HomeMy WebLinkAboutR-1986-021 I
RESOLUTION NO. 21 _86
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
DANIA, FLORIDA, CONCURRING WITH THE POSITION OF THE
BROWARD COUNTY COMMISSION REGARDING ELIMINATION OF
VENDORS OPERATING WITHIN ANY PORTION OF THE PUBLIC
RIGHTS-OF-WAY; PROVIDING THAT ALL RESOLUTIONS OR PARTS
OF RESOLUTIONS IN CONFLICT HEREWITH BE REPEALED TO THE
EXTENT OF SUCH CONFLICT; AND PROVIDING FOR AN
EFFECTIVE DATE.
WHEREAS, the Broward County Commission recently passed a resolution
which determined that sales from temporary wayside stands & median areas of
the public rights-of-way, and other portions of the public rights-Of-way
create dangerous and hazardous conditions for the traveling public, as
well as for the individuals conducting such sales; and
WHEREAS, The City Commission of the City of Dania is aware of the
recent proliferation within Broward County of the sale Of various types of
merchandise by vendors from the median strip and other portions of public
rights-of-way; and
WHEREAS, the City Commission concurs with the position of the Broward
County Commission regarding elimination of vendors operating within any
portion of the public rights-of-way;
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF
DANIA, FLORIDA:
I. That the City Commission finds and determines that sales from
temporary wayside stands & median areas of the public rights-of-way, and
other portions of the public rights-Of-way create dangerous and hazardous
conditions for the traveling public.
2 . That the City Commission concurs with the position of the Broward '
County Commission regarding elimination of vendors operating within any
portion of the public rights-Of-way.
3. That a copy of this resolution be immediately delivered to the
Broward County Commission.
PASSED AND ADOPTED the IIth day of March
1986.
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ATTEST:
J MAYOR COMMISS ONER � �
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CITY CLERK AUDITOR
APPROVED AS TO FORM AND CORRECTNESS:
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Frank C. Adler, City Attorney f '
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CITY OF DANIA
INTER-OFFICE MEMORANDUM; P-07-86
DATE: February 5 , 1986
TO: City Commissioners COPY:
City Manager
FROM: Michael Smith
SUBJECT: Employee Health Plan
HIGHLIGHTS OF CHANGES
Well Baby Care for Newborns Covers well care for newborns while
confined to the hospital after delivery only.
Increased Dental Limits: Total benefits payable during one calendar
year has been increased from $1000 to $2000. Same deductible apply.
No change in orthodontic benefit.
Vision Plan: $150 allowance per year (no deductible or co-insurance)
Tor eye exams and corrective lenses. . Benefit is available only to
employees who have completed one year of service. Dependents are not
eligible.
Prescription Drue Card• Instead of filing prescription claim forms,
employees are issued a P.C.S. Card. Employees pay a $2 deductible per
prescription regardless of the cost of the. drug. Cost saving is
realized through automatic use of generics except when otherwise
prescribed by doctor and through volume buying.
Preferred Provider Organization (PPO) : Has been The PPO which is called Florida added to the Plan.Health Network, is a network of
hospitals and physicians who have agreed to give discounts to the City
employees. Use of a PPO hospital or an office visit to a PPO doctor
is covered at 100% with no deductible. Use of a non-PPO hospital or
doctor is covered at 80%. Deductibles apply.
Second Surgical Opinion: Covered 100%.
Out-Patient Surgery and Pre-Admission Testin Covered 100%.
Pre-Certification/Utilization Review: Is a significant cost
containment feature. Persons who are to be confined in any hospital
must call a toll free number prior to admission (except in
emergencies) . Hospital stays are monitored by the medical staff and
Florida Health Network, to advise treating physicians of the cost
containment benefits available under our plan, monitor length of stay
and audit billings after discharge. Failure to pre-certify will
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result in a $200 deductible per confinement penalty.
Effective Date: 11/1/85 - General Employees
Effective Date: 2/1/86 Police and Fire
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EMPLOYEE HEALTH BENEFIT PLAN
TABLE OF CONTENTS
Page
Introduction To The Employee Health Plan 2
MEDICAL CARE BENEFITS
You Can Help Control Costs 3
Special Cost Containment Features 3
Schedule of Benefits 4
How Much Does It Cost 8
How The Plan Works 8
Who Is Covered And When 8
How Benefits Can Be Lost 10
Benefits After Termination 11
Definitions 11
Conversion Of Health Coverage 11
How To File A Claim 14
How To Appeal A Claim 15
Coordination Of Benefits 16
Third Party Reimbursement 17
What Is Covered By The Plan 18
Pre-Admission Testing 19
Preferred Provider Organization (PPO) 19
Pre-Certification/Utilization Review Program 20
Pre-Existing Conditions 21 w
! Prescription Drugs 22
Second Surgical Opinion 22
Medicare 24
Vision Benefit 25
The Following Charges Are Covered 25
The Following Charges Are Not Covered 26
Plan Termination 28
Dental Care Benefits
Eligibility & Coverage 29
Schedule of Dental Services 29
The Following Charges Are Covered 31
The Following Charges Are Not Covered 32
Definitions 34
Pre-Determination of Benefits 35
Orthodontia Benefits 37
ERISA INFORMATION
Employee Retirement Income Security Act 40
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INTRODUCTION TO THE EMPLOYEE HEALTH
BENEFIT PLAN
The Health Benefit Plan described in this booklet
provides benefits for a wide range of health care
services and supplies to employees and their
families. Your Employer offers this coverage to you
and your family to encourage you to obtain the care
necessary to secure and maintain the best physical
condition.
Your Employer also covers you with Life Insurance
to give you a full package of benefits that will
add to your financial security. The Life Insurance
is explained in a separate certificate issued by
the Life Carrier.
This summary is designed solely to assist you in
understanding your Employer' s Group Health Benefit
Plan. The actual provisions of the Plan will be
controlling in any case where there is or might be
a conflict between the Plan and this summary.
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The Plan falls under the jurisdiction of the
Federal Government ' s Employee Retirement Income
Security Act of 1974 ( ERISA) .
The Plan should not be deemed to constitute a
contract between the Employer and any Employee or
to be a consideration for, or an inducement or
condition of, the employment of any employee .
This booklet is your Summary Plan Description and
provides details of your Employers Group Health &
Welfare Benefit Plan. The Plan Document itself
contains the entire wording and its language will
control the operation of the Plan for the
.,., participant and for the employer. A complete copy
with full details of the Plan is on file with your
Employer.
PLAN CONSULTANT: Frank Porto
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YOU HELP CONTROL COSTS
The benefits for the Health Care described in �.,is
booklet have been designed to pay a large part of
the customary charges for a broad range of
necessary services, treatments and supplies, and
will give you substantial protection against the
cost of Health Care .
Like any good tool , the Plan must be used properly
if it is to endure . For the Plan to work
successfully, it is important that its cost is kept
reasonable. Of course , the cost is governed by the
claims submitted by you and your fellow employees.
when arranging health services, discuss the charges
that are to be made with your doctor and others who
are to furnish treatment. Generally, your doctor
will be pleased to discuss the charges with you . In
fact, most doctors encourage patients to talk over
charges with them in advance.
Satisfy yourself that charges will not be more than
you would pay if you were not covered by this Plan
and not more than is generally charged in your area
for similar services. Also, make sure only
necessary services are ordered . In this way, you
will be doing your part in keeping the Plan
�+ available for everyone and, at the same time, will
be holding your own out-of-pocket expenses to a
minimum.
SPECIAL COST CONTAINMENT FEATURES
To assist you in holding down your out-of-pocket
expenses, the City of Dania has included a
Preferred Provider Organization ( PPO) thru Florida
Health Network , which will give you discounts if
you use their facilities. Additionally, there is a
p »� Pre-Certification Utilization Review Program thru
Florida Health Network, which pre-certifies each
In-Patient Hospital confinement, may suggest
surgery be performed on an Out-Patient basis or if it might be a good idea to obtain a Second Surgical
Opinion. Finally, the Plan provides benefit savings
for Prescription Drugs thru Pharmaceutical Card
System, Inc. ( PCS) . Each of these benefits is fully
explained in this Booklet.
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SCHEDULE OF BENEFITS
EFFECTIVE DATE OF THE PLAN is October 1 , 1985
EFFECTIVE DATE OF BENEFIT CHANGES November 1, 1985
WHEN INDIVIDUAL COVERAGE IS EFFECTIVE
The Waiting Period is One Month for all full-time
employees.
Coverage becomes effective on the day following
completion of the Waiting Period . For those
employees who were covered under the prior Plan at
the time this Plan became effective, there is no
waiting period.
Coverage for dependent children automatically
terminates on the date of their 19th birthday,
however, coverage will be extended to the
dependent's 25th birthday, if a full-time student
(See page 9) .
LIFE INSURANCE
Benefits are as stated in the individual
certificate issued by the Life Insurance Carrier.
WEEKLY INCOME BENEFIT
_., The weekly income benefits will not exceed 50% of
the employee's weekly earnings to a maximum payment
of. . .
$300 .
Benefits if totally disabled, due to an accident
begin on day
1
Benefits if totally disabled , due to an illness
begin on day 8
Benefits if hospital confined , begin on day 1
Maximum period benefits are payable 26 Weeks
NOTE: Elected Commissioners and the City
Attorney, along with Retirees are not
eligible for Weekly Income Benefits.
SUPPLEMENTAL ACCIDENT BENEFIT
Maximum Benefit (Per Accident) 100% of 1st $500 .
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j DEDU +LE
Deductible ( Per Person, Per Calendar Year)
NOTE: The Deductible is Waived if you use the
services or facilities of the Florida
Health Network PPO, as shown below.
The deductible will be reduced by the deductible
amount you satisfied with this Plan' s prior
carrier.
Note : Only "eligible" charges can be used to
satisfy your Major Medical Deductible .
Family Deductible is THREE TIMES per calendar year.
The Plan requires that each time you or your
covered dependents are confined in "Any" hospital ,
you must notify Florida Health Network and have
your hospitalization Pre-Certified . In an EMERGENCY
situation, please notify Florida Health Network as
soon as reasonably possible. (See Page 20 )
If your hospitalization "is not" Pre-Certified even
though you are confined in a PPO Hospital, your
eligible hospital charges will be subject to an
additional $200. deductible, per confinement.
If you are confined in a Non-PPO Hospital and do
not obtain Pre-Certification, your Out-Of-Pocket ' ^�
expenses will include the $100 : Major Medical
Deductible, the additional $200 . deductible for Non
Pre-Certification, and you must pay 20% of the
incurred hospital charges.
The City of Dania has also contracted with Florida
Health Network for Preferred Provider Discounts, if
you use their "Network" of Doctors and Hospitals .
(See Page 19)
BENEFITS ARE PAYABLE based upon the usual ,
reasonable and customary fees.
MAJOR MEDICAL BENEFITS
( Payable at 80% , unless otherwise stated)
Full Payment Feature
After a person has incurred $2 ,500 . of covered
charges during a calendar year, which are payable
at 80% , Major Medical pays 100% of covered charges
( other than those for ( i) mental and nervous
conditions and ( ii ) dental conditions) subsequently
incurred within that calendar year which are not
required to satisfy a deductible.
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e Hosp( (Confined in PPO Hospital - No Deduct!
Rouiu & Board 100% of Semi-Pric, .:e
ICU/CCU 100% of Actual Charge
j Other In-Patient Hospital 100%
Hospital (Confined in Non-PPO Hos808tof) Semi -Private
Room & Board
ICU/CCU 80% of Actual Charge
Other In-Patient Hospital 80%
Pre-Admission Testing (No Deductible) 100%
Out-Patient Hospital 80%
X-Ray & Laboratory 80%
Surgery ( In-Patient) 80%
Surgery (Out-Patient - No Deductible) 100%
Second Surgical Opinion (No Deductible) 100%
Medical Care ( If PPO Provider) 1008
Physician Visits (No Deductible)
Medical Care ( If Non-PPO Provider) 80%
Physician Visits
Prescription Drugs
Deductible Each Prescription $2 •
Benefit Percentage after $2. Deductible 1008
Vision Benefit (Employees Only)
Benefit Percentage (No Deductible) 100%
Calendar Year Maximum (Per Person) 5150 .
NOTE: You must be employed by the City for a
period of twelve consecutive months to be
eligible for this benefit.
l Alcohol & Drug Benefit
Out-Patient (Per Visit) $35 .
9 Lifetime Maximum (Out-Patient) 44 Visits
In-Patient Services 80%
Lifetime Maximum all Services $2,000 .
Mental Illness $20
j Out-Patient ( Per Visit)
Calendar Year Maximum (Out-Patient ) $1 ,080%
In-Patient Services
Lifetime Maximum all Mental Services $2 ,000.
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Ma te' y
Ma,;rnity is an illness and usually billed _s
surgery by the physician. There are no pregnancy
benefits for dependent children.
NOTE: Certain Well Baby Care services are covered.
(See Page 26 )
Pre-Existing Conditions
Maximum Benefit $250 .
MAJOR MEDICAL BENEFIT MAXIMUM
Lifetime Maximum $1 ,000 ,000 .
DENTAL EXPENSE BENEFITS
Deductible
(Per Person, Per Calendar Year) $50 .
Family Deductible is TWO TIMES per calendar year.
Preventative Dental Services 80%
Basic Dental Services 80%
Major Dental Services 80%
Calendar Year Maximum (Per Person) $2,000 .
ORTHODONTIA EXPENSE BENEFITS
Deductible
(Lifetime - Per Person) $50 . w
Orthodontia Services 50%
Lifetime Benefit Maximum (Per Person) $1 ,000 .
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HOW MUCH DOES IT COST?
The cost of health coverage for Employees and their
eligible Dependents is paid by the City of Dania.
HOW THE PLAN WORKS
YOU PAY THE DEDUCTIBLE
Payment of medical benefits will begin after the
deductible amount, as stated in the Schedule of
Benefits, has been satisfied by covered charges.
Any covered expenses incurred during the last three
months of a calendar year (October, November,
December) that are applied toward meeting that
year' s deductible, will be carried over and applied
toward the satisfaction of the next year' s
deductible.
Any expenses of a covered employee that were used
toward satisfaction the the Calendar Year Major
Medical Deductible under the employer ' s previous
Plan ( if that previous Plan terminated immediately
prior to the effective date of this Plan) can be
used toward satisfying this Plan' s Calendar Year
Deductible.
' DEDUCTIBLE - COMMON ACCIDENT
If two or more persons in your family, while
covered under this Plan, incur covered charges as
the result of the same accident, a single
deductible shall apply to the combined covered
charges for that accident during the calendar year
in which the accident occurred .
WHO IS COVERED AND WHEN
EMPLOYEES
••«�` All permanent, full-time employees who meet the
eligibility requirements of the Plan will be
eligible to participate in the Plan following
completion of the Waiting Period . You will be
covered on the date you become eligible for
benefits, provided you have completed an enrollment
card supplying whatever information may be required
and authorizing payroll deduction, if required .
If you do not enroll dependents within the 31 days
following your eligibility date, then they will be
required to furnish Evidence of Health.
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If nare not actively at work, because of ry
or sickness, on the date you would otherwise be_ome
eligible for this coverage, or any increase in
coverage, your coverage will not be effective until
such time as you return to active full-time
employment with the employer.
The Waiting Period is as shown in the Schedule of
Benefits.
DEPENDENTS
Your dependents are also eligible to enroll in the
Plan. The Term "dependent" means the spouse of the
employee (who is not divorced or legally separated)
and children to the date of their 19th birthday and
provided such children are unmarried , unemployed ,
residing with and principally dependent upon their
parent(s) for their majority of support and
maintenance. An employee cannot be covered as a
dependent and no person can be covered as a
dependent of more than one employee .
The term "children" shall include natural children,
legally adopted children and step-children.
Dependents coverage will be extended , as stated in
the Schedule of Benefits, for children who are
financially dependent upon their parents for
support, are unmarried and attending an accredited
educational institution full-time . Newly acquired
dependents may be added during the month in which
they are acquired . You must apply for such
dependent coverage. Newborn dependents are
automatically covered from the day they are born,
provided you have applied for and have been
accepted for dependent coverage.
Any unmarried child who is physically or mentally
incapable of self-support may be continued in the
'r Plan, after age 19 , for as long as the child is
incapacitated and unmarried, provided the
disability occurred prior to age 19 . To continue a
child under this provision, proof of incapacity
must be received before coverage for the child
would otherwise terminate. Additional proof will be
required from time to time.
You must complete an enrollment card and either
accept or reject dependent coverage. If dependent
coverage is requested within 31 days following the
employee ' s eligibility date, the dependent
coverage will go into effect on the date the
application for coverage is made, regardless of the
medical history of the dependent( s) .
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If,� wever, your application for dep� ht
coverage is not made within this 31 day period, an
Evidence of Health Statement must be completed for
each dependent you wish to enroll , and coverage is
subject to approval . If approved , coverage will
begin coinciding with the date of approval .
Newborn children, however, may be added to the
coverage without Evidence of Health whether or not
previous eligible dependents coverage has or has
not been requested , if such request is made, in
writing, within 31 days of the date the child is
born. Coverage will become effective, if approved,
on the date application for such coverage is made.
IF YOU HAVE NOT PREVIOUSLY ENROLLED ALL ELIGIBLE
DEPENDENTS, YOU MUST SUBMIT EVIDENCE OF HEALTH ON
THOSE DEPENDENTS.
If a dependent, other than a newborn child, is
confined at home, in a hospital , or elsewhere
because of injury or sickness on the date the
dependent' s coverage would have become effective or
would have been increased , the dependent's date of
coverage, or any benefit increase therein will not
be effective until; ( 1 ) the dependent is discharged
from the hospital or place of confinement; and ( 2)
the dependent has engaged in the normal activities
of a healthy person of the same age and sex.
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HOW BENEFITS CAN BE LOST
EMPLOYEE TERMINATION
The coverage of any Employee covered under this
Plan shall terminate when any of the following
occurs:
the day following termination of employment;
the Group Plan coverage terminates; or
you become a full-time member of the Armed
Forces of any Country; or
premium payments for your coverage are
discontinued; or
if you no longer are in the classes of
employees eligible for coverage, or upon
termination of employment with the employer.
If you cease active work for any reason, you should
find out immediately from your employer what
coverage, if any, can be continued in force so that
you will be able to exercise any rights you may
have under the Plan.
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DE1 ENT TERMINATION '
The coverage of any Dependent covered under nis
Plan shall terminate on the earliest of the
following dates:
the date the employee' s coverage terminates; or
the date a dependent no longer qualifies as an
eligible dependent; or
the date of termination of the Plan; or
the last date to which contributions, if
required has been made .
BENEFITS AFTER TERMINATION OF COVERAGE
EXTENSION OF BENEFITS
Notwithstanding any language in this Plan to the
contrary, if upon the date of termination of an
individual ' s coverage hereunder, he is totally
disabled, the medical coverage hereunder will be
extended during the subsequent period of total
disability, but not beyond twelve ( 12 ) monhts after
the date the individual ' s coverage terminates or
the first possible date of eligibility for any
other company sponsored Plan. Such extension of
benefits will be provided only for the illness
which caused the disability. If the Plan
terminates, benefits will cease immediately. y^
DEFINITIONS
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ACCIDENT
The term "accident" and/or "accidental bodily
injury" used in connection with Medical Expense
Benefits should be interpreted as :
by chance. . .without intent or volition.
....h Something specific which happens, and is of
itself unusual . . .resulting in bodily strain or
trauma.
AMBULANCE SERVICES
A legally licensed company with a recognized
vehicle for the transportation of the sick or
injured to a hospital . Such charges are only
eligible for local ambulance services.
CONVERSION OF HEALTH COVERAGE
Your employer' s Health Care Plan has a conversion
privilege where, upon termination of employment,
you may convert to an individual health care
policy. However, application for conversion MUST be
made within thirty one ( 31 ) days of termination of
employment.
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HOC� AL
A 11uspital is defined as a legally oper" .ed ,
accredited institution providing care and treatment
through medical , diagnostic, and major surgical
facilities on its premises. It must be under the
supervision of a staff of doctors who are licensed
to provide medicine, and which continually provides
24-hour nursing service by registered graduate
nurses . The term "hospital" includes institutions
qualified to participate in, and receive payments
under, the Government' s Medicare Program. It also
includes surgi-care centers. The term does not
include a nursing home or any other institution
used mainly for convalescence, nursing , rest, to
house the elderly, or to care for those who cannot
care for themselves. It also does not include
confinement in an educational institution or
rehabilitation center. Rehabilitative services
provided by a hospital would not be a covered
expense.
Successive periods of hospital confinement due to
the same or related causes are considered one
period of confinement if, ( 1 ) in the case of an
employee, they are not separated by a return to
full-time work for a period of two consecutive
weeks, or (2 ) in the case of a dependent, they are
not separated by at least three months.
