

Yes, there is a lifetime maximum benefit of $250,000 per person.

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.

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.

All eligible members and dependents, as defined in the General Information section, are covered for vision care benefits.

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.

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.

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.

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.

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.

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).

All eligible members and dependents, as defined in the General Information section, are covered for prescription drug reimbursement benefits.

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.

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.

No.

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.

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.

All eligible members and dependents, as defined in the General Information section, are covered for hearing care benefits.

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.

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.

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.

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.

You are responsible for paying the difference between the cost of the hearing aid and the amount the plan provides.

There are no deductibles for any covered services.

The plan does not cover the following:

• Procedures not listed in the plan as covered services;
• Charges performed more frequently than the plan allows, such as more than once every calendar year for hearing examinations;
• Treatment from anyone other than a licensed physician, surgeon or audiologist;
• Any service or supplies incurred, installed, or delivered before you or your dependents become eligible for benefits under this Plan;
• Replacing a lost, missing or stolen hearing appliance;
• Repairs of hearing appliances;
• Non-durable equipment, such as batteries;
• A broken appointment;
• Any service payable under Medicare or any other governmental plan (including the City’s plan), or any other health insurance plan;
• Any service that is not necessary or is not normally performed for proper care of your hearing condition or any service that is not approved by the attending physician, surgeon or audiologist;
• An injury covered by No Fault or any similar insurance law;
• Medical or surgical treatment of the ear or ears;
• Special procedures or training, such as lip reading courses, schooling or institutional expenses;
• Experimental services or supplies;
• Services or supplies received as a result of hearing ailment, defect, or injury due to an act of war, declared or undeclared;
• Any duplicate hearing appliance;
• Completing claim forms;
• An injury arising from employment;
• An injury covered by Workers’ Compensation; or Services or supplies for which you are n to paot requiredy.

All eligible members, as defined in the General Information section, are covered for this benefit.

In the event of a member’s death, the plan pays to the named beneficiary designated on the enrollment form on file with the

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.

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.

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.

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.

All eligible members and dependents, as defined in the General Information section, are covered for the Variable Benefit plan.

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).

The Variable Benefit Plan provides up to $100 per calendar year per family for eligible expenses incurred in any one of the above benefits.

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.

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.

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.

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.

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.