ILLNESS
"Illness" means a bodily disorder or disease ,
mental infirmity or bodily injuries sustained by an
individual in a single accident, or all illness (es)
which are due to the same or related cause or
causes, will be considered an illness.
LEAVE OF ABSENCE
A Leave of Absence is a period of time during which
the employee does not work due to an illness or
accident, or other circumstance. There is to be an
agreed upon stated period of time after which the
employee is expected to return to active full-time
work. For the purpose of continuing health coverage
under this Plan , during an approved Leave of
Absence, coverage for benefits shall not continue
beyond six ( 6 ) months. The full cost of such
coverage is the sole responsibility of the
employee.
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MEN 1ILLNESS OR FUNCTIONAL NERVOUS DISORDER [
Chary<:s for professional services in connet _on
with mental illness illness(es) or functional
nervous disorder( s) of any type or cause or for
psychiatric or psychoanalytic care for any reason
are not covered, except those services rendered by
a legally qualified physician, during a visit by
or to the patient and which are not in excess of,
( 1 ) one visit on any one day, and ( 2) the benefits
as stated in the Schedule of Benefits. However,
charges for psychological testing , for any reason,
are ineligible for benefit consideration. (The word
"visit" includes each attendance of the physician
to the patient, regardless of the type of
professional services rendered, whether it might be
otherwise termed, consultation, treatment, or
described in some other manner. )
OUT—PATIENT
Treatment rendered for which no room and board
charges are made.
PHYSICIAN
A "physician" shall be a properly licensed person
holding the degree of Doctor of Medicine (MD) ,
Doctor of Osteopathy ( DO) , Doctor of Dental Surgery
(DDS) , Doctor of Podiatry (DPM) , or Doctor of
Chiropractic ( DC) . The term shall also include a
clinical psychologist who has a PHD in psychology
and who may be treating the patient upon referral
by a licensed physician. The term-, however, shall
not include a Social Worker.
Benefits for the services of a DPM shall not exceed
the benefits of this Plan that would have been paid
to an MD or DO for treatment of the given
condition.
REASONABLE & CUSTOMARY
An expense or charge will be considered "customary"
if it is within the range of usual fees charged by
Physicians of similar training and experience for a
given procedure within the same specific and
limited geographic area. "Reasonable" charges are
usually the same as the "Customary" fee; however,
expenses or charges exceeding those which are
customary will be considered " reasonable" if ,
determined by Medical Insurance Administrators ,
Inc. most current Reasonable & Customary guide that
those expenses or charges are justifiable ,
considering any special circumstances.
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RET. ENT
Retiibment is the cessation of all full-time wo_...
However, a retired employee may elect to continue
coverage under this Plan. Contact your Employer for
information on your rights under Florida Statue
SB153 .
SURGICAL CENTER
A surgical center shall be defined as a legally
operated health center with equipment and supplies
for surgical or medical care not usually available
in a doctor' s office. Such a center does not
require a person to be confined as an in-patient.
The facility shall have the ability to transfer
patients to a hospital with regularly scheduled
nursing care and an organized medical staff.
TOTAL DISABILITY
Total disability means that you are prevented ,
solely because of non-occupational injury or
non-occupational illness, from engaging in any
occupation or performing regular or customary
duties .and are not performing work of any kind for
compensation or profit; or if a dependent, you are
prevented, solely because of a non-occupational
�► injury or disease, from engaging in any occupation
or caring for yourself as could a person of like
age and sex who is in good health.
WELL BABY CARE
Well baby care is defined as the charges of a
hospital and attending pediatrician for the care of
a newborn child.
HOW TO FILE A CLAIM
You will be given an identification card as you
enroll in the Plan. This card should be shown to
the doctor, hospital or any other person or
institution providing medical treatment .
1 . Obtain a claim form from your employer.
2 . Complete your portion "The Employee ' s
Statement" , answering all questions in
response to:
(a) your claim, or
(b) your dependent' s claim, if applicable
3 . Sign and date the form in the space provided .
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If 'claim is for someone other than the emp,e011N'e
(spouse or child) , both the employee and me
patient must sign the form, unless the patient is a
minor.
Submit all bills in your possession regarding the
claim as soon as possible. All medical bills must
be itemized showing; ( 1) the name of the patient,
( 2) dates and types of treatment, ( 3 ) nature of the
illness or diagnosis, and (4 ) the charges for each
treatment.
Mail the claim form to Medical . Insurance
Administrators, Inc. for claim processing . Benefits
will be assigned directly to the hospital , doctor
or other facility providing services or treatment,
unless otherwise advised or unless no assignment of
benefits is tendered by the employee .
If you have incurred additional expenses for an
illness or accident after submission of the
original claim for that condition, simply submit
further bills with a note attached stating your
Name , the Name of your Employer, and indicate
"Continuing Claim" . This will identify your claim,
and additional claim forms will not be required.
Please note, ALL CLAIMS SHOULD BE SUBMITTED AS SOON
AS POSSIBLE AFTER THE EXPENSE IS INCURRED.
Intentional failure to do so, or bills more than
one year old, may result in a claim being
disallowed .
HOW TO APPEAL A CLAIM
If your claim is denied in whole or in part, you
will receive a written explanation from the Plan
Supervisor.
This explanation will be either in letter form or
on a claim worksheet showing the calculation of the
total amount payable, the charges not payable, and
the reason. If additional information is needed for
consideration of a claim, it will be requested .
If any portion of a claim is not paid and you do
not understand, or disagree with the handling of
the claim, you should first write the Plan
Supervisor for additional clarification.
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If } ,`eel the claim was not properly handled
shoula file a written request for a review with ne
Plan Administrator, within ninety (90 ) days after
denial is received .
However, it is suggested it be filed promptly
wherever possible.
Upon receipt of written request for a review of a
claim, the Plan Administrator will review the claim
and furnish copies of all documents , reasons and
facts relating to the decision.
You or your authorized representative may examine
pertinent documents (except any information in the
documents which the physician does not wish to be
made known to the claimant) which the company has.
You may then submit, in writing, your opinion of
what the issues are and any comments you wish to
add .
A decision by the Plan Administrator will be made
within sixty (60) days unless special circumstances
require an extension.
This decision will be delivered to you, in writing,
stating the specific reasons for the decision, and
specific references to the pertinent Plan provision
upon which the decision is based . This decision
will be final .
A participant will be required to pay legal fees if
a claim is deemed frivolous.
COORDINATION BETWEEN THE PLAN AND
AVAILABLE GROUP INSURANCE BENEFITS
�.•.� The Plan has been designed to help meet the cost of
sickness or injury. Since it is not intended that
greater benefits be paid to you than your actual
medical expenses, the amount of benefits payable
under the Plan will take into account any coverage
a member has under other "Plans" . The benefits
under the Plan will be coordinated with the
benefits of the other "Plans" .
The Plan will always pay either its regular
benefits in full , if the primary carrier, or a
reduced amount which, when added to the benefits
payable by the other Plan or Plans, will equal 100
percent of "Allowable Expenses" .
16
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"Alroible Expenses means any nece: 7,
reas.iiable and customary expense, incurred w.,ile
you are eligible for benefits under the "Plan" ,
part or all of which would be covered under any of
the Plans, but not any expenses contained in the
list of exclusions. "Plan" means any Plan providing
benefits or services for or by reason of medical or
dental care or treatment, which benefits or
services are provided by group insurance,
self-insurance, group auto "no fault" insurance,
individual insurance, or any similar plan or
program.
THIRD PARTY REIMBURSEMENT
This provision does not apply to Life Insurance
Benefits, Accidental Death & Dismemberment Benefits
or benefits payable for any loss of time on account
of disability, if any such benefits are provided in
the Plan.
The following provisions shall be applicable to all
other Sections of this Plan now or hereafter
included therein.
If payments are made under this Plan for any
treatment or service because of injury to, or
° sickness of, a covered individual who has a lawful
claim, demand a right against a Third Party or
parties ( including an insurance carrier) for
indemnification, damages or other payment with
respect to such injury or sickness, then:
a) the City of Dania shall be reimbursed to the
extent the covered individual receives payment
from any such Third Party or parties because
of injury to, or sickness of the covered
individual . The covered individual shall
reimburse the City of Dania from such payment
so received ( but not excess of the amount
received) for all payments made under this
Plan for treatment or service with respect to
the same injury or sickness; and
b) the covered individual shall execute or secure
the execution of such instruments as the City
of Dania may reasonably require to enforce
its ' rights hereunder.
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WHAT IS COVERED BY THE PLAN
ANESTHESIA
The Plan will allow the reasonable and customary
charge for anesthesia administration if done by a
physician, other than the operating surgeon. ( If
anesthesia is administered by the surgeon, the
charge is considered as part of the surgical fee. )
CHIROPPRACTIC SERVICES
The Plan will pay reasonable and customary charges
per visit, for services rendered by a chiropractor
for the detection and correction, by manual
mechanical means ( including x-rays pertaining to
the service ) , of structural imbalance, distortion
or subluxation in the human body for the removal of
nerve interference where such interference is the
result of, or related to, distortion, misalignment
or subluxation of, or in, the vertebrae column.
DOCTOR'S VISITS (Medical Care)
The Plan will cover the charges for doctors visits
to the patient while in the hospital , in the
doctor' s office or at the patient' s home as
outlined in the Schedule of Benefits.
HOSPITAL ROOM AND BOARD
The maximum room allowance considered is as stated
in the Schedule of Benefits. Normal hospital
services, in addition to the semi-private room,
include meals and special diets, • operating room,
anesthetics, oxygen, drugs , nursing care, x-ray and
laboratory services and physical therapy. Also
covered are intensive care units , cardiac care
units, and similar necessary accommodations up to
the amount stated in the Schedule of Benefits .
Private rooms are covered when specifically
prescribed by a physician for medically necessity,
such as isolation.
In some instances, your physician may recommend
surgery be performed in a "hospital surgi-center"
or "mini" surgical care center. These centers are
also covered under this Plan.
MATERNITY
Pregnancy is considered as any other illness and
subject to the same benefits and limitations as any
other condition . Maternity benefits include
coverage for delivery and miscarriage.
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NUR
The . ,an will cover private duty nursing seru .. _es
by a Registered Nurse (RN) or a Licensed Practical
Nurse (LPN) not related to the Covered Person.
These services must be required by a physician in
connection with treatment for an illness or injury
and must be for other than custodial or
rehabilitative care .
OUT-PATIENT SURGERY
Benefits in connection with charges incurred on an
"Out-Patient" basis , at the time of, and in
connection with a surgical operation, wherever
performed, are payable as stated in the Schedule of
Benefits. In order to be considered "Out-Patient"
surgery, no room and board charges must be incurred
and recuperation must take place at home.
OUT-PATIENT X-RAY AND LABORATORY
The Plan will cover the reasonable and customary
charges for diagnostic x-ray, laboratory and
pathology tests prescribed by a doctor and
performed as the result of a covered accident or
illness. The cost of office visits in connection
with these services or tests is also covered .
PRE-ADMISSION TESTING
A maximum benefit as stated in the Schedule of
Benefits are payable in connection with charges
incurred for laboratory and radiological "
examinations performed on an Out-Patient basis
within forty eight ( 48) hours preceding In-Patient
confinement for surgery or other treatment in
connection with the same illness for which such
examinations have been performed. Such examinations
repeated following commencement of such In-Patient
confinement, but prior to such surgery or other
treatment, are not, however, included within the
meaning or intent of this benefit.
If the testing is done on an In-Patient basis or
earlier than forty eight (48) hours prior to
entering the hospital as an In-Patient, the charges
will be subject to the deductible.
PREFERRED PROVIDER ORGANIZATION (PPO)
The City of Dania has contracted Florida
Health Network for PPO services, which provide you
with discounts on your medical bills. When you use
these PPO facilities, you MUST advise the
"Provider" that you are a member of the PPO. If you
do not do so, you will not be entitled to any PPO
Discount on your incurred medical charges.
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Itl ip to you whether or not you wish to use ie
PPO Facilities. If you decide to do so, you ..�11
have a free choice of Providers. By using PPO
facilities whenever possible, you will be saving
yourself out-of-pocket expenses.
NOTE: If you choose not to use the services of PPO
Providers, there may be benefit disadvantages .
( Refer to the Schedule of Benefits)
A listing of PPO Providers is available from the
Personnel Department.
PRE-CERTIFICATION/UTILIZATION REVIEW PROGRAM
The nature of the Group Health Plan requires that
each employee share in the cost of their own
medical care through a co-payment factor. This
co-payment plus the calendar year deductible,
determines your out-of-pocket expenses during a
calendar year. It is in your best interest to be
concerned about medical costs and try to keep them
as low as possible .
Pre-Certification/Utilization Review is a program
which will assist you in helping to hold down your
out-of-pocket costs for in-patient confinement.
What is Pre-Certification?
Pre-Certification is a program designed to review
the number of days you are required to be confined w
as an in-patient. Florida Health Network works with
your doctor to avoid unnecessary in-patient days
through suggesting the use of out-patient care or
alternate facilities wherever possible.
How Does Utilization Review Reduce Costs?
Throughout your hospital stay, Florida Health
Network monitors your progress and assists your
doctor with your timely discharge .
How Do I Benefit?
You are assured that a hospital stay is necessary
for the planned procedure and are assured that your
stay is not over-extended, therefore your hospital
bill and co-insurance payment may be smaller.
What Do I Do?
Step 1 : If your doctor suggests hospitalization
for you or a family member, ask the doctor
to fill out an Employee Pre-Admission
Review Form and return it to Florida
Health Network .
20
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Stet You or a family member must notify Ela
Health Network as soon as possi: _e,
(preferably five ( 5 ) days prior to a
scheduled in-patient hospital admission. )
Florida Health Network
In Florida: 1-800-331-0017
Out of Florida: 1-800-341-4367
Step 3: Be prepared to provide the Florida Health
Network with the following:
Group Plan Number/Employer Name
Employee' s Name/Social Security No.
Doctor' s Name/Address/Telephone No.
Hospital Name/Date of Admission
IN THE EVENT OF AN EMERGENCY, a family member '
should telephone Florida Health Network as soon as
reasonably possible .
IF YOU DO NOT NOTIFY FLORIDA HEALTH NETWORK , YOUR
HOSPITAL CHARGES WILL BE SUBJECT TO AN ADDITIONAL
$200 . DEDUCTIBLE.
PRE-EXISTING CONDITIONS
A maximum benefit as stated in the Schedule of
Benefits will be allowed for covered charges
relating to a pre-existing condition. Pre-existing y.,.
conditions are any injury or illness for which the
person has incurred otherwise covered expenses or
has been advised by a physician regarding treatment
within three ( 3 ) months prior to the effective date
of coverage.
Such conditions may include the taking of
medication, advice or information during telephone
conversations with medical providers, consultations
or actual treatment by a physician or medical
provider. This exclusion will cease to apply if :
after three ( 3 ) consecutive months of
continuous coverage during which the person
has received no treatment with respect to the
illness, or
after a period of twelve ( 12 ) consecutive
months during which the person is continuously
covered hereunder.
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PRE, PTION DRUG BENEFIT
No benefits are payable under this Plan for urug
charges which are payable under the Pharmaceutical
Card System, Inc . through the use of a PCs Card
issued to eligible employees.
Simply take the prescription, given to you by your
physician, to any participating pharmacy, show your
PCs Drug Card and pay the pharmacy $2 .00 deductible
per prescription.
Most pharmacies honor the PCs Drug Card . However,
if you use a drug store which does not accept the
PCS Card, obtain a PCs Claim Form from your
employer, for completion by the pharmacy. Mail the
claim form directly to PCS for benefit
reimbursement. You might also ask the Pharmacy if
they would like to participate; if so, please have
them telephone Medical Insurance Administrators.
Drug Limitations:
(a) Any drug labeled , "Caution - Limited by
Federal Law to Investigation Use" or
experimental drug , even though a charge is
made to the individual , is not covered;
�k (b) prescription drugs in excess of 40 capsules or
tablets per prescription are not covered;
(c) ointments or creams in excess 'of 4 ounces per
prescription are not covered;
RADIATION/CHEMOTHERAPY
The Plan will cover the reasonable and customary
charges for in-patient and out-patient
radiation or chemotherapy.
y SECOND SURGICAL OPINION
Benefits as stated in the Schedule of Benefits are
payable in connection with the medical advice of a
Surgeon regarding a Surgical procedure . The advice
must be based upon the Physician' s examination of
the patient. The examination must be performed by a
Board Certified Specialist, after another Physician
has proposed to perform the surgery, but prior to
such performance.
If the Second Surgical Opinion differs from the
Eirst physician 's opinion, the Plan will cover the
cost of a Third Opinion, in full .
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NOT The following list of surgical proc crom*`!s
are buggested procedures for which you may wish to
obtain a Second Surgical opinion.
Hysterectomy Bunionectomy
Tonsillectomy Cataract Removal
Adenoidectomy Coronary Bypass
Dilation & Curettage Herniorrhaphy
Exploratory Laporatomy Knee Surgery
Hemorrhoidectomy ( Including Excision
Cholecystectomy of knee cartilage)
Mastectomy Laminectomy
Ligation & Stripping of Varicose Veins
SUPPLEMENTAL ACCIDENT
Expenses incurred by a covered individual as a
result of the accidental bodily injury, sustained
while covered, and for which treatment is rendered
within. . .
three months following the date of the accidental
injury. . .
will be payable in an amount equal to the eligible
charges and fees incurred up to the maximum benefit
stated in the Schedule of Benefits . Follow-up care
necessitated as a result of such injury will be
payable for a period of no longer than three months
form the date the original injury occurred provided
the maximum benefit has not been paid .
SURGERY
The reasonable and customary surgical charges for a
surgeon and assistant surgeon are covered under
the Plan.
Surgical fees are paid for surgery or for
,,.. correcting fractures and complete dislocations,
whether performed in a hospital , doctor' s office or
at home . If there is more than one surgical
procedure done through the same incision, the
procedure with the highest benefit will be allowed.
If two or more operations are performed through
separate incisions, in different operative fields
while in the operating room, the maximum benefit
will be allowed for the first procedure, plus one
half of the allowable benefit for each of the
lessor procedures .
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MEW l BENEFITS FOR THOSE AGE 64 OR UNDER, AF i0
OR OLuER
! Integration with Medicare
Any benefits payable under the medical expense
Plan provisions of this Plan will be reduced
by the amount of any benefits or compensation
to which the covered individual is entitled
under Medicare . The reduction will apply
whether or not the individual has received, or
made application for, such other benefits ,
and;
A covered individual is deemed "entitled" to
all Medicare benefits for which he is or has
been eligible; and
Coverage is available for all permanent,
full-time employees and their eligible
dependents who meet the eligibility
requirements for coverage under the provisions
of the Plan.
MEDICAL BENEFITS FOR THOSE AGE 65 THRU 69
Employees and their eligible dependents 65-69 years
old are entitled under Section 116 (a) of Public Law
97-242, the Tax Equity and Fiscal Responsibility
Act of 1982 (TEFRA) , Amended Section 4 of the ADEA,
to receive the same group health coverage, under
the same conditions, as those employees and
dependents under age 65 . Eligibility for these
benefits applies to the period beginning with the �►
first day of the month of entitlement in which the
individual attains the age of 65 (or the month of
entitlement to Part A of Medicare, if later) and
ending with the last day of the month before the
month in which the individual attains age 70 ,
unless the individual voluntarily elected to
terminate coverage under this Plan by choosing
Medicare as primary carrier.
b•.JF
Each employee 65-69 should complete a medicare
Election form notifying your employer whether you
and your spouse want the Employer' s Group Plan as
your primary carrier or Medicare as your primary
carrier. You should also forward a copy of your
election form to Medicare. Election forms are
available from your employer or MIA.
This Plan provision shall automatically be
interpreted and be in compliance with any and all
amendments to the Act.
24
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SP '00�THERAPY
The . .an will pay benefits for Restoratorp or
Rehabiliatory speech therapy by a legally qualified
physician or qualified Speech Therapist, other than
a close relative, for speech loss or impairment due
to a congenital anomaly, except that surgery to
correct the anomaly, must have been performed prior
to the therapy. If the speech therapy is performed
as a result or a development disorder, or a
learning disability, no coverage shall be extended .
VISION BENEFIT
only employees of the City of Dania are eligible
for this coverage, if , they have been employed with
the City for a period of twelve ( 12 ) consecutive
months.
The Plan will pay the reasonable & customary
benefits for complete visual analysis, including
examination, eye tests, case history, refraction,
glasses and contact lenses.
The maximum benefits payable under this Vision
Benefit will not exceed the amount stated in the
Schedule of Benefits.
THE FOLLOWING CHARGES (IF NECESSARY REASONABLE AND
CUSTOMARY) ARE COVERED
Certain drugs and medicines dispensed by a
licensed pharmacist obtainable only by
prescription;
Consulting Surgeon Fees;
Local Ambulance Service from the place of
disability is contracted to a hospital
equipped to furnish special treatment
necessary for the disability;
Organ transplant, excluding donor or donation;
Rental of Iron Lung , wheelchair, or Hospital
Bed;
Braces, crutches , or eyes, provided the
condition that caused the loss began after the
patient was eligible for charges;
for charges made by an extended care facility;
Casts, splints and trusses;
Physiotherapy;
25
• Jygen and Rental of Equipment
. dministration; for s
Vasectomies, Tubal Ligations & Circumcision;
Electronic Heart Pacemakers;
Restoratory or Rehabilatory Speech Therapy by
a legally qualified physician or qualified
speech therapist, other than a close relative,
for speech loss or impairment due to an
illness other than a functional nervous
disorder, or due to surgery on account of an
illness. If the speech loss or impairment is
due to a congenital anomaly, surgery to
correct the anomaly must have been performed
prior to the therapy, If the speech therapy is
performed as a result of a development
disorder, no coverage shall be extended .
Treatment of or addiction to, or use of
narcotics or on
or alcohol in any
form, as stated in the Schedule of Benefits;
Charges for (a) newborn nursery "Well Baby
Care" , along with charges of the pediatrician
while hospital confined, (b) premature birth,
(c) abnormal congenital condition, and (d) an
illness contracted after birth.
i
THE FOLLOWING CHARGES ARE NOT COVERED
All charges not specifically
Charges and listed as Covered
in addition no payment will be made
under the Medical Plan • . •
i
for, or in connection with an injury arising
out Of, or in the course of any employment for
wage or profit;
for, or in connection with a sickness or
is entitled
accident for which the Employer or Dependent
to benefits under any Workers
Compensation or similar local, State or
Federal Statue, or to the extent the Employee
or Dependent is entitled to benefits or
payments under Automobile Personal Injury
Protection Insurance issued pursuant to any
No-Fault type automobile reparations ordinance
or statute;
to a hospital owned or operated by the United
States Government;
where prohibited by law;
for charges you are not legally required to
pay or for charges which would not made if no coverage existed; have been
for charges made which are in excess of
reasonable and customary charges or for
charges for unnecessary care or treatment;
26
i
)r charges for education, trai ^ ,
psychological testing , bed and board while you
are confined to an institution which is
primarily a school or other institution for
training, a place of rest, a place for aged , a
nursing home, or for custodial care or for
rehabilitative services;
for occupational therapy;
for charges for, or in connection with care,
treatment or operations, which are performed
for cosmetic, elective or non-functional
purposes, unless such expenses are incurred as
a result of an accident which occurred while
covered;
for services or treatment of injury due to
declared or undeclared war or any related act
of war declared or undeclared;
for charges incurred while covered, for the
treatment of injuries as the result of an
accident, which occurred prior to coverage
under this Plan;
for radial keratotomy or refractive
keratoplasty;
for hearing aids or hearing examinations;
for routine physical examinations, pre-school
physicals, pre-marital examinations, routine
immunizations or annual boosters, for
transportation (other than local ambulance) ,
or for reduction of weight by diet control;
for an illness or injury to which a w
contributing cause was the commission of, or
attempted commission of, an act of aggression
j or a felony by the covered person;
for charges for dental work , examinations or
treatment of any kind, except that performed
by a licensed dentist or dental surgeon as a
result of an accident which occurred while
covered . If the result of a covered accident,
treatment must be to sound natural teeth and
shall include only replacement of such teeth,
or setting of jaw, if fractured or dislocated,
in the accident. Treatment must begin within
1 ninety (90) days of the date of the accident
and must be completed within twenty-four ( 24 )
months following the date of the accident.
(See Page 29 for eligible dental expenses. )
for professional medical or surgical services
rendered by an individual who is related to
jthe covered person by blood or marriage;
for services and supplies related to sexual
dysfunctions or inadequacies, or sex change
operations;
for surgery to reverse surgical sterilization
procedures;
27
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r birth control services and supplies c >r
artificial insemination, or fertility druy_ .
for "Well Baby Care" for routine physicals,
examinations, immunizations, shots, annual
boosters and routine pediatric care of a
newborn following hospital confinement.
PLAN TERMINATION
While the City of Dania has every intention of
continuing the Group Health Plan, the City of Dania
j reserves the right to amend or terminate the Plan
i at any time.
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DENTAL EXPENSE COVERAGE f
DATE OF ELIGIBILITY AND COVERAGE
All permanent, full-time employees who meet the
eligibility requirements shown in this booklet will
be eligible to participate in the Dental Expense
Coverage following completion of the appropriate
Waiting Period .
The expenses must be incurred for dental procedures
necessary to the care and treatment of the patient
and performed by or under the direct supervision of
a legally qualified dentist .
DEDUCTIBLE
The deductible is as shown in the Schedule of
Benefits . The deductible applies to you and each of
your covered dependents. It may be on a Calendar
Year basis, Lifetime basis or a combination of
either, as stated in the Schedule of Benefits. Only
covered dental expenses may be used to satisfy the
deductible.
SCHEDULE OF DENTAL SERVICES
Covered dental services will not include any dental
service not provided for in the Schedule shown in
' the Plan, unless the reinsurer reviews and accepts
the expenses as covered dental expenses upon their
determination that such expenses are consistent
with those listed as eligible in the Plan.
Expenses incurred for precision or semi-precision
attachments, surgical implants of any type ,
including any prosthetic device attached to them or
instruction for plaque control or oral hygiene bite
registrations, splinting or dental services which
do not have uniform professional endorsement will
s, not be accepted nor considered as eligible dental
expenses.
A temporary dental services will be considered an -.
integral part of the final dental services rather
than a separate service.
29
AF
PRE' ATIVE AND DIAGNOSTIC DENTAL SERVICES
Peri".�c oral examination (no more than one in 1y
six ( 6) consecutive month period) . Intra-Oral
X-Rays; complete series with or without bitewings
(only one series in a thirty six (36 ) consecutive
month period) .
Bitewing X-Rays (no more than one charge in any six
( 6 ) consecutive month period) ;
single film
two films
Prophylaxis with or without oral examination (no
more than two dental prophylaxis in any twelve ( 12)
consecutive month period) ;
individuals under fourteen ( 14 ) years of age
individuals fourteen ( 14 ) years of age or older
Periodontal prophylaxis
Topical application of stannous fluoride for
individuals under age nineteen ( 19) (no more than
one in any twelve ( 12 ) consecutive month period )
BASIC RESTORATIVE/ENDODONTICS/PERIODONTICS
PROSTHODONTICS/ORAL SURGERY
! General anesthesia (only when necessary and in
connection with oral surgery and when the
anesthetic agent 9 produces a state of
unconsciousness with absence of pain over the
entire body.
Amalgam fillings -- deciduous teeth
Amalgam fillings -- permanent teeth
Sillicate cement, per filling
Composite acrylic resin filling
Topical application of sealant on a posterior tooth
for individuals under age fourteen ( 14) (no more
than one per tooth in a thirty six (36 ) month
period)
Root canal therapy; including treatment plan and
follow-up care -- one canal
Not in conjunction with apicoectomy
In conjunction with apicoectomy
Apicoectomy (considered a separate service if
performed with root canal therapy)
Gingivectomy or gingivoplasty, per quadrant
Osseous surgery, per quadrant
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If f J than one periodontal surgical servi dlo�+s
performed per quadrant, only the most inclu-.ve
surgical service performed will be considered a
dental service, provided for, in this schedule.
Flap entry and closure is considered part of the
dental service for osseous surgery and osseous
graft.
Periodontal scaling -- twelve ( 12 ) or more teeth
Repairs and adjustments to dentures -- not covered
if ;
performed within six ( 6) months of installation
of denture
Adjustments to dentures, partial denture
Replace broken tooth on complete or partial
denture, not in conjunction with other repairs
Recement bridge
Simple extractions -- first tooth
Simple extractions -- each additional tooth
Space maintainers, fixed , unilateral
Surgical extractions -- impacted
Soft tissue
Bone -- partial or complete
MAJOR RESTORATIVE & INSTALLATION OF PROSTHODONTICS
Gold inlay fillings -- two surfaces
Gold inlay fillings -- three surfaces
a Single crown restorations
Crowns -- porcelain
Crowns -- cast gold , full
Crowns -- cast gold , three-fourths
Fixed or removable prosthetic appliances
Complete dentures, upper or lower
Partial dentures
Lower, with two clasps and gold lingual bar
Upper, with two clasps and gold palatal bar
Bridge pontics -- cast gold
Bridge pontics -- porcelain fused to gold
A Bridge pontics -- plastic processed to gold
Abutment crowns -- porcelain
Abutment crowns -- porcelain fused to gold
Abutment crowns -- full , cast gold
THE FOLLOWING CHARGES ( IF NECESSARY REASONABLE AND
CUSTOMARY) ARE COVERED
Charges for any accidental bodily injury, (a) which
does not arise out of or in the course of any
employment with the Employer, and ( b) for which the
employee is not entitled to benefits under any
Worker ' s Compensation or Occupational Disease Law,
and;
31
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Char/ for any sickness not entitling the emp, 3
to belLefits under any Worker' s Compensation it
Occupational Disease Law, and;
Charges which are necessary to the care and
treatment of such accidental bodily injury or such
sickness and are incurred on the recommendation of
and performed by or under the direct supervision of
a legally qualified dentist, and;
Charges which are not in excess of the reasonable
and customary charges for the procedure performed
or the materials furnished, which excess, if any,
shall not be considered as eligible dental charges
under the Plan, nor counted as part of the
deductible amount hereunder, and;
Charges which are incurred for dental services ,
supplies and x-ray examinations, and;
Charges which are not excluded dental charges and
are not otherwise excluded from coverage by the
terms this Plan.
THE FOLLOWING CHARGES ARE NOT COVERED
All charges not specifically listed as Covered
Dental Charges and in addition:
Charges for services or materials for which the
individual is not in the absence of this coverage,
legally required to pay, and;
Charges for services or materials received from a
dental or medical department maintained by an
employer, a mutual benefit association, a labor
union, or a health and welfare fund, or for
services or materials furnished by or at the
.•«F direction of the United States Government or any
state, province, or other political subdivision,
unless the covered individuals would be required to
pay such charges in the absence of this coverage,
and;
Charges for services or materials for cosmetic
purposes, except charges for cosmetic dental
procedures, incurred while covered hereunder, as a
result of and within twenty four ( 24 ) months after
an accident suffered while covered hereunder for
Dental Expense Benefits, and;
Charges for facings on crowns, or pontic, posterior
to the second bicuspid , and;
32
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Chart I for orthodontic treatment, ( inclu,P) I
treatment or correction of malocclusion) , exc,,,t
charges for space maintainers for deciduous teeth,
and;
Charges due to war or any act of war, whether
declared or undeclared , and;
Charges for partial or full removable dentures or
fixed bridgework , or for the addition of one or
more teeth thereto, or for a crown or gold
restoration if involving a replacement or
modification of a denture, bridgework, crown or
gold restoration which was installed during the
five ( 5) years immediately preceding such
extraction, replacement or modification, and;
Charges for partial or full removable dentures or
fixed bridgework, if involving replacement of one
or more natural teeth extracted prior to the
individual ' s becoming covered under this Plan,
unless the denture or fixed bridgework also
includes replacement of a natural tooth which is
extracted while the individual is covered
hereunder, and was not an abutment to a partial
denture or fixed bridgework installed within the
five (5) years immediately preceding such
extraction or modification, and; w
Charges for adjustment to or relining of partial or
full removable dentures for which 11ke service was
rendered within the two years immediately preceding
such adjustment or relining, and;
Charges for replacement of lost, missing or stolen
appliances or dentures or bridgework, and;
Charges for replacement of broken, or worn
appliances or dentures or bridgework, unless the
dentist certifies such equipment unserviceable and _
such equipment has been installed for a period of
five (5) or more years , and;
Charges for service to a covered person which
involves an appliance, or modification of an
appliance for which the impression was made before
the individual became covered hereunder, or a
crown, bridge or gold restoration for which a tooth
was prepared before the individual became covered
hereunder, or root canal therapy for which the pulp
chamber was opened before the individual became
covered hereunder , and;
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Chaff for dental appointments which are not ,
and;
Charges for any service or material not furnished
by a dentist, except a service performed by a
licensed dental hygienist under the direction of a
dentist or an x-ray ordered by a dentist.
The charge for a dental procedure is considered to
have been incurred on the day of performance of the
procedure. If a procedure is not completed in one
day, the day upon which the procedure is completed
is deemed to be the incurred day for any charges in
connection with such procedure.
In the event that more than one dentist furnishes
services or materials for one dental procedure, the
Plan shall be liable for not more than its
liability had one dentist furnished the services or
materials.
No payment shall be made under this coverage
provision for dental benefits on account of any
procedure with respect to which payment is made
under any of the other coverage provisions of the
Plan, except to the extent, if any, that the amount
- provided in this provision of dental benefits
exceeds the total amount payable on account of such
procedure in all such other provisions .
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DEFINITIONS
DENTIST
A licensed Dentist who is practicing within the
scope of his license. Dentist shall also mean a
licensed physician who provides dental services
which are within the scope of his license.
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DENTAL HYGIENIST
A person who is licensed to practice dental hygiene
and who works under the direct control and
supervision of a Dentist.
EMERGENCY
An urgent, unplanned visit to diagnose or relieve
an acute, unexpected dental condition.
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F-7 .
PRERMINATION OF BENEFITS
Recognizing that many dental problems can be solved
in more than one way, the Plan will pay an amount
equal to that applicable for that generally
accepted treatment method which will provide
adequate dental care at the lowest cost to the
covered individuals . In determining liability, the
Plan shall be guided by the nationally established
standards of the dental profession.
Those persons contemplating dental work should
submit, in advance, a resume of the treatment plan
being contemplated . If this is done, , the Plan
Supervisor will determine the benefits available
and advise the patient and dentist of the benefits
allowable before treatment commences .
If pre-determination of benefits is not done, the
Plan retains the right to pay the claim on the
basis of the amount of benefits which would have
been paid had pre-determination been requested .
Pre-determination is recommended, particularly if
the course of treatment is expected to involve
total dental charges of $200 . or more.
a USUAL CHARGE
The charge usually made by an individual Dentist
for a given service. .•,,
CUSTOMARY CHARGE
The charge usually made by Dentists for a given
service within the locality where the service is
rendered.
REASONABLE CHARGE
A charge which is both Usual and Customary for the
service rendered .
LIMITATIONS
LATE ENROLLEES
If you or your eligible dependents become covered
under this Dental Plan later than 31 days after the
date on which you or such dependents become
eligible, no benefits will be payable for;
1 . Charges for Preventative procedures during the
first 12 months that the individual is covered;
and
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2. cges for Basic procedures during thet
months that the individual is covered; o:. _
3 . Charges for Major procedures during the first
24 months that the individual is covered.
BENEFITS AFTER TERMINATION OF COVERAGE
EXTENSION OF BENEFITS
There will be no payment made under this Dental
Plan for expenses on or after the date you or your
dependent' s coverage terminates , except as below:
1 . In the case of appliances or modification of
appliances other than for Orthodontic
Treatment, benefits will be payable if;
s
a. the master impression was taken while
coverage was in force; and
b. the appliance was delivered or installed
within 30 days after the date coverage
terminates .
2. In the case of a crown, a bridge , or inlay or
onlay restoration, benefits will be payable if ;
a. the tooth or teeth were prepared while
coverage was in force; and
b. such crown, bridge, or cast restoration was
installed within 30 days after the date
coverage terminates.
3. In the case of root canal therapy, benefits
will be payable if;
a. the pulp chamber was opened while coverage
was in force; and
b. such root canal therapy is completed within
30 days after the coverage terminates.
The coordination of benefits provision stated in
this Booklet also applies to dental services.
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ORTHODONTIA EXPENSE BENEFITS
DATE OF ELIGIBILITY & COVERAGE
All permanent, full-time employees who meet the
eligibility requirements shown in the Schedule of
Benefits of this booklet will be eligible to
participate in the Orthodontic Expense Coverage
following completion of the appropriate Waiting
Period.
DEDUCTIBLE
Benefits are payable for covered orthodontic
expenses in excess of the deductible amount which
is incurred by an individual who is covered for
these benefits and who is pursuing a Treatment
Plan, but only to the extent that the expenses are
usual, customary and reasonable in the geographical
area where the treatment is given.
The deductible amount for each individual is shown
in the Schedule of Benefits. This deductible
applies once during a calendar year and must be
satisfied before benefits become payable for
orthodontic expenses incurred by the individual .
Only covered orthodontic expenses an individual
incurs while covered for these benefits may be used
to satisfy the deductible amount.
BENEFITS FOR COVERED ORTHODONTIC SERVICES
Covered orthodontic expenses will equal a
percentage of the covered orthodontic expenses
incurred by an individual and not used to satisfy
the deductible amount. The amount of benefits is
determined by multiplying the covered orthodontic
expenses by the percentage shown in the Schedule of
Benefits. The total benefits for all covered
m orthodontic expenses an individual incurs during a
lifetime will not exceed the Lifetime Maximum
stated in the Schedule of Benefits.
INCURRED ORTHODONTIC EXPENSES r
Expenses are considered "incurred" at the beginning
of each quarter ( 3 month period) of a Treatment
Plan. The first quarter begins on the date the
orthodontic appliances are installed . The amount of
covered orthodontic expenses incurred in one ( 1 )
quarter are determined as follows:
1 . the initial deposit, up to 30% of the total
cost for the Treatment Plan is the covered
expense for the first quarter;
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2. first payment is subtracted from the
e-,imated cost of the Treatment Plan;
3 . the balance is pro-rated over the remaining
quarters of the Treatment Plan or seven
quarters, whichever is lessor.
Fractional amounts due to rounding will be added to
the first quarter payment.
DEFINITIONS
ORTHODONTIC TREATMENT
Orthodontic treatment means the movement of teeth
by means of active appliances when required to
correct either (a) overbite or overjet of at least
four millimeters, or (b) maxillary and mandibular
arches in either protrusive or retrusive relation
of at least one cusp, or (c) crossbite, or (d) arch
length discrepancy of more than four millimeters.
TREATMENT PLAN
A treatmetn plan is a series of interdependent
orthodontic services prescribed by a dentist to
correct a specific condition, a report of which
has, prior to the performance of the services, been
(a) submitted to and reviewed by the administrator
and (b) returned to the dentist with an estimate of
the benefits. R
LIMITATIONS
LATE ENROLLEES
Covered orthodontic expenses do not include and no
benefits are payable for expenses incurred by a
covered individual;
1 . Prior to the date that the individual completes
(a) three ( 3) months of continuous coverage for
these benefits on or within 31 days after the
date he first became eligible, or (b) twelve
( 12 ) months of continuous coverage for these
benefits, if he becomes covered for these
benefits more than 31 days after the date he
first became eligible .
2 . After the individual ' s orthodontic expense
benefits terminate .
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3 . c he extent that the individual is reimb; d
i or is entitled to be reimbursed for 5. ch
expenses or is in any way indemnified through
any charitable or governmental public program.
4 . In connection with an injury or sickness
resulting from war or any act of war, whether
declared or undeclared.
If an individual becomes covered for these benefits
on the date this coverage becomes a part of the
Group Health Plan, and was covered for orthodontic
benefits immediately prior to that date under
another Group Policy or Plan issued to or through
the Employer, he shall receive credit towards the
waiting period specified in item ( a) above for his
continuous coverage under the other Group Policy or
Plan.
The coordination of benefits provision stated in
this Booklet also applies to orthodontic services.
BENEFITS AFTER TERMINATION OF COVERAGE
EXTENSION OF BENEFITS
In the case of Orthodontic Treatment which began
while coverage was in force, benefits will be
payable through the end of the month in which
coverage was terminated. Payment will be based on a
pro-ration of any applicable quartely installments.
If the Group Health Plan terminates, benefits will
cease immediately.
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ERISA INFORMATION
HEALTH PLAN PD 8511
PLAN NUMBER: 501 - 20928
EFFECTIVE DATE: October 1 , 1985
EFFECTIVE DATE OF BENEFIT CHANGES: 11/l/85
PLAN YEAR: October 1 thru September 30
The Plan described in this summary plan description
is the City of Dania Employee Health & Welfare
Benefit Plan.
The Plan is Sponsored by:
i Name : City of Dania, Florida
Address: 100 W. Dania Beach Boulevard
City/State/Zip: Dania, Florida 33004
Benefits provided by the Plan are paid from
contributions from the City of Dania Employee
Health & Welfare Benefit Plan.
The Employer is the City of Dania and each of its
associates participating in the Plan .
The Plan Administrator is :
Name : City of Dania, Florida
Address: 100 W. Dania Beach Boulevard v
City/State/Zip: Dania, Florida 33004
The Plan Supervisor is :
Name : Medical Insurance Administrators
Address: 1591 East Atlantic Boulevard
P.O. Box 619001
City/State/Zip: Pompano Beach, Florida 33061-9001
Telephone Number: ( 305) 942-7991
The Company has hired Medical Insurance
Administrators, Inc . , (MIA) to handle certain
administrative responsibilities associated with the
Plan as follows :
Process and pay claims as provided by the Plan
Document;
Determine eligibility of individual claimants
for benefits;
Notify the employee of ineligible and denied
claims , indicating the reason;
Maintain records of participants .
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SCHEDULE OF PARTIES TO THE PLAN f�`
The City of Dania,Florida an EMPLOYER having its principal place of
business in Dania, Florida, (hereinafter referred to as the
"EMPLOYER") hereby adopts the City of Dania, Florida HEALTH & WELFARE
Benefit Plan.
PLAN NUMBER: 501 - 20928
The purpose of which said Plan is established is to provide Health
Coverage and related benefits for the EMPLOYER' S and said Plan shall
be administered and conducted for the sole benefit of the Plan
participants and their beneficiaries.
The ADMINISTRATOR shall be the City of Dania, Florida.
The PLAN SPONSOR shall be the City of Dania, Florida.
Medical Insurance Administrators, Inc . , (MIA) has been employed by the
EMPLOYER to handle certain administrative responsibilities associated
with the Plan; the specifics of which are outlined in a separate
Agreement entitled; ADMINISTRATIVE SERVICES & COMPENSATION AGREEMENT.
TRUSTEES for the Plan will be the City of Dania, Florida.
SCHEDULE OF ELIGIBILITY & COVERAGE
EFFECTIVE DATE of the Plan shall be October 1 , 1985 .
PLAN YEAR shall be a twelve month period ending September 30 .
ELIGIBLE INDIVIDUALS
The individuals eligible for coverage hereunder are as follows :
1 ) Employees who have completed the Plan WAITING PERIOD and who
are actively expending time and energy, and are full-time
employees of the EMPLOYER (hereinafter called "Employees
Within The Eligible Classes" ) , and
,,... 2) dependents of those employees who are meeting the requirements
of 1 ) above, and
3) a covered child will continue to be covered beyond the age of _
nineteen ( 19) , if a full-time student, to age 25.
Benefits are payable with respect to RETIRED employees and their
eligible dependents, if so elected under Florida Statute SB153 .
WAITING PERIOD
The Waiting Period is One Month, however, for those employees who
are employed on the Date of Issue, there is no waiting period.
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EFFECTIVE� E OF COVERAGE
Coverage becomes effective on the day following completion of the
Waiting Period .
CONTRIBUTIONS TOWARD PREMIUM BY EMPLOYEE
Coverage with respect to employees is issued on a NON-CONTRIBUTORY
basis. Coverage with respect to the dependents is issued on a
NON-CONTRIBUTORY basis.
CLASSIFICATION CHANGE DATE
A change in an employee's benefits caused by a change in his
Classification will be effective immediately upon the date such
change in Classification becomes effective.
EMPLOYEE COVERAGE CLASSIFICATION
All employees will be considered to be in the same Classification,
however, as noted, Elected Commissioners and the City Attorney,
along with Retirees are not eligible for Weekly Income Benefits.
TERMINATION OF COVERAGE
Employee Termination
The coverage of any employee covered under this Plan shall
terminate on the earliest of the following dates :
1 ) the date the employee ceases to be eligible for coverage under
the Plan, or
2) the date the employee becomes a full-time member of the Armed
Forces or any Country, or
3) the date the employee terminates employment, or
4) the date the employee retires, unless Paragraph "ELIGIBLE
INDIVIDUALS" states otherwise.
5) the date of termination of this Plan, or
6 ) the last date to which contributions, if required, have been
made.
Dependent Termination
The coverage of any Dependent covered under this Plan shall
terminate on the earliest of the following dates :
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1) the dar�'he employee 's coverage terminates, or
2) the date a dependent no longer qualifies as an eligible
dependent, or
3) the date of termination of the Plan, or
4) the last date to which contributions, if required , have been
made.
CONVERSION OF HEALTH COVERAGE
Within thirty one ( 31 ) days from the date of termination ( provided
the employer' s Plan Document has not been terminated) an employee
may convert himself and his covered dependents to an individual
policy. Covered dependents of the employee may only convert if the
employee himself converts (unless otherwise stated by the carrier
providing the conversion policy) . The converted policy shall
provide on a reimbursement basis, at least the benefits required by
law.
In no event will the benefits provided under the conversion policy
be in excess of the benefits provided for such persons under the
Plan from which the covered employee has terminated. The EMPLOYER
or Medical Insurance Administrators, Inc. , upon request, will
furnish to an employee the appropriate application for conversion.
R SCHEDULE OF BENEFITS
WEEKLY INCOME BENEFITS
All Employees, except Elected Commisisoners and the City Attorney,
along with Retirees are not eligible for Weekly Income Benefits.
The benefits allowable will not exceed a maximum payment of $300 .
Commencing with the 1st day of total disability due to accidental
bodily injury and the 8th day of total disability due to any other
illness(es) , or the 1st day of hospital confinement, benefits are
payable for a maximum of 26 weeks, during any continuous period of
total disability.
An employee ' s maximum benefit will not exceed 50 percent of the
employee' s weekly earnings, minus the total amount, if any, the
employee receives, or is entitled to receive, for the same period
of time during which weekly income benefits are payable as. . .
Federal Social Security Disability Benefits, and as Benefits
payable under any Worker' s Compensation or Occupational Disease
law.
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The amoun Social Security Benefits and Benef under any
Worker's l jensation or Occupational Disease Law which the
Weekly Benefit will be reduced will be the total amount to which
the employee is entitled as of the date the period of continuous
disability begins.
BENEFITS ARE PAYABLE BASED UPON THE USUAL, REASONABLE & CUSTOMARY FEES
DEDUCTIBLE $100 .
The deductible is waived if a covered individual uses the services
or facilities of the Florida Health Network PPO.
However, there is no deductible in connection with, ( 1 ) charges
made for hospital-type services on the same day of a surgical
operation wherever performed, and ( 2 ) fees of physicians for such
surgical operation .
This deductible provision applies only to Out-Patient Services.
In addition to the Major Medical Deductible, an additional $200.
deductible applies to charges incurred for In-Patient confinement
in "any" hospital , if such confinement is not pre-certified thru
Florida Health Network .
PREFERRED PROVIDER (PPO) HOSPITAL OR (PPO) PHYSICIAN is defined as
•A a licensed hospital or licensed physician which has agreed , by
contract with the Employer, to provide a discount to all covered
individuals who use their facilities. w
PRE-CERTIFICATION/UTILIZATION REVIEW is defined as a formal program
operated for the purpose of avoiding unnecessary in-patient
confinement days through suggesting the use of out-patient care or
alternate facilities wherever possible and seeing that the patient
is discharged on a timely basis.
The deductible applies to the eligible charges of each calendar
year, but it applies only once for the covered employees and only
once for each covered dependent, in any calendar year regardless of
the number of illnesses. Furthermore, when any part of a year' s
deductible is applied against eligible charges arising during the
last three months of that calendar year, the following years'
deductible will be reduced by the amount so applied.
Any expenses of a covered individual that were used toward
satisfaction of the Calendar Year Major Medical Deductible under
the employer' s previous Plan ( if that previous Plan terminated
immediately prior to the effective date of this Plan) can be used
toward satisfying this Plan' s Calendar Year Deductible.
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Three Tim`4"**%ductible
When an aa, it of eligible expenses incurred by I ae or more
members of a family of four or more members equals three cash
deductibles, all covered members of the family unit are in a
benefit period and no further cash deductible is required during
that calendar year.
If a single accident causes injuries to two or more members of a
family unit, a single deductible will apply to all such members for
whom a benefit period is not in effect with respect to eligible
charges incurred during that calendar year and resulting from all
such injuries. In no event will a lessor amount be paid that would
be payable if this single deductible did not apply.
MAJOR MEDICAL BENEFITS
Maximum Benefits
Lifetime Aggregate $1 ,000 ,000 .
In no event will more than a lifetime maximum of $2 ,000 . in the
aggregate be payable in connection with mental illness(es) or
functional nervous disorder( s) of any type or cause, for
psychiatric, psychoanalytic, or psychological care.
BENEFIT PERCENTAGE 80%
Full Payment Feature
After a person has incurred $2 ,500 . of covered charges during a
calendar year, which are payable at 80% , Major Medical pays 100% of
covered charges (other than those for . ( i) mental and nervous
conditions, and ( ii) dental conditions) subsequently incurred
within the calendar year which are not required to satisfy a
deductible .
Covered individuals who were in the 100% feature of the employer' s
previous Plan ( if that previous Plan terminated immediately prior
to the effective date of this Plan) will continue to be in the 100%
feature of this Plan for the balance of the calendar year during
which this Plan became effective.
BENEFIT PERIOD
A benefit period with respect to a covered individual commences
when the individual has incurred during a calendar year eligible
charges for illnesses which exceed the deductible amount. Included
will be eligible charges incurred during October, November and
December of the preceding calendar year for which no benefits were
payable because such charges were applicable to the deductible.
5
A benefit tiod with respect to an individual ' s ill terminates
on the ear. st of the following dates:
1 . the last day of the calendar year in which it was established ,
2. the day coverage is provided herein terminates, or
3. the day the maximum benefit is paid .
MAXIMUM ELIGIBLE FOR ROOM & BOARD
Confinement in PPO Hospital
The maximum eligible charge for Room & Board in a hospital will
be equal to the actual charge made up to the semi-private room
charge of the hospital . Benefits, however, will be payable at
100% without satisfying a deductible .
The maximum eligible charge for Intensive Care Units, Coronary
Care Units and similar necessary accommodations in a hospital,
exlcluding private room accommodations, will be equal to the
actual charge made by the hospital . Benefits, however, will be
payable at 100% without satisfying a deductible.
Confinement in a Non-PPO Hospital
The maximum eligible charge for Room & Board in a hospital will
be equal to the actual charge made up to the semi-private room
charge of the hospital .
The maximum eligible charge for Intensive Care Units, Cardiac
Care Units and similar necessary accommodations in a hospital ,
excluding private room accommodations,. will be equal to the
actual charge made by the hospital .
OUT-PATIENT SURGERY
Benefits in connection with, ( 1 ) hospital-type charges on the same
day of a surgical operation, wherever performed, and ( 2 ) fees of
physicians for such surgical operations are payable at 100% , no
deductible.
Charges for out-patient surgery will include all charges related to
the surgery on the day the procedure is preformed .
In order to be considered "Out-Patient" surgery, no room and board
charges must be incurred and recuperation must take place at home.
MEDICAL CARE (Physician Visits)
Visits By PPO Provider
Visits to or by the physician will be payable at 100% , without
satisfaction of the deductible.
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b Visits byre PPO Physician ; }
Visits to or by a physician will be payable at 80% , after
satisfaction of the deductible.
SURGERY
If there is more than one surgical procedure done through the same
incision, the procedure with the highest benefit will be allowed.
If two or more operations are performed through separate incisions,
in different operative fields while in the operating room, the
maximum benefit will be allowed for the first procedure, plus one
half of the allowable benefits for each of the lessor procedures.
PRE-ADMISSION TESTING
Benefits are payable in connection with charges incurred for
laboratory and radiological examinations performed on an Out-
Patient basis within 48 hours preceding In-Patient confinement for
surgery or other treatment in connection with the same illness for
which such examinations have been performed . Such examinations
repeated following commencement of such In-Patient confinement, but
prior to such surgery or other treatment, are not, however,
included within the meaning or intent of this benefit.
Maximum Benefit (No Deductible) 100%
SECOND SURGICAL OPINION ° t
Benefits are payable in connection with the medical advice of a
surgeon regarding a Surgical Procedure. The advice must be based
upon the Physician's examination of the patient. The examination
must be performed by a Board Certified Specialist, after another
physician has proposed to perform the surgery, but prior to such
performance.
.1 If the Second Surgical Opinion differs from the first physician's
opinion, the Plan will cover the cost of a Third Opinion.
Maximum Benefit (No Deductible) 100%
SUPPLEMENTAL ACCIDENT BENEFIT
Expenses incurred by a covered person as a result of accidental
bodily injury, sustained while he is covered hereunder and for
which treatment is rendered within
three months following the date of the accidental injury
7
will be pr�le in an amount equal to the eligible es and fees
incurred L., cc the maximum benefit of the Plan. _low-up care
necessitated as a result of such injury will be payable for a
period of no longer than three months from the date the original
injury occurred provided the maximum benefit has not been paid .
Maximum Benefit ( for each bodily injury) $500 .
MENTAL AND NERVOUS CONDITIONS
Charges for professional services in connection with mental
illness( es) or functional nervous disorders(s) of any type of cause
or for psychiatric or psychoanalytic care for any reason are not
covered, except those services rendered by a legally qualified
physician, during a "visit" by or to the patient and which are not
in excess of one visit on any one day. However, charges for
psychological testing , for any reason, are ineligible for benefit
consideration.
The word "visit" includes each attendance of the physician to the
patient regardless of the type of professional services rendered
whether it might be otherwise termed consultation, treatment or
described in some other manner.
Maximum Out-Patient Benefit (Per Visit) $20 .
Maximum Out-Patient Benefit (Per Calendar Year) $1 ,000 .
In-Patient Benefit Percentage 80%
MATERNITY BENEFITS
Maternity benefits are only payable;
1 . with respect to Major Medical Benefits on the same basis as any
other illness, and
2 . for delivery, miscarriage,
3 . for complications of pregnancy .
4 . Benefits are not payable for or in behalf of dependent children
PRE-EXISTING CONDITIONS
Benefits for charges incurred in connection with an illness or
injury for which the person has incurred otherwise covered expenses
or has been advised by a physician regarding treatment within three
months prior to the effective date of coverage are limited
hereunder to a maximum of $250 . benefits.
Such conditions may include the taking of medication, advice or
information during telephone conversations with medical providers,
consultations or actual treatment by a physician or medical
provider. This exclusion will cease to apply if :
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after thr ,onsecutive months of continuous coverac nding after
the effec,. ,e date of coverage during which the pers. has received
no treatment with respect to the illness, or
after a period of twelve consecutive months during which the person
is continuously covered hereunder.
PRESCRIPTION DRUG BENEFIT
No benefits are payable under this Plan for drug charges which are
payable under the Pharmaceutical Card System, Inc. through the use
of a PCS Card issued to eligible employees.
Deductible (Per Prescription) $2
Benefit Percentage (After Payment of $2 . Deductible) 100%
ALCOHOL & DRUG BENEFIT
Benefits are payable for treatment of or addiction to, or use of
narcotics or hallucinogens or alcohol in any form, excluding
treatment or services provided for detoxification.
Out-patient (Per Visit) $35.
Lifetime Maximum (Out-Patient) 44 visits
In-Patient Benefit Percentage 80%
Lifetime Maximum all Services $2 ,000 .
4
VISION BENEFITS
Employees who have been employed by the Employer for a period of
twelve ( 12 ) consecutive months are eligible for this Vision
Benefit. Covered dependents are not eligible and no benefits will
be provided under this Vision Benefit.
The Plan will pay the reasonable & customary benefits for complete
visual analysis, including examination, eye tests, case history,
refraction, glasses and contact lenses.
Benefit Percentage (No Deductible) 100%
Maximum Benefit (Per Employer, Per Calendar Year) $150 .
THE FOLLOWING CHARGES ( IF NECESSARY REASONABLE AND CUSTOMARY) ARE
COVERED
A) Certain drugs and medicines which require a written prescription
of a PHYSICIAN and which must be dispensed by a licensed
pharmacist or PHYSICIAN.
1 ) Provided such drug charges are eligible expenses.
2) The charges billed by PCS will be eligible for Reinsurance
reimbursement.
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B) Blood other fluids to be injected into circulatory
system,
C) Artificial limbs and eyes for loss of natural limbs and eyes
which loss occurred while covered;
D) Lens implants, lens, each eye (contact or frames) immediately
following and because of cataract surgery only;
E) Casts, splints, trusses , braces, crutches and surgical
dressings;
F) Rental of certain hospital-type equipment, including wheelchair,
hospital bed , iron lung and other mechanical equipment for the
treatment of respiratory paralysis and equipment for the
administration of oxygen, for the personal and exclusive use of
the patient.
1 ) The total price to be eligible on a monthly pro-rata basis,
so long as the equipment continues to be medically
necessary; but
2 ) not to exceed twelve ( 12 ) months;
G) Purchase or rental of hospital-type equipment for kidney
#� dialysis for the personal and exclusive use of the patient.
1 ) The total price to be eligible on a monthly pro-rata basis
during the first twenty four ( 24 ) months of ownership, beut
only so long as dialysis treatment continues to be
medically required .
2) The Plan will also consider as eligible all charges for
supplies, materials and repairs necessary for the proper
operation of such equipment and also reasonable and
necessary expenses for the training of a person to operate
.+� and maintain the equipment for the sole benefit of the
patient,
H) Consulting Surgeon Fees;
I) Local Ambulance Service from the place the disability is
contracted to a hospital equipped to furnish special treatment
necessary for the disability;
J) Organ Transplant (excluding charges as an organ donor) ;
K) Physiotherapy;
L) Electronic Heart Pacemaker;
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M) VasecG�s, Tubal Ligations, Circumcision;
N) Restoratory or Rehabilatory Speech Therapy by a legally
qualified speech therapist, other than a close relative, for
i speech loss or impairment due to an illness, (other than a
functional nervous disorder or learning disability) , or due to
surgery on account of an illness. If the speech loss or
impairment is due to a congenital anomaly, surgery to correct
the anomaly must have been performed prior to the therapy. If
the speech therapy is performed as a result of a developmental
disorder, no coverage shall be extended .
0) Charges for, or in connection with, treatment performed to
correct a congenital anomaly, if such condition occurred while
covered hereunder.
P) Treatment of , or addiction to, or use of narcotics or
hallucinogens or alcohol in any form;
Q) Services rendered for Alcohol or Drug Detoxification;
R) Charges for newborn nursery services and charges of physicians,
while hospital confined;
S) Charges for a newborn child prior to its discharge from the
hospital for, ( 1 ) a premature birth, ( 2) for an abnormal
congenital condition, and ( 3 ) for an illness contracted after
birth.
THE FOLLOWING CHARGES ARE NOT COVERED
A) for, or in connection with an injury arising out of , or in the
course of any employment for wage or profit;
B) for, or in connection with a sickness or accident for which the
Employer or Dependent is entitled to benefits under any Workers
Compensation or similar local , State or Federal Statue, or to
the extent the Employee or Dependent is entitled to benefits or
payments under Automobile Personal Injury Protection Insurance
issued pursuant to any No-Fault type automobile reparations
ordinance or statue;
C) to a hospital owned or operated by the United States Government;
D) where prohibited by law;
E) for charges you are not legally required to pay or for charges
which would not have been made if no coverage existed;
F) for charges made which are in excess of reasonable and customary
charges or for charges for unnecessary care or treatment;
11
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G) for chair\' for education, training , psychologica \sting , bed
and boar ,chile you are confined to an institute which is
primarily a school or other institution for training, a place of
rest, a place for aged, a nursing home, or for custodial care or
for rehabilitative services;
H) for occupational therapy;
I) for charges for, or in connection with care, treatment or
operations, which are performed for cosmetic, elective or
non-functional purposes, unless such expenses are incurred as a
result of an accident which occurred while covered;
J) for services or treatment of injury due to declared or
undeclared war or any related act of war declared or undeclared;
K) for charges incurred while covered, for the treatment of
injuries as the result of an accident, which occurred prior to
coverage under this Plan;
L) for radial keratotomy, hearing aids or examinations for
prescriptions or fitting of hearing aids;
M) for routine hearing examinations, routing physical examinations,
routine physical examinations, pre-employment physicals,
pre-school examinations, routine immunizations or annual
boosters, for transportation (other than local ambulance) , or
l for reduction of weight by diet control;
N) for an illness or injury to which a contributing cause was the
commission of, or attempted commission of, an act of aggression
or a felony by the covered person;
0) for charges for dental work, examinations or treatment of any
kind, except that performed by a licensed dentist or dental
surgeon as a result of an accident which occurred while covered.
If the result of a covered accident, treatment must be to sound
natural teeth and shall include only replacement of such teeth,
or setting of jaw, if fractured or dislocated, in the accident.
Treatment must begin within ninety ( 90) days of the date of the
accident and must be completed within twenty-four ( 24 ) months
following the date of the accident. Dental charges, other than
as the result of an accident are payable as outlined in the
Dental Expense Coverage section of this Schedule of Benefits.
P) for professional medical or surgical services rendered by an
individual who is related to the covered person by blood or
marriage;
Q) for services and supplies related to sexual dysfunctions or
inadequacies, or sex change operations;
12
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R) for sur/ to reverse surgical sterilization proc *es;
S) for birth control services and supplies or for artificial
insemination, or fertility drugs;
T) for charges for Well Baby Care for visits to the physician for
routine examinations, physicals, shots, immunizations or annual
boosters following hospital confinement.
MEDICAL BENEFITS FOR THOSE AGE 64 OR UNDER AND 70 OR OLDER
INTEGRATION WITH MEDICARE
Any Benefits payable under the medical expense Plan provisions of
this Plan will be reduced by the amount of any benefits or
compensation to which the covered individual is entitled under
Medicare. The reduction will apply whether or not the individual
has received, or made application for such other benefits, and
• A covered individual is deemed "entitled" to all Medicare benefits
for which he is or has been eligible, and
• Coverage is available for all full-time employees and their
eligible dependents who meet the eligibility requirements for
coverage under the provisions of this Plan.
MEDICAL BENEFITS FOR THOSE AGE 65 THRU 69
Employees and their eligible dependents 65-69 years old are
entitled under Section 116 ( a) of Public Law 97-242 . The Tax Equity
and Fiscal Responsibility Act of 1982 (TEFRA) , amended Section 4 of
the ADEA, to receive the same Group Health Coverage, under the same
conditions, as those employees/dependents under age 65. Eligibility
for these benefits applies to the period beginning with the month
of entitlement in which the individual attains the age of 65 (on
the month of entitlement to Part A of Medicare, if later) and
ending on the last day of the month in which the individual attains
the age of 70, unless the individual has voluntarily elected to
terminate coverage under this Plan.
This Plan provision shall automatically be interpreted and be in
compliance with any and all amendments to the Act.
LEAVE OF ABSENCE
If a covered employee requested and has been granted a leave of
absence by the employer, the employee must pay the applicable
premium in order to continue health coverage . .
In any event , coverage under the Plan may not continue for longer
than Six ( 6 ) months following the date on which the leave is
granted .
13
EXTENSION OF 'FITS FOLLOWING TERMINATION OF EMPLOYME
Notwithstanding any language in this Plan to the contrary, if upon
the date of termination of an individual ' s coverage hereunder, he
is totally disabled, the MEDICAL COVERAGE hereunder will be
extended during the subsequent period of total disability, but not
beyond twelve ( 12) months after the date the individual ' s coverage
terminates or the first possible date of eligibility for any other
Company sponsored Plan. Such extension of benefits will be provided
only for the ILLNESS which caused the disbility. If the Plan
terminates , benefits will cease immediately.
REINSTATEMENT OF BENEFITS
On the first day of each year, each covered family member who then
has benefits charged to his lifetime maximum benefit will
automatically have $ 1 ,000 . or the amount needed to restore the
Maximum Benefit back to the full amount, whichever is less ,
restored for future use . The automatic restoration will not apply
to you if you are a retired employee, or to a covered family member
covered only if the Extension of Benefits provision is applicable.
This automatic restoration will continue to apply to you if you are
a retired employee, but not to a covered family member only if the
Extension of Benefits provision is applicable.
RETIREMENT
Should a retired employee elect to continue coverage under this ,,,_,.
Plan under Florida Statute SB 153, coverage will continue under
this Plan during such retirement until terminated under the terms
of the Plan.
DENTAL EXPENSE COVERAGE
Dental Deductible (Per Person, Calendar Year) $50 .
The Family Deductible is TWO TIMES per calendar year.
Preventative Dental Services 80%
Basic Dental Services 80%
Major Dental Services ( excluding Orthodontia) 80%
Calendar Year Maximum ( Per Person) $2,000 .
ORTHODONTIA BENEFIT
Deductible ( Lifetime - Per Person) $50 .
Orthodontia Services 50%
Lifetime Maximum ( Per Person) $1 ,000 .
14
ERISA INFORMATION
HEALTH PLAN: PD 8511
The Plan falls under the jurisdiction of the Federal Government's
Employee Retirement Income Security Act of 1974 (ERISA) . Plan benefits
are provided in accordance with ERISA Qualified Self-Funded Employee
Health & Welfare Benefit Plans .
The Plan should not be deemed to constitute a contract between the
Employer and any Employee or to be a consideration for, or an
inducement of or condition of employment of any employee.
The Plan Document itself contains the entire wording and its language
will control the operation of the Plan for the participants and for.
the Employer.
The Plan is established and maintained by the Employer shown below:
Name: City of Dania, Florida
Address: 100 W. Dania Beach Boulevard
City, State, Zip: Dania, Florida 33004
Employer Identification Number:
Plan Number: 501 - 20928
The name, business address and business telephone number of the Plan
Administrator/Sponsor is:
Name : City of Dania, Florida
Address: 100 W. Dania Beach Boulevard
City, State, Zip: Dania, Florida 33004
Telephone : ( 305) 921-8700
The name designated as agent for service of legal process and the
address at which process may be serviced on is :
'R..r
Name : City of Dania, Florida
Address: 100 W. Dania Beach Boulevard
City, State, Zip: Dania, Florida 33004
The name of the trustee of the Plan and the address of the principal
place of business is as follows :
Name : City of Dania, Florida
Address: 100 W. Dania Beach Boulevard
City, State , Zip: Dania, Florida 33004
The Plan utilizes a funding medium for the accumulation of assets
through which benefits are provided .
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The fund is ma �ined on behalf of the Plan by: City o is F1
The fund account number is: 2050004173 Bank: Caribank of Dania
The effective date of the Plan is : October. 1 , 1985
The date of the end of the year for purpose of maintaining the Plan' s
fiscal records is : September 30
The Plan Supervisor is:
Name : Medical Insurance Administrators, Inc.
Address: 1591 East Atlantic Boulevard
City, State. Zip: Pompano Beach, Florida 33061-9001
Post Office Box 619001
Telephone Number: ( 305) 942-7991
The Employer has hired Medical Insurance Administrators, Inc. , to
handle certain responsibilities associated with the Plan, as follows:
• Process and pay claim as provided by the Plan Document.
• Determine eligibility of individual claimants for benefits.
Notify the Employee of ineligible or denied claims and reason(s) .
Maintain claim records of participants on behalf of the Employer.
16
ARTICLE I - DEFINITIONS
For all purposes of this PLAN:
The purpose of this group health coverage is to protect covered
INDIVIDUALS in times of sickness or injury to lesson the burden
of hospital and medical expenses for the NECESSARY CARE and
TREATMENT of such ILLNESSES .
1 . 01 ADMINISTRATOR shall be the EMPLOYER/SPONSOR or person (s) , if so
designated by EMPLOYER/SPONSOR.
1 . 02 BASIC HEALTH COVERAGE means only coverages provided HEREIN.
1 . 03 CERTIFICATE means a written statement including all riders and
supplements , if any, setting forth the benefits to which the
covered INDIVIDUAL is entitled , to whom the benefits are
payable , and any limitations or requirements applicable to the
covered EMPLOYEE . Such CERTIFICATES will not constitute a part
of this PLAN.
1 . 04 COMPLICATIONS OF PREGNANCY means conditions , requiring hospital
confinement (when pregnancy is not terminated) , whose diagnoses
are distinct from pregnancy but adversely affected by or are caused by pregnancy , pregnancy
cardiac such as acute nephritis, nephrosis ,
de
surgical conditions onOf m comparable
issed tiseverity,on and mibut lar mshalledical nand
ot
b include false labor , occasional spotting , physician prescribed
rest during the period of pregnancy , morning sickness , w
hyperemesis gravidarum, pre-eclampsia and similar conditions
associated with the management of • a difficult pregnancy and
non-elective cesarean section , ectopic pregnancy which
terminated
g which
and spontaneous y � is
p aneous termination of pregnancy which occurs
during a period of gestation in which a viable birth is not
Possible . Complications of pregnancy, as defined above are
covered under the Plan the the same extent as any other ILLNESS .
1 . 05 COSMETIC SURGERY means the surgical alteration of tissue for the
`s improvement of the covered INDIVIDUAL ' S a
improvement or restoration of bodily functioarance rather than
1 . 06 COVERED PERSON means an employee who is covered under this Plan. !
1 . 07 CUSTODIAL CARE means care which is designed essentially to help
a person in the activities of daily living and which does not
require the continuous attention of trained medical or
paramedical personnel . Such care may involve preparation of
special diets , supervision over medication that can be
self-administered and assistance in getting in or out of bed ,
walking , bathing , dressing , eating and using the toilet .
1 . 08 DEPENDENT means
A) an EMPLOYEE ' S spouse (unless such spouse is legally
sep.+rated from the EMPLOYEE) , or
L�
1PLOYEE ' S unmarried child (including stepchild or
legally adopted child) from live birth , wh, is domiciled
with him in a regular parent-child relationship , until the
date the child attains 19 years of age ; except that the term
DEPENDENT includes an EMPLOYEE ' S unmarried child who has
attained age 19 while the child is ;
1) mentally or physically incapable of earning his own
living , and proof of incapacity is submitted to the
ADMINISTRATOR within 31 days of the date his HEALTH
COVERAGE would have terminated due to age , and
2) actually dependent on the EMPLOYEE for a majority of his
maintenance and support , and
3) a covered INDIVIDUAL, on the date immediately preceding
the date his DEALTH COVERAGE would have terminated due
to age , and
4) the child is registered in an accredited school as a
full-time student as defined in the regulations of the
school which he is attending . In no event , however , is
such child eligible or covered HEREUNDER on or after the
date as stated on Schedule of Eligibility.
5) In the event both parents of an eligible dependent
^ children) are covered persons , then for the purposes of
this coverage , such child (ren) is considered as a
dependent of either parent , but not both parents .
6) An employee cannot he covered as a dependent and no
person can be covered as a dependent of more than one
employee .
1 . 09 EMPLOYED ON A PART-TIME BASIS means that the employment of a
person results in his active expenditure of less than the number
of hours per week referred to in Section 2 . 01 A) . Such person
EMPLOYED ON A PART-TIME BASIS is not eligible for HEALTH
COVERAGE HEREUNDER unless he qualifies under Section 2 . 01 HEREIN
1 . 10 EMPLOYEE means a person
A) who is directly employed in the regular business of and
compensated for services by the EMPLOYER or any Subsidiary
or Affiliate , and
B) who actively expends time and energy in the service of the
EMPLOYER or any Subsidiary or Affiliate on a fulltime basis ,
and
I
C) who is in a class eligible for coverage under this Plan .
Reference to an EMPLOYEE(S) of the FMPLOYER includes an
EMPLOYEE (S) of a Subsidiary or Affiliate .
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No ctor or officer of a corporate EM DER will be
considcred as being an EMPLOYEE unless such pers. : is otherwise
eligible as a bona fide EMPLOYEE of the corporation by
performing services other than the usual duties of a director .
No individual proprietor or partner will be considered as being
an EMPLOYEE unless' he is actively engaged in and devotes time
and energy to the conduct of the business of the proprietorship
or partnership .
Notwithstanding 1 . 10 B) , a person will be deemed actively
expending time and energy in the service of the EMPLOYER on each
day of a regular paid vacation, and on a regular non-working day
on which he is not disabled , provided he was actively expending
time and energy in the service of the EMPLOYER , including any
Subsidiary or Affiliate , on the last preceding regular working
day.
Any person performing services of a recognized profession ,
including but not limited to an attorney-at-law and an
accountant , who is remunerated on a basis other than regular
wage or salary by the EMPLOYER will not be considered an
EMPLOYEE for the purposes of this definition .
1 . 11 EMPLOYER/SPONSOR shall mean the EMPLOYER named in Section 1 . 01
and any other business corporation or professional association
which , with the consent of the EMPLOYER , shall assume the
obligations of the EMPLOYER under this PLAN . Such assumption of
said obligations shall be in writing and shall be signed by the
EMPLOYER and by an officer of the corporation or association , as
the case may be , assuming the obligations of this PLAN . Y
1 . 12 EXTENDED CARE FACILITY means an institution operated pursuant to
law for the care and treatment of sick or injured persons , with
24 hour nursing services and facilities for the care of at least
6 resident patients . "Extended Care Facility" does not include
an institution operating other than incidentally as a place for
treatment of drug addiction, alcoholism or mental illness .
1 . 13 FAMILY UNIT means a covered EMPLOYEE and , if they are covered
persons , his children , if any , and his spouse .
1 . 14 GRACE PERIOD means the period of 31 consecutive days beginning
with any PREMIUM due date which will be allowed the Employer for
payment of any PREMIUM without interest charge and during which
this PLAN will continue in force provided the EMPLOYER has not ,
prior to the PREMIUM due date , given written notice to Medical
Insurance Administrators , Inc . or the Reinsurer that this Plan
is to be terminated on the day immediately preceding such
PREMIUM due date .
1 . 15 HEALTH COVERAGE means any coverages provided HEREIN .
1 . 16 HEREIN , HEREOF, HEREUNDER AND HEREINAFTER refer to the PLAN in
its entirety .
r7�'.
1 . 17 HOME. LTH CARE AGENCY means ( 1) a non-profit is home care
service or agency possessing a valid certifica . of approval
issued in accordance with Title XVIII of the Social Security Act
of 1965 , as amended , or duly licensed if such licensing is
required , by the appropriate licensing AUTHORITY , or (2) a
Hospital possessing a valid operating certificate authorizing
the Hospital to provide home health care services .
1 . 18 HOME HEALTH CARE PLAN means a program for care and treatment of
the
a COVERED PERSON established and approved in writing by
an prior to the start of home
covered person' s attending physici
health care services . The physician must also certify that
hospitalization would be required if home care is not provided .
1 . 19 HOSPITAL means an institute which
A) is licensed as a HOSPITAL (if hospital licensing is required
where it is situated) ,
8) is open at all times ,
C) is operated primarily for the medical treatment of sick
and/or injured persons as in-patients ,
D) has a staff of one or more licensed PHYSICIANS available at
. A all times ,
E) provides continuous 24-hour nursing service by graduate
registered nurses (R.N . ) ,
F) provides organized facilities- for diagnosis and major
surgery , or if primarily a facility for the treatment of
mentally ill or mentally retarded persons , has a bona fide
arrangement by contract or otherwise , with n accredited
HOSPITAL to perform such surgical procedures a
s may be
required by the facility for mentally ill or retarded
persons , and
G) is not primarily a clinic , nursing home , rehabilitative
facility , convalescence home , rest home or similar
establishment , and
H) has accreditation by the Joint commission on The
Accreditation of Hospitals .
"Hospital " also includes a licensed ambulatory surgical center ,
the primary purpose of which is provide elective surgical
to p
care which does not require confinement , but does not include a
facility for the primary purpose of performing terminations
pregnancy or an office maintained by a physician
practice of medicine or an office maintained for the practice of
dentistry .
1 . 20 ILLN1N eans a bodily disorder , disease , p ancy, mental
infirmity or accidental bodily injury. All ,lily injuries
sustained by an INDIVIDUAL in a single accident , or all
ILLNESS (ES) which are due to the same or related cause or causes
will be deemed one ILLNESS , EXCEPT THAT:
With respect to the transplant of a natural organ (refer to
the Schedule of Benefits to determine whether or not Organ
Transplants are covered expenses) or organs or other natural
tissue from one living person to another, the medical
expense of the donor will not be considered as eligible
charges for an ILLNESS of the donor , (unless the donor is a
covered person under this Plan) , subject to the other
provisions of this Plan.
1 . 21 INDIVIDUAL means
A) an EMPLOYEE and/or
B) a DEPENDENT with respect to whom an EMPLOYEE is or may
become covered .
1 . 22 INTENSIVE CARE UNIT means a section, ward or wing within the
HOSPITAL which is separated from other HOSPITAL facilities and
A) is operated exclusively for the purpose of providing
professional medical treatment for critically ill patients ,
B) has special supplies and equipment necessary for such
medical treatment available on a stand-by basis for
immediate use , and
C) provides constant observation and treatment by registered
nurses (R. N. ) or other highly trained HOSPITAL personnel .
A HOSPITAL facility maintained for the purpose of providing
normal post-operative recovery treatment or service is not
considered an INTENSIVE CARE UNIT.
1 . 23 MEDICARE means the medical benefits provided by Title XVIII of
the Social Security Act as amended from time to time .
1 . 24 MONTH means "calendar month" which for the purposes HEREOF will
mean the time period from and including any date of any of the
months in the calendar tc F.ut not including the corresponding
date of the next month in the calendar; but if there be no
corresponding date , than to and including the last day of the
next month in the calendar . For example , June 15 through July 14
inclusive , or January 31 through February 28 inclusive .
1 . 25 ONE CONTINUOUS PERIOD OF DISABILITY mean:: a period of time
during which an INDIVIDUAL is disabled . Successive periods of
disability due to the same or related cause or causes will be
considered ONE CONTINUOUS PERIOD OF DISABILITY unless they are
separated by ,
L�
A) respect to an EMPLOYEE, two or more WE" ,Of employmentcontinuous
with the EMPLOYER on a full-time ive basis , or
B) with respect to the DEPENDENT of an EMPLOYEE, a period of
three or more MONTHS during which no total disability due to
the same or related cause or causes occurs .
1 . 26 ONE CONTINUOUS PERIOD OF HOSPITAL CONFINEMENT means a period of
time during which a person is confined in a HOSPITAL, as a
registered bed patient . Successive periods of HOSPITAL
confinement due to the same or related cause or causes will be
considered one period of HOSPITAL confinement separated by unless they are
A) with respect to an EMPLOYEE, two or more WEEKS of
continuous employment with the EMPLOYER on a full-time
active basis , or
B) with respect to the DEPENDENT of an EMPLOYEE, a period
of three or more MONTHS during which the DEPENDENT has
not been HOSPITAL confined due to the same or related
i
cause or causes .
i 1 . 27 PHYSICIAN means a licensed practitioner of the healing arts
acting within the scope of his or her license , who is not a
covered person or a member of a covered persons ' immediate
brothers , f'sistersTE FAMILY"or parents ofeans the covered spouse , child ren
shall be a properly licensed Person . A PHYSICIAN"
of Medicine M. D . Person holding the degree of Doctor
( ) Doctor of Osteopathy (D . O. ) ,
Dental Surgery (D .D. S . ) , Doctor of Podiatr Doctor of
Doctor of Chiropractic (D . C. ) . y (D P M• ) � or a
The term shall also include a clinical psychologist who has a
Ph.D in PSYCHOLOGY and who may be treating the patient upon
referral by a licensed physician . The term may also include a
duly certified Midwife (if so stated in the Schedule of
Benefits) . Service or care rendered by such a Nurse Midwife must
be within the scope of practice of a duly"Nurse Midwife" certified Midwife .
means a REGISTERED NURSE who is certified as a
Nurse Midwife by the American College of Nurse-Midwives and who
Is authorized to practice as a Nurse Midwife under regulations . The term, however, state
shall not include a Social
Worker.
Benefits for services of D . P.M.
plait that will not exceed benefits of this
would have been paid to an M. D. or D. O. for treatment
of the given condition.
1 . 28 PLAN whenever used HEREIN without qualification will mean this
PLAN.
I
1 . 29 PRE-E ING CONDITONS
Pre-existing conditions are any injury or illness -or which the
person has incurred otherwise covered expenses or has been
advised by a physician regarding treatment within three months
prior to the effective date of coverage .
Such conditions may include the taking of medication, advice or
information during telephone conversations with medical
providers , consultations or actual treatment by a physician or
medical provider .
This Plan shall be a continuation of the Plan it replaces .
1 . 30 PREMIUM means the monetary contributions necessary to Y a all
pay
expenses of the PLAN and to pay all claims as required under the
PLAN.
1 . 31 QUALIFIED SPEECH THERAPIST means a speech therapist who has a
master ' s degree in speech pathology , who has completed a
supervised internship and who is licensed by the state in which
he performs his services , if that state requires licensing .
1 . 32 REASONABLE AND CUSTOMARY means the usual charge made by the
physician or supplier of services , medicines or supplies , and
shall not exceed the general level of charges made by others
rendering or furnishing such services , medicines or supplies
within the area in which the charge is incurred for illnesses or
injuries comparable in severity and nature to the illness or
injury being treated , as outlined in MIA' s then current
reasonable and customary guidelines . The term "area" as it would
apply to any particular services , medicine or supply, means a
county, or Fuch greater area as is necessary to obtain a
representative cross-section of persons , groups , or other
entities rendering or furnishing such services , treatment or
material .
1 . 33 REINSURER OR STOP LOSS CARRIER means an insurance company or
�. underwriter or reinsurer who contractually agrees to accept a
liability risk for the payment of eligible incurred claims . The
extent of the risk is defined in a contract issued by the
reinsurer and agreed to by the employer .
1 . 34 ROOM AND BOARD CHARGES are charges made by the HOSPITAL for the
cost of the room, meals and services (such as general nursing
services) that are routinely provided to all in-patients .
1 . 35 SKILLED NURSING FACILITY means an institution qualified as such
under Medicare .
1 . 36 SPFCIAL CHARGES means those charges made by the HOSPITAL for
other than ROOM AND BOARD . SPECIAL CHARGES include , but are not
limited to , charges made by a legally qualified PHYSICIAN for
professional services in connection with radiology and
Pathology . Anesthesiology is included unless otherwise provided
under the Surgical benefits .
1 . 37 SPONSOR (Refer to EMPLOYER at Section 1 . 09) .
1 . 38 IOTA. D PERMANENT DISABILITY means TOTAL DISA r�TY continuing
for at least nine MONTHS .
1 . 39 TOTAL DISABILITY and TOTALLY DISABLED mean
A) with respect to an EMPLOYEE, his inability to engage , as a
result of ILLNESS in his normal occupation with the
EMPLOYER, and
B) with respect to a DEPENDENT, his inability to perform the
usual and customary duties or activities of a person in good
health and of the same age and sex .
1 . 40 WAGE (S) , EARNING(S) AND SALARY (IES) mean only that basic
remuneration received by the EMPLOYEE from the EMPLOYER on the
date he is eligible for HEALTH COVERAGE HEREUNDER .
Any reference to length of employment or service refers only
to length of employment or service with the EMPLOYER.
1 . 41 WAITING PERIOD means the time beginning with the EMPLOYEE ' S most
recent date of continuous employment with the EMPLOYER, and
ending on the date he is eligible for HEALTH COVERAGE HEREUNDER.
1 . 42 WELL BABY CARE is defined as the charges of a hospital and
�1 attending pediatrician for the care of a newborn child .
Whenever a personal pronoun in the masculine gender is used , it will
be deemed to include the feminine unless the context clearly indicates
the contrary.
T71
ARTICLE II — ELIGIBILITY AND COVERAGE
2 . 01 ELIGIBLE INDIVIDUALS
The INDIVIDUALS eligible for HEALTH COVERAGE HEREUNDER are as
follows :
A) EMPLOYEES in the employ of the EMPLOYER (HEREIN called
EMPLOYEES within the eligible classes) who have completed
the WAITING PERIOD and who are actively expending time and
energy of at least the number of hours per week stated in
Section 2 . 02 , and
B) DEPENDENTS of those EMPLOYEES who are meeting the
requirements of A) above .
Benefits with respect to retired EMPLOYEES and their DEPENDENTS
is as stated in the Schedule of Eligibility .
To maintain the eligibility under Section 2 . 01 B) above , due
proof that the EMPLOYEE ' S child continues to qualify as a
covered DEPENDENT must be furnished to the ADMINISTRATOR as it
reasonably requires .
Any spouse or child who is covered under the PLAN as an
(! EMPLOYEE, or who is entitled to benefits under any extension of
such HEALTH COVERAGE, is not a DEPENDENT. r
In the event that a husband and wife are both covered as
EMPLOYEES HEREIN , their DEPENDENTS , if any, may be considered
DEPENDENTS of either the husband or' the wife for purposes of
this PLAN.
An EMPLOYEE cannot be covered as a DEPENDENT and no person can
be covered as a DEPENDENT of more than one EMPLOYEE.
,...F` 2 . 02 WAITING PER10D
The WAITING PERIOD is the period of time between the date of
employment and the date coincident with or next following
completion of the WAITING PERIOD as stated in the Schedule of
Eligibility.
2 . 03 CLASSIFICATION CHANGE DATE
A change in an EMPLOYEE ' S benefits caused by a change in his
classification will be effective immediately upon the date such
change in classification becomes effective .
2. 04 CONTRIBUTIONS TOWARD PREMIUM BY EMPLOYEE.
HEALTH COVERAGE may be issued on a contributory basis , if so
stated in Section 2 . 05 A) 2) .
I I �
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HEAL':jVERAGE with respect to the DEPENDENTS ' an EMPLOYEE
may be on a contributory basis , if so stated a.. Section 2 . 05
S) 2) .
HEALTH COVERAGE becomes effective as provided in Section 2 . 05 .
2 .05 EFFECTIVE DATES OF HEALTH COVERAGE
An INDIVIDUAL ' S HEALTH COVERAGE HEREUNDER will be effective as
follows :
A) EMPLOYEES
1) If it is shown on the Schedule of
ligibility that
EMPLOYEE HEALTH COVERAGE is on a Enon—contributory
basis , an EMPLOYEE' S HEALTH COVERAGE will become
effective automatically on the datc- fie becomes eligible .
2) If it is shown on the Schedule of Eligibility that
EMPLOYEE HEALTH COVERAGE is on a contributory basis ,
each EMPLOYEE who
a) makes written request for HEALTH COVERAGE provided
HEREUNDER on a form approved by the reinsurer , and
b) so agrees in writing to contribute toward the
PREMIUM will become covered as follows:
c) if the EMPLOYEE makes such written request prior to
the end of the 31 day period immediately following
the first day on which - he is eligible , he will
become covered on the later of
i) the date of such written request , or
ii) the date on which he becomes eligible .
iii) the date shown in the Schedule of Eligibility.
d) If the EMPLOYEE makes such written request after
i) the end of the 31 day period , indicated in c) ,
above , or
ii) he previously terminated his HEALTH COVERAGE
on a voluntary basis ,
he must furnish without expense to the
ADMINISTRATOR, evidence of satisfactory health
before he may become covered . The EMPLOYEE will
become covered only after the ADMINISTRATOR
determines such evidence of health to be
satisfactory and the EMPLOYEE becomes covered on the
date as determined by the ADMINISTRATOR or Reinsurer
B) 1 NDENTS
1) If it is shown on the Schedule of Eligibility that
DEPENDENT HEALTH COVERAGE is issued on a
non—contributory basis, an EMPLOYEE' S HEALTH COVERAGE
with respect to his DEPENDENT(S) will become effective
automatically with respect to each DEPENDENT on the date
such DEPENDENT of the EMPLOYEE becomes an eligible
INDIVIDUAL. HEREUNDER and while the EMPLOYEE qualifies as
an INDIVIDUAL eligible for HEALTH COVERAGE as shown in
Section 2 . 01 B) .
2) If it is shown on the Schedule of Eligibility that
DEPENDENT HEALTH COVERAGE is on a contributory basis ,
the DEPENDENT(S) of each EMPLOYEE who
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a) makes written request for HEALTH COVERAGE provided
for DEPENDENTS HEREUNDER on a form approved by
Medical Insurance Administrators or the Refnsurer .
b) so agrees in writing to contribute toward the
payment of PREMIUMS for DEPENDENTS will
covered as follows : become
c) If the EMPLOYEE makes such written request prior to
the end of the 31 day period immediately following
the first day on which he is eligible for DEPENDENT
HEALTH COVERAGE, his DEPENDENT(S) will become
covered on the later of w-
1) the date of such written request , or
the date the EMPLOYEE becomes covered .
d) If the EMPLOYEE makes such written request after
i) the end of the 31 day period indicated in c)
L above , or
if) he previously terminated on a voluntary basis
his HEALTH COVERAGE with respect
DEPENDENTS to his
while continuing to have
DEPENDENT(S) eligible HEREUNDER ,
his DEPENDENT (S) will not be covered until the
EMPLOYEE furnishes , without expense for the ADMINI—
STRATOR . evidence of satisfactory health for each
person who is a DEPENDENT of such EMPLOYEE on the
date of such request . if evidence of health is
submitted , the DEPENDENT(S) will become covered only
after the ADMINISTRATOR, determines such evidence of
health to becomes he satisfactory and the DEPENDENT(S)
he
on the date as determined by the
ADMINISTRATOR or Reinsurer .
A DEPENDENT will become a cov INDIVIDUAL
automatically if the EMPLOYEE is coverea nor DEPENDENTS
on the date such person becomes a DEPENDENT.
C) EMPLOYEES AND DEPENDENTS
An EMPLOYEE who must furnish Evidence of Health as a
condition to becoming covered or as a condition of
having his DEPENDENT(S) becoming covered , will in no
event become covered nor will a DEPENDENT become covered
until such evidence is furnished to and approved with
respect to each such INDIVIDUAL .
2 .06 TERMINATION OF INDIVIDUAL ' S HEALTH COVERAGE
An INDIVIDUAL' S HEALTH COVERAGE will automatically terminate
immediately upon the earliest of the following dates :
A) the date the PLAN terminates .
B) the date of the expiration of the last period for which any
required contribution agreed to in writing has been made .
C) the date of the EMPLOYEE ' S termination of employment with
the EMPLOYER or the date he otherwise ceases to be eligible
for HEALTH COVERAGE or as stated in the Schedule of
Eligibility.
1 ) For the purposes of this PLAN, an EMPLOYEE ' S employment " °
will cease upon cessation of his active expenditure of
time and energy for the - EMPLOYER , unless otherwise
stated in the Schedule of Eligibility .
2) Notwithstanding 1 ) above , a person may continue to be an
EMPLOYEE for coverages other than Weekly Income Benefits
if such EMPLOYEE is
�..` a) on an approved leave of absence ,
b) temporarily laid off ,
c) employed on a part-time basis , or
d) unable to work because of disability,
if the EMPLOYER acting in accordance with principles
precluding individual selection continues making
PREMIUMS for such EMPLOYEE ' S HEALTH COVERAGE .
In any event , such coverage may continue no longer than
the period of time stated in the Schedule of Benefits ,
following the date on which the EMPLOYEE ' S HEALTH
COVERAGE is e::tended under the terms of subsections
2)a) , b) , and c) , of this sub-paragraph .
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with respect to DEPENDENTS ,
1) the date he ceases to be a DEPENDENT as defined
HEREIN, or
2) the date of termination of all DEPENDENTS coverage
HEREUNDER.
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ARTICLE III - BENEFITS
3. 01 HEALTH COVERAGE BENEFITS
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The individual HEALTH COVERAGE Benefits provided under the PLAN
for a covered INDIVIDUAL will be in accordance COVERAGE Benefit with the HEALTH
Provisions and the individual HEALTH COVERAGE
classification shown on the Schedule of Eligibility, all as
provided HEREIN . If more than one HEALTH COVERAGE classification
is designated on the Schedule of Eligibility, any change in the
amount of an INDIVIDUAL ' S HEALTH COVERAGE, occasioned by change
in an EMPLOYEE ' S classification , is effective on the
Classification Change Date Shown in Section 2 . 03 , EXCEPT THAT:
A) if an INDIVIDUAL ' S HEALTH COVERAGE HEREUNDER is being
continued solely as a result of Section 2 . 06 C) 2) HEREIN,
his HEALTH COVERAGE and his DEPENDENT ' S HEALTH COVERAGE will
not be increased until the next following day on which he
qualifies as an INDIVIDUAL, eligible for HEALTH shown in Section 2 . 01 A) , and COVF,RACE as
B) the amount of HEALTH COVERAGE with respect to a DEPENDENT
will not be increased while the DEPENDENT is confined in a
HOSPITAL.
3 . 02 NOTICE AND PROOF OF CLAIM AND EXAMINATION
NOTICE-20 DAYS
A) Written notice of each injury or ILLNESS for which benefits
may be claimed must be given to the ADMINISTRATOR within
twenty (20) days of the date any expenses are incurred .
B) Failure to furnish notice within twenty (20) days will not
invalidate or reduce any claim if it is shown that notice
was provided as soon as was reasonably possible .
C) The ADMINISTRATOR, upon receipt of such notice , will furnish
its form(s) for filing proof of claim to the EMPLOYEE. If
such forms are not furnished within fifteen ( 15) clays after
ADMINISTRATOR ' S receipt of notice , the INDIVIDUAL covered
will be deemed to have complied with the requirements of the
PLAN as to proof of claim upon submitting , within the time
fixed in the PLAN for filing proofs of claim, written proof
concerning the occurrence , character and extent of the loss
for which claim is made .
3. 03 PROOF - 90 DAYS
A) Affirmative proof of claim on account of HOSPITAL confine-
ment for which claim is made must be furnished .
B) Affirmative proof of any other claim must be furnished the
ADMINISTRATOR not later than ninety (90) days ,after the date
of loss .
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C) F ire to furnish proof of any claim wit: ! ninety (90)
days will not invalidate or reduce any claim-_i it is shown
that proof was provided as soon as was reasonably possible .
D) EMPLOYER has responsibility of forwarding claims and forms
to Medical Insurance Administrators , Inc . within ninety (90)
days .
3 . 04 EXAMINATION
The INDIVIDUAL covered will upon request from the ADMINISTRATOR
submit to an examination as is provided in Section 4 . 05 .
3 . 05 CHOICE OF PHYSICIAN
The INDIVIDUAL will have free choice of any legally qualified
PHYSICIAN.
3 . 06 WORKER' S COMPENSATION
This PLAN is issued on a non—occupational basis and is not in
lieu of , and does not affect , any requirement for coverage by
Worker ' s Compensation Insurance .
3 . 07 HOSPITAL BENEFITS
If a covered INDIVIDUAL incurs charges as a result of being
confined in a HOSPITAL (or Skilled Nursing Facility if so stated
in the Schedule of Benefits) , payment , if applicable , will be
made equal to the sum stated in the Schedule of Benefits , or
A) ROOM AND BOARD CHARGES made by
1 ) the HOSPITAL , or
2) the SKILLED NURSING FACILITY , (if eligible)
Payment will be limited to the applicable daily benefit for each
day of confinement and limited to the applicable Maximum Benefit
in the aggregate for any ONE CONTINUOUS PERIOD OF HOSPITAL
CONFINEMENT shown in Section 3 . 11D) 1) 2) .
B) SPECIAL CHARGES
1 ) if the covered INDIVIDUAL is confined as a registered
bed patient
2) other than as a registered bed patient :
a) for emergenry treatment in connection with and
rendered within 48 hours immediately following
accidental bodily injury necessitating such
treatment , or
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S) in connection with a surgical opera
c) for diagnostic X—Ray and laboratory examinations
provided they are made in contemplation of surgery
and are made within
1) 48 hours prior to such scheduled surgery with
respect to urinalysis or blood count
examinations , or
ii) 168 hours before such scheduled surgery with
respect to all such SPECIAL CHARGES other than
urinalysis or blood count examinations .
If for necessary medical reasons the surgery
scheduled is cancelled or postponed for more than
two (2) weeks , benefits will be payable for those
other similar diagnostic , X—Ray and laboratory
examinations again made in connection with and prior
to the rescheduled surgery.
Payment will be limited to the Maximum Benefit for any ONE
CONTINUOUS PERIOD OF HOSPITAL CONFINEMENT shown in Section
3 . 07 A) 2) .
C) Charges for the use of a local ambulance to transport a
° covered INDIVIDUAL to , but not returning from , the HOSPITAL ,
or the Skilled Nursing Facility , if medically necessary .
3 . 08 MEDICAL TREATMENT BENEFITS
A) If a covered INDIVIDUAL incurs charges as a result of
medical treatment for other than a surgical operation, such
treatment is rendered by a legally qualified PHYSICIAN while
the covered INDIVIDUAL is a registered bed patient in a
HOSPITAL , payment will be made equal to the fee for such
treatment up to the Maximum Benefit per day shown on the
r . Schedule of Benefits , provided HOSPITAL room and board
benefits are payable for the date such charges are made .
Such payment will be made for the first treatment while a
patient is confined otherwise than as a registered bed
patient , provided the confinement is for emergency treatment
rendered within 48 hours immediately following at.. accidental
bodily injury necessitating such treatment .
B) Payment vil '_ he made up to the Maximum Benefit shown on the
Schedule of Benefits for any one continuous period of
disability.
3 . 09 SURGICAL BENEFITS
A) If a covered INDIVIDUAL incurs chr;rgee. oF a result of
treatment in the form of a surgical operation , Surgical
Benefits will be paid in an amount equal to the surgical fee
actually charged the covered INDIVIDUAL , but no more than
the Maximum Benefit applicable as shown in Section 3 . 11
B) 1 ) .
B) ao or more such operations are
1) performed during any ONE CONTINUOUS PERIOD OF
DISABILITY, and are due to the same or related cause or
causes , the total amount payable for all such operations
will not exceed the Maximum Benefit shown in Section
3 . 11 B) 1 ) .
2) performed on the same surgical occasion and in the same
operative field , the total amount payable for all
operations performed in such operative field will not
exceed the maximum amount applicable for that operation
or as shown in the Schedule of Benefits .
3 . 10 ADDITIONAL ACCIDENT BENEFITS
{ A) If a covered INDIVIDUAL incurs charges for
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1 ) medical , dental or surgical treatment for supplies ,
2) confinement in a HOSPITAL ,
3) laboratory and X-ray examinations , and/or
4) services of
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a) a registered nurse (R .N. ) for private duty nursing ,
and/or
b) a licensed practical nurse (L . P . N. ) for private duty
nursing services , while the covered INDIVIDUAL is a
registered bed patient in a HOSPITAL,
as a result of an accidental bodily injury and treatment
commences within three (3) months of the date of the injury
benefits will be paid in an amount equal to the charges and
fees incurred up to the Maximum Benefits , if any , shown in
the Schedule of Benefits . Follow-up care necessitated as a
result of such injury will not be applied toward any
deductible for a period of no longer than three (3) months
from the date the original injury occurred , if so stated in
the Schedule of Benefits .
3 . 11 MAJOR MEDICAL BENEFITS
If a covered INDIVIDUAL incurs eligible charges during a
Benefit Period established with respect to him, Major
Medical Benefits are payable .
A) Benefit Period
A Benefit Period with respect to a covered INDIVIDUAL
commences and terminates as shown on the Schedule of
Benefits .
B letermination of Benefit
Benefits payable are equal to
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1) the Benefit Percentage shown on the Schedule of
Benefits ; and multiplied by,
2) the total eligible charges incurred during the
Benefit Period which exceed the deductible amount .
C) Maximum Benefit
1 ) The total Major Medical Benefits payable for an
INDIVIDUAL' S ILLNESS will not exceed his Maximum
Benefit shown in the Schedule of Benefits , even
though he may not have been continuously covered .
D) Eligible Charges are those charges incurred for one of
the following, unless otherwise excluded in the Schedule
of Benefits :
1 ) ROOM AND BOARD and routine nursing services for each
day of confinement in a HOSPITAL , up to the
applicable Maximum Daily Benefit , if any , shown on
the Schedule of Benefits ;
2) ROOM AND BOARD for each day of confinement in a
SKILLED NURSING FACILITY , up to the Maximum Daily
Benefit , if any , shown on the Schedule of Benefits :
3) Intensive Nursing Care For each day of confinement
in a HOSPITAL, as follows :
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� a) For those HOSPITALS which make a separate charge
for ROOM AND BOARD and a separate charge for
Intensive Nursing Care , the HOSPITAL ' S specific
charge for Intensive Nursing Care is eligible ;
a- b) For those HOSPITALS which make a separate charge
for ROOM AND BOARD and Intensive Nursing Care ,
that portion of the combined charge which is in
excess of the HOSPITAL' S prevailing semi—private
BOARD AND ROOM rate will be considered as the
eligible charge for Intensive Nursing Care ;
4) medical services and supplies furnished by the HOSPITAL:
5) anesthetics and their administration;
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6 uedical treatment (including but not lii�\d to surgical
operations) rendered by and in the physical presence of
a legally qualified PHYSICIAN, EXCEPT THAT:
the maximum eligible charges for treatment of mental
illness , functional nervous disorder of any type or
cause, or psychoanalytic care for any reason (except
that psychological testing shall be excluded from
coverage) rendered by a legally qualified PHYSICIAN
during a visit by or to the patient will not exceed
a) the amount stated in the Schedule of Benefits ,
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b) one visit on any one day , and
(The word "Visit" as used herein is deemed to include
each attendance of the PHYSICIAN to the patient in his
physical presence , regardless of the type of profes-
sional service rendered during such attendance which
might be otherwise termed a consultation, treatment , or
described in some other manner . )
7) service provided by
a) a licensed practical nurse (L. P .N. ) for private duty
nursing services while the covered INDIVIDUAL, is a
registered bed patient in a HOSPITAL or
b) a licensed physiotherapist ;
8) X-ray examination (other than dental) , microscopic and
laboratory tests and other diagnostic services ;
9) X-ray and radiation therapy ;
10) Charges for the use of local ambulance to transport a
covered INDIVIDUAL to , but not returning from, the
HOSPITAL , or a SKILLED NURSING FACILITY .
11 ) Additional COVERED EXPENSES are as listed in the
Schedule of Benefits .
3 . 12 PREGNANCY
Benefits for PREGNANCY are payable on the same basis as benefits
for any other 1LLNESS , as stated in the Schedule of Penefits .
3 . 13 PRE-EXISTING CONDITIONS
A maximum benefit as stated in the Schedule of Benefits will .'. he
allowed for covered charges relating to a pre-existing condition.
Pre-Existing conditions are any INJURY or ILLNESS for which the person
has incurred otherwise covered expenses or has been advised by a
physician regarding treatment within three (3) months prior to the
effective date of coverage .
j Such condit s may include the taking of medics' , advice or
j information during telephone conversations with meo-._al providers ,
consultants or actual treatment by a physician or medical provider .
This exclusion will cease to apply as stated in the Schedule of
Benefits .
3 . 14 Specific exclusions , other than those stated above , are listed
in Article IV, Sections 6 . 01 and 6 . 02 .
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Al LE IV - MEDICAL INSURANCE ADMINISTRATORt
4 . 01 COMPUTATION OF PREMIUMS
A) The rates used in computing the PREMIUMS due under this PLAN
will be the rates of The Underwriter adjusted to reflect the
underwriting risk as determined by The Underwriter and may
include billings fees charges by Medical Insurance
Administrators , Inc .
The Underwriter may , however , establish a new rate for the
computation of all future PREMIUMS as well as the one then
due
1 ) on any PLAN Anniversary ,
2) on any PREMIUM due date provided that The Underwriter
notifies the EMPLOYER of such change at least 31 days in
advance of such PREMIUM due date , or
3) when the terms of this PLAN are charged
However, the rates may not be changed in accordance with b)
above within the first twelve ( 12) MONTHS following the Date
of Agreement , or as stated in the Reinsurance Contract .
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B) If PREMIUMS are payable on other than a monthly basis ,
PREMIUMS for additional , increased , reduced or terminated
HEALTH COVERAGE becoming effective during a PLAN MONTH will
cause a pro rata adjustment to the next PREMIUM due date to
be charged from the first day of the PLAN MONTH which is
coincident with or next follows the date such change becomes
effective .
C) Notwithstanding the above , PREMIUMS may be computed by any
method mutually agreeable to The Underwriter and the
EMPLOYER which will produce approximately the same total
amount .
4 . 02 AMENDMENT AND ALTERATION OF PLAN
A) This PLAN may be amended or altered at any time by written
agreement between the EMPLOYER and The Underwriter without
the consent of the covered EMPLOYEES or their beneficiaries ,
if any .
B) Only The Underwriter has the authority to amend , alter ,
waive or change in any manner the provisions of this PLAN .
Should the Employer wish to amend the benefits of the Plan ,
such benefits shall be payable under this Plan on a non-
contractual basis without liability on the part of the
Underwriter.
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C) M +r The Underwriter will not be bound by (04411j promise or
representation heretofore or hereafter made , or to any
agent or person other than as authorized in B) above .
4. 03 TERMINATION OF PLAN
MIA in conjunction with The Underwriter may terminate this PLAN
on any PREMIUM due date by giving written notice to the EMPLOYER
at least 31 days in advance .
4. 04 PAYMENT OF CLAIM
Benefits Payable
A) All benefits are payable to the EMPLOYEE. If any such
benefits remain unpaid at the death of the EMPLOYEE, or if
the EMPLOYEE is a minor or is , in the opinion of Medical
Insurance Administrators , Inc . , incapable of giving a
legally binding receipt for payment of any benefit , the
EMPLOYER at his option, may issue such benefit to any one or
more of the following relatives of the EMPLOYEE: spouse ,
parent (s) , child(ren) , brother (s) , or sister (s) . Any payment
so made by the EMPLOYER will complat2ly dischar;e
obligation to the extent of such payment . Medical lnsui:,a,o
Administrators , Inc . will not be responsible as to the
application of such payment .
B) Subject to due proof of clam, upon request of the covered
EMPLOYEE , the accrued daily HOSPITAL and/or weekly income
benefits , if provided HEREIN, will be paid each week during
any period for which the EMPLOYER is liable . Upon receipt of
due proof , any balance remaining unpaid at the termination
of such period and any benefits provided in this PLAN will
be paid immediately.
C) The EMPLOYER may allocate the deductible amount , if any, to
any eligible charges and apportion , if necessary , the
benefits to any assignee . Such actions will be binding upon
covered INDIVIDUALS and assignees .
4 . 05 EXAMINATION
A) FMPLOYER will have the right and opportunity at its own
expense to examine the person of any INDIVIDUAL whose injury
or ILLNESS is the basis of a elnim HEREUNDER when and so
often as it may reasonably require during pendency of such
claim.
B) EMPLOYER will have the right and opportunity to make an
autopsy where not prohibited by law.
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4. 06 EMPLI� BOOKLET
Medical Insurance Administrators , Inc . will prepare , based upon
the Plan design specified by the EMPLOYER, for delivery to each
covered EMPLOYEE an individual BOOKLET stating
A) the coverage provided,
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B) to whom benefits are payable , and
C) limitations or requirements of this PLAN that may apply to
the covered INDIVIDUAL .
The BOOKLETS will not constitute a part of this PLAN.
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ARTICLE V — ADMINISTRATOR
5 . 01 RECORDS
A) The ADMINISTRATOR will maintain a record which will show at
all times
1 ) the names of all EMPLOYEES covered RF.REUNDER,
2) the date when each EMPLOYEE becomes covered ,
3) the effective date of any increase or decrease in the
amount of each EMPLOYEE ' S HEALTH COVERAGE , and
4) such other information as may be required to administer
the HEALTH COVERAGE HEREUNDER.
B) The ADMINISTRATOR may be the EMPLOYER . The ADMINISTRATOR
will furnish the other party to this agreement , as indicated
above , with a similar record , as of the Date of Agreement of
this PLAN, and will report to that party all subsequent
changes in said record . Such of the EMPLOYER' S and/or
records as may , in the opinion of Medical Insurance
Administrators , Inc . have a bearing on the HEALTH COVERAGE
HEREUNDER will be open to inspection by Medical Insurance
Administrators , Inc . at any reasonable time.
5 . 02 EFFECT OF ACTIONS OF ADMINISTRATOR
The ADMINISTRATOR may act for and on behalf of the EMPLOYER and
all Subsidiaries and Affiliates in • all matters pertaining to
this PLAN . Every agreement made with the ADMINISTRATOR will be
binding on such ADMINISTRATOR, the EMPLOYER and the Subsidiaries
and Affiliates . Every notice given to the ADMINISTRATOR will be
deemed to have been given to the ADMINISTRATOR, the EMPLOYER and
the Subsidiaries and Affiliates .
` 5 . 03 RECORD OF EMPLOYEES COVERED
A) The EMPLOYER and its Subsidiaries and Affiliates will
furnish periodically to the ADMINISTRATOR information
relative to INDIVIDUALS
1) who qualify to become covered ,
2) whose amounts of coverage change , and/or
3) whose coverage terminates ,
all as the ADMINISTRATOR may require for its administration
of the benefits HEREUNDER. Such of the EMPLOYER ' S records
which , in the opinion of the ADMINISTRATOR, have a bearing
on the coverage HEREUNDER will be opened for inspection by
the ADMINISTRATOR at any reasonable time upon a timely and
reasonable request .
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B) i bertent error or omission on the part one EMPLOYER to
report the name of any individual who _ a qualified
INDIVIDUAL in accordance with the prescribed requirements,
or whose amounts of HEALTH COVERAGE is to be changed in
accordance with provisions HEREUNDER, will not deprive such
EMPLOYEE of coverage nor affect its amount ; nor will the
EMPLOYER ' S failure to report the name of any EMPLOYEE. whose
HEALTH COVERAGE has terminated or reduced be construed as
involving or effecting continuation of such HEALTH COVERAGE
beyond the date of termination or reduction determined in
accordance with the provisions HEREOF.
5 . 04 PAYMENTS
A) All PREMIUMS due under this PLAN, including adjustments
thereof , if any, are payable by the EMPLOYER on or before
their respective due dates , as specified in the Schedule of
Dates of this PLAN, at the office of Medical Insurance
Administrators , Inc . , in Pompano Beach , Florida . Any
required PREMIUMS not made will subject EMPLOYER to
liability under the Employee Retirement Income Security Act
of 1974 ,
5 . 05 PREMIUM REFUNDS - EMPLOYEE PORTION
If the Covered EMPLOYEES contribute toward the payment of
PREMIUMS , the aggregate of PREMIUMS , if any , in excess of the
EMPLOYER ' S share of the aggregate cost will be applied by the
ADMINISTRATOR for the sole benefit of the EMPLOYEES . However , "e^
nothing contained HEREIN will obligate the ADMINISTRATOR. to see
to the application of any refund or •any portion thereof paid to
the EMPLOYER.
5 . 06 REPRESENTATIONS
In the absence of fraud all statements made by the EMPLOYER will
be deemed representations and not warranties .
,.. 5 . 07 EMPLOYEE BOOKLETS
The EMPLOYER will deliver to each covered EMPLOYEE a BOOKLET.
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ARTICLE VI — GENERAL PLAN PROVISION4j
6.01 BENEFIT EXCLUSIONS AND LIMITATIONS APPLYING TO OTHER THAN LIFE
INSURANCE BENEFITS
A) Non—occupational Coverage
No benefits are provided as a result of
1) any accidental bodily injury which arises out of or in
the course of any employment with any EMPLOYER and/or
for which the INDIVIDUAL is entitled to benefits under
any Workmen ' s Compensation Law or Occupational Disease
Law, or receives any settlement from a Workmen ' s
Compensation Carrier , or
<) any ILLNESS in which the INDIVIDUAL is entitled to
benefits under any Workmen ' s Compensation or
Occupational Disease Law, or receives any settlement
from a Worker ' s Compensation carrier ,
unless it is shown in Section 3 . 06 that the coverage
provided by a benefit is on both an occupational and
non—occupational basis .
B) War
No benefits are provided for losses which are due to war , or "Y
any action of war, ' whether declared or undeclared .
C) INDIVIDUAL Must Be Under the Direct Care of a PHYSICIAN
No benefits are payable unless the INDIVIDUAL is under the
direct care of a legally qualified PHYSICIAN.
D) Legal Obligation
HEALTH COVERAGE is provided only in connection with charges
for treatment for which the INDIVIDUAL is , in the absence of
this HEALTH COVERAGE , legally obligated to pay .
E) Necessary , Reasonable , and Customary
1 ) treatment which is necessary to the treatment of ILLNESS
and is incurred on the recommendation of a legally
qualified PHYSICIAN , and
2) charges which are not in excess of the regular and
customary charges for the services performed and the
materials furnished .
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6 . 02 BENE EXCLUSIONS AND LIMITATIONS APPLYING TO /�R THAN LIFE
INSURANCE BENEFITS , ACCIDENTAL DEATH BENEFITS WEEKLY INCOME
BENEFITS
A) Legal Obligation
HEALTH COVERAGE is provided only in connection with charges
for treatment for which the INDIVIDUAL is , in the absence of
this HEALTH COVERAGE , legally obligated to pay.
B) Necessary, Reasonable , and Customary
j HEALTH COVERAGE is provided only for;
1) treatment which is necessary to the treatment of an
ILLNESS and is incurred on the recommendation of a
legally qualified PHYSICIAN , and
2) charges which are not in excess of the regular and
customary charges for the services performed and the
materials furnished .
C) Additional PLAN EXCLUSIONS and LIMITATIONS are listed in the
SCHEDULE OF BENEFITS .
D) Charges incurred in connection with an Illness considered by
Medical Insurance Administrators , Inc . as pre—existing will
be limited as shown on the Schedule of Benefits .
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E) Transferred Benefits Provision
If an Individual incurs expenses which would otherwise be
excluded by Section 6 . 02 (D) of this Plan, and if
1 ) the Individual is covered on the Date of Issue , and
2) the Individual was covered on the immediately preceding
day under any policy or plan which was replaced by this
Plan, and
3) such expenses would have been payable under the policy +
or plan which was replaced by this Plan ,
The Plan will pay the lesser of the total amount payable
for the excluded expenses under
4) the policy or Plan replaced , or
5) this Plan without Section 6 . 02 (D) in effect .
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6 . 03 EXTEiN OF CERTAIN BENEFITS ITPON TERMINA! j OF HEALTH
COVERAGE WHILE TOTAL DISABILITY EXISTS
Notwithstanding any language in the PLAN to the contrary , if
upon the date of termination of an INDIVIDUAL 'S HEALTH COVERAGE
HEREUNDER, he is totally disabled , the basic medical coverage
HEREUNDER will be extended during the subsequent period of
continuous disability , but for no longer than the period of time
stated in the schedule of Benefits , following the date of such
termination and Major Medical benefits HEREUNDER will he
extended during the subsequent period of continuous total
disability , but for no longer than the period of time stated in
the Schedule of Benefits , following the date of such
termination .
The HEALTH COVERAGE so provided will be only for the condition
for which the INDIVIDUAL is disabled .
6 . 04 CHANGE IN HEALTH COVERAGE CLASSIFICATION NOT AS A RESULT OF
AMENDMENT OF POLICY
(This Provision Applies Only to Major Medical Benefits)
If a change in HEALTH COVERAGE classification of an INDIVIDUAL
would otherwise increase the Maximum Benefit applicable to him
under Major Medical Benefits , such increase will not apply in
4 connection with an INDIVIDUAL ' S ILLNESS in existence on the date
of such change until ; in the case of an EMPLOYEE , two or more
weeks of continuous employment with the EMPLOYER on a full-time s '
basis and in the case of a DEPENDENT, a period of three or more
months during which the DEPENDENT has not been hospital confined
due to the same or related cause or causes , ending after the
date of such change .
6. 05 NON-FORFEITURE
If the terms and conditions set forth in this PLAN are performed
by the covered INDIVIDUAL within the prescribed period , then the
" f benefits which accrue under this PLAN will become payable .
However, if any terms and conditions are not performed within
the prescribed period , then the covered INDIVIDUAL will forfeit
his right to such benefits which may have arisen under this PLAN
with respect to the loss not timely reported.
6. 06 CHARGE FOR SERVICE OR PURCHASE
The charge for a service or purchase will be deemed to have been
incurred on the date the service is performed or the purchase
occurs .
6 . 07 COORDINATION OF BENEFITS
A) Benefits Subject to this Provision
All HEALTH COVERAGE benefits HEREIN are subject to this
provision except any Life Insurance Benefits , Accidental
Death Benefits , or Weekly Income Benefits which may be
provided herein .
i
B) nitions
1) The Term "Plan" as used HEREIN will mean any Plan pro-
viding benefits or services for or by reason of medical
treatment , which benefits or services are provided by
a) group insurance or any other arrangement for
coverage for INDIVIDUALS in a group whether on an
insured or uninsured basis , including but not
i
limited to
A
1 ) hospital indemnity benefits with regard to the
amount in excess of $30 . 00 per day , and;
ii) hospital reimbursement-type plans which permit
the insured person to elect indemnity benefits
at the time of Clain , or
b) hospital or medical service organizations on a group
! basis , group practice and other group pre-payment
plans , or
i
c) hospital or medical service organization on an
individual basis having a provision similar in
effect to this provision , or
" d) any coverage for students which is sponsored by, or
provided through , a school or other education
institution, other than accident coverage for
grammar school or high school students for which the
parent pays the entire premium, or
e) group automobile or no-fault auto insurance , or
f) individual automobile insurance coverage on
automobile leased or owned by covered INDIVIDUAL.
g) individual health Plans or Policies , if so stated in
the Schedule of Benefits .
2) the Term "Plan" will be construed separately with
respect to each policy , contract , or other arrangement
for benefits or services and separately with respect to
that portion of any such policy , contract , or other
arrangement which reserves the right to take the
benefits or services of other Plans into consideration
in determinirp its benefits and that portion which does
not .
3) The term "Allowable Expense" means any necescary item of
expense , the charge for which is reasonable , regular and
customary , at least a portion of which is covered under
at least one of the Plans covering the person for whom
claim is made . When a Plan provides benefits in the form
of services rather than cash payments , the reasonable
cash value of each service rendered will be deemed to be
both an allowable experee r.nd a benefit paid .
The term "Claim Determination Period"
Year or that portion of a Calendar Year . _ring whichnda
the
INDIVIDUAL for whom claim is made has been covered this PLAN. under
5) "Benefit Determination Period" means a calendar year .
C) Coordination Procedures
The benefits following : under the Plan shall be subject to the
i
1 ) this provision shall apply in figuring the benefit as to
I a INDIVIDUAL covered under the PLAN for a Benefit
Determination Period if the sum of :
a) the benefits payable under this PLAN in the absence
of this provision ; and
b) the benefits payable under all other Plans in the
absence of provisions similar to this one exceed the
Allowable Expense incurred by or on behalf of such
person during such time ;
2) as to any Benefit Determination Period , the Allowable
Expense tinder this PLAN shall be reduced, except as
�1 provided in item 3) below, so that the sum of such
benefits and all of the benefits paid , payable or
furnished which relate to such Allowable Expenses under
other Plans shall not exceed the total Allowable
Expenses incurred by the COVERED PERSON . All benefits
under other Plans shall be taken into account whether or
not claim has been made ;
3) if coverage under any other Plan is involved , as shown
in item 2) above; and
n a) such Plan, contains a provision coordinating
benefits with other Plans and such Plan requires
that their benefits be payable only after other
Plans are payable ; and
b) the terms set forth ill item 4) would require
benefits under this PLAN be figured before benefits
under the other Plan are figured ;
then the benefits under this PLAN will be determired aF
though such other Plan were not involved ;
4) for the purposes of item 3) above , the tae:is for
establishing the order in which Plans determine benefits
shall be as follows :
J
' 1) the benefits of a Plan which cover a person on
whom claim is based as an EMPLOYEE o__. member shall
be determined before the benefits under a Plan which
covers the person as a DEPENDENT;
b) the benefits of such a Plan which covers the person
on whose expenses the claim is based , as a dependent
of a male person whose month and date of birth
occurs earlier in a calendar year , shall be
determined before the benefits of a Plan which
covers such person as a dependent of a female person
whose mouth and date of birth occurs later in a
calendar year .
i) when the parents are separated or divorced and
the parent with custody of the child has not
remarried , the benefits of a Plan which covers
the child as a DEPENDENT of the parent with
custody of the child will be determined before
the benefits of a Plan which covers the child as
a DEPENDENT of the parent without custody;
ii) when the parents are divorced and the parent
with custody of the child has remarried , the
benefits of a Plan which covers the child as a
DEPENDENT of the parent with custody shall be
determined before the benefits of a Plan which
covers that child as a DEPENDENT of the
stepparent . The benefits of a Plan which covers w-
that child as a DEPENDENT of the stepparent will
be determined before the benefits of a Plan
which covers that child as a DEPENDENT of the
parent without custody.
In spite of i) and ii) above , if there is a court
decree which would otherwise decide financial duty
for the medical , vision , dental or health care
.4 expenses for such child , the benefits of a Plan
which covers the child as a DEPENDENT of the parent
with such financial duty shall be decided before the
benefits of any other Plan which covers the child
as a DEPENDENT;
c) when a) and b) above do net establish the order of
benefit determination , the Plan which covers the
person for the longer time shall be determined
first ;
5) when this provision operates to reduce the benefits
under this Plan , each benefit that would have otherwise
been paid will be reduced proportionately and each
reduced amount shall be charged against the benefit
limits of this Plan.
J
EMPLOYER may, with consent of the I�YEE, or the
employee ' s spouse when the claim is for a _ ,,Ouse , or the
parent or guardian when the claim is for a minor child ,
release or obtain any data which is needed to implement this
provision.
D) Payment
When payments should have been paid under this PLAN , but
were already paid under some other Plan , the EMPLOYER shall
have the right to make payment to such other Plan of the
amount which would satisfy the intent of this provision.
Such payment shall discharge the EMPLOYER' S liability under
this PLAN.
E) Overpayment
If fcr any reason payments made under this Plan plus
payments made under any other Plan or Plans exceed Allowable
Expenses , the EMPLOYER will have the right to recover such
payments to the extent of the excess , from any other
insurance company or other organization or person to or for
or with respect to whom such excess payments were made , as
the EMPLOYER may determine .
q 6 . 08 HOSPITAL AND SURGICAL INSURANCE. CONVERSION PRIVILEGE.
A) The Reinsurer , or Life Insurance Carrier , if any , (subject
to the terms of such issued policy) may issue an individual
j
policy of hospital and surgical. insurance which will insure :
1 ) the EMPLOYEE and , at his option, his DEPENDENTS who were
covered INDIVIDUALS on the date of termination of his
HEALTH COVERAGE HEREUNDER. Such policy may be issued
only if the EMPLOYEE ' S HEALTH COVERAGE HEREUNDER
terminates because of termination of employment or
:....f' membership within the eligible classes for hospital
benefits and/or major medical benefits ;
2) the covered EMPLOYEE ' S spouse , and at such spouse ' s
option , the DEPENDENT children , provided each was a
covered DEPENDENT on the day of termination of the
EMPLOYEE ' S HEALTH COVERAGE HEREUNDER, if termination of
the EMPLOYEE ' S HEALTH COVERAGE HEREUNDER was caused by
the death of the EMPLOYEE or if the EMPLOYEE died within
31 days following termination of his HEALTH COVERAGE
HEREUNDER and had not made application for an individual
hospital and surgical policy under this PLAN, or
3) or. EMPLOYEE ' S child , if such DEPENDENT was a covered
INDIVIDUAL HEREUNDER, and such child ' s HEALTH COVERAGE
HEREUNDER terminates because of the age or marriage of
the child .
Lam..
i
° ❑ EMPLOYEE ' S
dependent spouse , if such
was a covered INDIVIDUAL HEREUNDER, ails , endent
spouse ' spouse
s coverage HEREUNDER terminates abecausech endent
spouse no longer q as an eligible HEREUNDER, g qualifies said
g � DEPENDENT
B) The PLAN to which INDIVIDUAL;; to
be issued on the may be entitled
following basis :
covert may
1 ) the converted policy accordance will provide benefits which are in
with applicable state laws and
regulations ;
2) if Major Medical Benefits are the Daily Hospital Benefit of thet Provided HEREUNDER,
not exceed the am°ullt of converter. policy Will
Of hospital room and ioarda —ychargesBnefit for reimbursement
INDIVIDUAL was eligible under for which the covered
herein ; the Hospital Benefits
3) an individual policy will be issued in accordance
this section only if application is
first with
premium therefore made to and the
termination of is Paid within 31 days after
covered INDIVIDUAL ' S HEALTH COVERAGE;
4) the effective date of any policy issued will be the
next following the date of termination will
day
HEALTH COVERAGE the covered
HF.RF.UNDER;
5) initial premiums will
be determined
rmined according to the
schedule of
individual policy.premiums of the company issuing such
6) the converted Policy will be subject to the
if different company actually issuin Provisions
from the above , the g the policy and
provisions will supercede the above Converted
guidelines , policy
C) The conversion privilege does not,,.. INDIVIDUAL whose coverage terminates
termination or amendment of the PLAN aHEREUNDER any covered
because of
D) This conversion privilege does not , in any wa +
coverage under this group PLAt, beyond the
termination of y, extend
specified a covered INDIV7DIIAL 'S actual date of
HEREIN. HEALTH COVERAGE as
E) Conversion privilege is only applicable if the EMPLOYER
chosen. this benefit option for his F.MPLOYF,F.S .
applies has
it will be so stated in the Schedule off Conversion
6. 09 MEDICARF. Benefits .
A) Benefits payable under the medical expense provisions
this PLAN, for IP:D1VII)UALS entitled to Medicare , will
determined P of
orzig
Schedule Benefits . to the provisions stated be
Of Benefits , in the
r
B) bered INDIVIDUAL is deemed "entitled" all
are
benefits for which he is or has been eligibl. whether leorcnot
the benefits are no charge to the INDIVIDUAL or may be
obtained by the INDIVIDUAL at a cost .
6 . 10 LEGAL PROCEEDINGS
No action at law or in equity will be brought to recover on this
PLAN prior to the expiration of sixty (60) days after proof of
claim has been filed in accordance with the requirements of this
PLAN. No such action will be brought at any time unless brought
within the time allowed by the laws of the State of Delivery . If
the laws of the State of Delivery do not designate the maximum
length of time during which such action may be brought , no
action may be brought after the expiration of two (2) years from
the time within which proof of loss is required by the PLAN.
6 . 11 STATEMENTS
In the absence of fraud , all statements made by a covered
EMPLOYEE and his DEPENDENTS will be deemed representations and
not warranties . No such representations will void the HEALTH
COVERAGE or be used in defense to a claim HEREUNDER unless a
copy of the instrument containing such representation is or has been furnished to such EMPLOYEE or to his beneficiary, if any.
6 . 12 THIRD PARTY REIMBURSEMENT
This provision does not apply to Life insurance Benefits ,
Accidental Death and Dismemberment Benefits , or benefits
payable for any loss of time on account of disability , if any
such benefits are provided in the Plan .
The following provision shall be applicable to all other
Sections of this Plan now or hereafter included therein .
If payments are made under this policy for any treatment or
service because of injury to , or sickness of , a covered
» individual who has a lawful. claim, demand or right against a
third party or parties (including an insurance carrier) for
indemnification, damages or other payment with respect to such
Injury or sickness , then:
A) the EMPLOYER shall be reimbursed , to the extent of the-
payments
made under this PLAN, to the rights of the covered
INDIVIDUAL, to receive or claim such indemnification, damages
Of other payments and the covered INDIVIDUAL shall execute
or secure the execution of such instruments as the EMPLOYER
may reasorahly require to enforce its rights hereunder ; and
J
I'
g) / overed INDIVIDUAL who shall receive
su, n third party or parties because of ,ijur from any
sickness of, a covered INDIVIDUAL shall reimburse or
he
EMPLOYER from such payment so received (but not in excesstof
the amount received) for all payments made under the PLAN
for treatment or service with respect to the same injury or
sickness .
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. I
ARTICLE VII - DEFINITIONS
For all purposes of this Plan :
7 . 01 DENTIST: A duly licensed dentist practicing within the scope of
the dental profession and any other Physician furnishing any
dental services which such Physician is licensed to perform.
7 . 02 TREATMENT PLAN: A DENTIST ' S report on a form satisfactory to
Medical Insurance Administrators , Inc. , which ( 1 ) itemizes the
dental services recommended by the DENTIST for the necessary
dental care of a person , (2) shows the DENTIST ' S charge for each
dental service and (3) is accompanied by supporting
pre-operative x-rays or other diagnostic records where required
or requested by Medical Insurance Administrators , Inc .
The DEFINITIONS as stated in Article I of this Plan will be
considered applicable to Dental Coverages outlined in this
section of the Plan.
i
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w-,
1
cIL
ARTICLE VIII - DENTAL EXPENSE COVE
8 . 01 Pental Expense Benefits are payable up to the maximum shown in
the Schedule of Benefits . The maximum benefit shown in the
Schedule of Benefits applies each calendar year to you and to
each of your dependents .
A) The expenses must be incurred for dental procedures
necessary to the care and treatment of the patient and
performed by or under the direct supervision of a legally
qualified dentist .
B) The deductible as shown in the Schedule of Benefits applies
each calendar year to you and to each of your dependents .
The deductible is applied to the expenses for the year
before any Dental Expense benefits are payable for that
year . Furthermore , when any part of a year ' s deductible is
applied against eligible charges arising during the last
three (3) months of that calendar year , the following year ' s
deductible will be reduced by the amount so applied .
i
8 . 02 SCHEDULE OF DENTAL SERVICES
This schedule lists the services covered . Covered Dental
Expenses will not include any dental service not provided for in
the Schedule shown in the policy unless the Reinsurer reviews
the services and accepts the expenses as Covered Dental
Expenses . The Covered Dental Expense for such Dental Service �r-
will be determined by the Reinsurer and will be consistent with
those listed in the Schedule shown in the policy .
A) Expenses incurred for precision or semi-precision
attachments , surgical implants of any type including any
prosthetic device attached to them; instruction for plaque
control or oral hygiene bite registrations , splinting or
dental services which do not have uniform professional
endorsement will not be accepted by the Reinsurer as Covered
Dental Expenses .
B) A temporary dental service will he considered an integral
part of the final dental service rather than a separate
service .
8. 03 DIAGNOSTIC AND PREVENTIVE
Periodic oral e:ccnirstion (no more than one ( 1 ) in any six
consecutive month period)
Intra-oral X-rays -- complete series with/without bitewings
(only one series in a 36 consecutive month period)
I
I
t
wing X-rays -- (no more than one charg( any six (6)
consecutive month period)
single film
two films
Prophylaxis with or without oral examination -- (no more
than two (2) dental prophylaxis in any twelve ( 12)
consecutive month period)
individuals 14 years of age or older
individuals under 14 years of age
Periodontal prophylaxis
Topical application of stannous fluoride for individuals
under age 19 (no more than one in any twelve ( 12)
consecutive month period)
Space maintainers , fixed , unilateral
8 . 04 BASIC RESTORATIVE , ENDODOrTICS , PERIODONTICS , MAINTENANCE OF
PP.OSTHODONTICS AND ORAL SURGERY
General anesthesia (only when necessary and in connection
with oral surgery and when the anesthetic agent produces a
state of unconsciousness with absence of plain over entire
body)
Amalgam fillings -- deciduous teeth , one surface
Amalgam fillings -- permanent teeth, one surface
w-e
Sillicate cement , per filling
Acrylic or plastic filling
Composite acrylic resin filling -- one surface
Topical application of sealant on a posterior tooth
for individuals under age 14 -- (no more than one
.... treatment per tooth in a 36 month period)
Root canal therapy -- including treatment plan and follow-up
Not in conjunction with apicoectomy
In conjunction with apicoectomy
Apicoectomv (considered a separate service if performed with
root canal therapy)
Gingivectomy or gingivoplasty , per quadrant
Osseous surgery , per quadrant
I i
J
f
n
i ire than one periodontal surgical servi is performed
per quadrant , only the most inclusive s-_-gical service
performed will be considered a Dental Service provided for
in this Schedule . Flap entry and closure is considered part
of the dental service for osseous surgery and osseous graft .
Periodontal scaling -- 12 or more teeth
Repairs and adjustments to dentures -- not covered if
performed within six months of installation of denture
jAdjustments to dentures , partial denture
Replace broken tooth on complete or partial denture , not
in conjunction with other repairs
Re-cement bridge
i
Simple extractions -- First tooth
Simple extractions -- each additional tooth
Surgical extractions -- impacted
Soft tissue
Bone -- partial
Bone -- complete
8. 05 MAJOR RESTORATIVE AND INSTALLATION OF PROSTHODONTICS
Gold inlay fillings -- two surfaces
Gold inlay fillings -- three surfaces
�7
Single crown restorations
Crowns -- porcelain
Crowns -- cast gold , full
Crowns -- cast gold , three-fourths
Fixed or removable prosthetic appliances
Complete dentures , upper or lower
Partial Dentures
.. Lower , with two (2) clasps and gold lingual bar
Upper , with two (2) clasps and gold palatal bar
Bridge pontics -- cast gold
Bridge pontics -- porcelain fused to gold
Bridge pontics -- plastic processed to gold
Abutment crowns -- porcelain
Abutment crowns -- porcelain fused to gold
Abutment crowns -- full , cast gold
The above services and treatments will be paid at a rate
shown in the Schedule of Benefits .
8 . 06 GENE. INFORMATION
A) The overall maximum payment for all. Dental Expenses per
calendar year is listed in. the Schedule of Benefits .
B) The charge for a dental procedure is considered to have been
incurred on the day of performance of the procedure . If a
procedure is not completed in one day , the day upon which
the procedure is completed is deemed to be the incurred day
for any charges in connection with such procedure .
C) In the event that more than one dentist furnishes services
or materials for one dental procedure , the Employer shall be
liable for not more than its liability had one dentist
furnished the services or materials .
D) No payment shall be made under this coverage provision for
dental benefits on account of any procedure with respect to
which payment is made under any of the other coverage
provisions of the Plan except to the extent , if any , that
the amount provided in this provision of dental benefits
exceeds the total amount payable on account of such
procedure in all such other provisions .
8 . 07 THE FOLLOWING DENTAL CHARGES (IF NECESSARY REASONABLE REASONABLE
AND CUSTOMARY) ARE COVERED
A) Charges for any accidental bodily injury : (a) which does
not arise out of or in the course of any employment by the
Employer and (b) for which he is not entitled to benefits r_t
under any Worker ' s Compensation law;
E) Charges for any sickness not entitling him to benefits under
any Worker ' s Compensation or Occupational Disease law;
C) Charges which are necessary to the care and treatment of
such accidental bodily injury or such sickness and are
incurred on the recommendation of and performed by or under
the direct supervision of a legally qualified dentist ;
r) Charges which are not in excess of the reasonable and
customary charges for the procedure performed or the
materials furnished , which excess , if anv , shall not be
considered as eligible dental charges under the plan, nor
counted as part of the deductible amount hereunder ;
E) Charges which are incurred for dental services , supplies and
x—ray examinations ;
F) ChnrFes which are not excluded dental charges and are not
otherwise excluded from coverage by the terms hereof .
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I� I
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8 .08 THE i OWING DENTAL CHARGES ARE NOT COVERED
i
All Charges Not Specifically Listed As Covered Charges And In
Addition :
A) Charges for services or materials for which the individual
is not in the absence of this coverage , legally required to
pay ;
B) Charges for services or materials received from a dental or
medical department maintained by an employer , a mutual
benefit association , a labor union , or a health and welfare
fund , or for services or materials furnished by or at the
direction of the United States Government or any state ,
province , or other political subdivision , unless the insured
individuals would be required to pay such charges in the
absence of insurance ;
C) Charges for services or materials for cosmetic purposes ,
except charges for cosmetic dental procedures incurred while
insured hereunder as a result of and within 24 months after
an accident suffered while insured hereunder for Dental
Expense Benefits ;
D) Charges for facings on crowns , or pontics , posterior to the
second bicuspid ;
E) Charges due to war or anv act of war, whether declared or
undeclared ;
F) Charges for periodic oral examinations and /or prophylaxis
performed which are in excess of two such same procedures in
any calendar year .
G) Charges for partial or full removable dentures or fixed
bridgework , or for the addition of one or more teeth
thereto , or for a crown or gold restoration if involving a
replacement or modification of a denture , bridgework , crowr
or gold restoration which was installed during the five (5)
years immediately preceding such extraction , replacement or
modification;
H) Charges for partial or full removable dentures or fixed
bridgework if involving replacement of one or more natural
teeth extracted prior to the indiv1dual ' s becoming insured
under the Flan unless the denture or fixed bridgework also
includes replacement of a natural tooth which is extracted
while the individual is insured hereunder and was rot Zr,
abutment to a partial denture or fixed bridge installer
within the five (s ) yearn immediately preceding such
extraction or modification :
J
n
I) ges for adjustment to or relining of vial or full
removable dentures for which like servic. was rendered
within the two (2) years immediately preceding such
adjustment or relining ;
J) Charges for service to a covered person which involves : an
appliance , or modification of an appliance for which the
Impression was made before the individual became insured
hereunder ; or a crown , bridge or gold restoration for which
a tooth was prepared before the individual became insured
hereunder ; or root canal therapy for which the pulp chamber
i
was opened before the individual became insured hereunder ;
K) Charges for replacement of lost or stolen appliances ,
dentures or bridgework ,
L) Charges for dental appointments which are not kept ;
M) Charges for any service or material not furnished by a
dentist except a service performed by a licensed dental
hygienist under the supervision of a dentist or an x-ray
ordered by a dentist .
N) Charges for the replacement of any prosthetic appliance ,
crown or bridge within five (5) years of the date of the
last placement of that appliance , crown or bridge , unless
replacement is required because of accidental bodily
injuries the individual suffers while covered for this
coverage .
0) Charges for appliances , restorations or procedures necessary
to increase vertical dimension or restore occlusion , or for
the purpose of splinting .
P) Charges for orthodontic treatment ( including treatment or
correction of malocclusion) , and charges for space
maintainers for deciduous teeth ;
8 . 09 PRE-DETERMINATION OF BENEFITS
A) Recognizing that many dental problems can be solved in more
than one way , the Plan will pay an amount equal to that
applicable for that generally accepted treatment method
which, in its sole judgement , will provide adequate dental
care at the lowest cost to the patient . In determining
'._ahi.li.ty the Plan will be guidee by nationally established
stanaards of the dental profession .
I �
P � ; e persons contemplating dental work submit , in
advance , a resume of the treatment plan ber.., contemplated .
j If this is done , Medical Insurance Administrators , Inc . will
determine the benefits available and advise the patient
and/or the dentist of the benefits available before
treatment commences .
C) If pre—determination of benefits is not done , the employer
retains the right to pay the claim on the basis of the
ancurt of benefits which would have been paid had
pre—determination been requested .
D) Pre—determination is recommended particularly if the course
of treatment is expected to involve total dental charges of
S'200 . or more .
8 . 10 EXTENSION OF BENEFITS
A) Charges for any portion of a dental procedure performed
before the effective date of or after the termination of the
individual ' s insurance for Dental Expense Benefits , except
eligible dental charges incurred by an individual for dental
care furnished within 30 days after termination of his
coverage for Dental Expense Benefits hereunder shall be
considered eligible for payment if :
1) The service involves an appliance , or modification of an
appliance for which the impression was taken prior to
the termination of the individual coverage ; or b
2) the service involves a crown , bridge or gold restoration
for which the tooth was prepared prior to the
termination of individual coverage ; or
3) the service involves root canal therapy for which the
pulp chamber was opened prior to the termination of
individual coverage ; and
4) the procedure is completed within 30 days after
termination of individual coverage and the individual is
not otherwise entitled to pavment under any other like
dental coverage of any type or source .
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j ARTICLE IX - ORTHODONTIC EXPENSE BE TS
i
9 . 01 BENEFITS ARE PAYABLE. for covered orthodontic expenses in excess
of the Deductible Amount which are incurred by an individual who
is covered for these benefits and is pursuing a Treatment Plan .
These benefits become payable when the covered orthodontic
expenses are incurred , as described below , but only if the
individual is then covered for orthodontic expense benefits and
is then pursuing his Treatment Plan .
9 . 02 BENEFITS FOR COVERED ORTHODONTIC EXPENSES will equal
percentage of the covered orthodontic expenses incurred by an
individual and not used to satisfy the Deductible Amount . The
amount of benefit is determined by multiplying, the covered
orthodontic expenses by the Percentage shown in the Schedule .
The total benefits for all covered orthodontic experses an
individual incurs during his lifetime will not exceed the
Lifetime Maximum shown in the Schedule .
9 . 03 THE DEDUCTIBLE AMOUNT for each individual is shown in the
Schedule . This deductible applies once during a calendar year
and must he satisfied before benefits become payable for
orthodontic expenses incurred by the individual . Only covered
orthodontic expenses an individual incurs while covered for
these benefits may he used to satisfy the Deductible Amount .
" a 9 . 04 COVERED ORTHODONTIC EXPENSES INCLUDE the er.perses incurred for
any orthodontic treatment recommended by a dentist which an
individual receives while he is covered for these benefits and
is pursuing a Treatment Plan , but only to the extent that the
expenses are usual , customary and reasonable in the geographical
area where the treatment is given .
9 . 05 INCURRED EXPENSES
A) Expenses are considered 1FCURRFD at the beginning of each
quarter (3 Perth period) of a Treatment Plan. The first
quarter begins on the date the orthodontic appliances are
installed . The amount of covered orthodontic expenses
incurred in ere quarter are determined as follows :
1 ) the initial deposit , up to 30% of the total cost of the
Treatment Plan is the covered expense for the first
quarter .
2) the first pa,vmeut is subtracted from the total estimatcc
cost of the Treatment Plor ,
3 ) the balance is pro-rated over the remainir.F quarters of
the Treatment Plan or seven quarters , whichever is
1vsrer .
P ) Fractional amounts due to rouEd ng will be added to the
first quarterly payment .
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9 , 06 ORTHF !LIC TREATMENT MEANS the movement of Lea h means of
active appliances when required to correct eithe (a) overbite
or overjet of at least four millimeters , or (b) maxillary and
mandibular arches in either protrusive or retrusive relation of
at least one cusp , or (c ) crossbite , or (d) arch 1CngL11
discrepancy of more than four millimeters .
9 . 07 TREATMENT PLAN MEANS a series of interdependent orthodontic
services prescribed by a dentist to correct a specific
condition , a report of which has , prior to the performance of
the services , been (a) submitted to and reviewed by the
rcihsurer , and (b) returned to the dentist with an estimate of
the benefits .
9 . 06 LIMITATIONS
A) LIMITATTONS - - "Covered Orthodontic Expenses" do not include
and no benefits are payable for expenses incurred by a
covered individual ,
1) Prior to the date that the individual completes ( a)
three months of cortir.ucus coverage for these benefits ,
if he becomes covered for these benefits on or within 31
days after the date he first became eligible , or (b)
twelve months of continuous coverage for these benefits ,
if he becomes covered for these benefits more than 31
rt days after the date he first became eligible .
2) After the individual ' s orthodontic expense benefits '
terminate .
3) To the extent that the individual is reimbursed or is
entitled to be reimbursed for such expenses or is in any
way indemnified through any charitable or governmental
public program.
4) In connection with an injury or aickress resulting from
-� war or any act of war , whether declared or undeclared .
B) If an individual becomes covered for these benefits on the
date this coverage becomes a part of the Group Plan , and was
covered for orthodortic benefits immediately prior to that
date under another group policy or plan issued to or through
the Policyholder , he shall receive credit towards the
waiting period specified in item I (a ) ;above for his
continuous coverage under the ether g oup pcjicy or plan .
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