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Section VIII: General Provisions
COST TO RETIREES
Retirees share in the cost of their health benefits by paying a percentage of
the Plan’s costs for retiree coverage. The copayment is less if you have Medicare.
The copayment is higher if you have dependents covered under this Plan or if
you do not have Medicare. You should call the administrative office to find
out the dollar amount of your copayment.
To continue your retiree coverage through the U.A. Local 447 Health and Welfare
Plan, you must complete an authorization card which allows the Plan to withhold
the required payment from your monthly pension check. If you need an authorization
card, call the administrative office.
COORDINATION OF BENEFITS
In General
All medical and prescription drug benefits are subject to coordination. If you
or your dependents are entitled to benefits under any other plan which will
pay part or all of the expense incurred for treatment of sickness or injury,
the benefits payable under this Plan and any other plans will be coordinated
so that the aggregate amount paid will not exceed 100% of the expense incurred.
In no event will the amount of benefits paid under this Plan exceed the amount
which would have been paid if there were no other plan involved.
Benefits under this Plan will be coordinated with any group plan providing
benefits or services for hospital or medical treatment that is: (a) group insurance
coverage, (b) blanket insurance coverage which does not contain a nonduplication
of benefits or excess policy provision, (c) group Blue Cross, Blue Shield, group
practice and other prepayment coverage provided on a group basis, (d) any coverage
under labor-management trusteed plans, union welfare plans, employer organization
plans, or any other arrangement of benefits provided on a group basis; (e) any
group coverage under governmental programs, and any group coverage required
or provided by any statute, and (f) no-fault auto insurance.
Which Plan Pays First?
If both plans have a coordination of benefits provision, the plan that insures
you as a dependent of an active employee pays first. If you receive benefits
as an active employee under one plan and as a retiree under another, the plan
you have as an active employee pays first. If you are insured as an employee
under two plans, the plan which has insured you longer is primary. If one plan
does not have a coordination of benefits provision, that plan is always primary.
A participant or qualified beneficiary is subject to this Plan’s rules even
if the Plan is a secondary carrier. If a dependent child is covered under two
plans, the plan of the parent whose birthday (month and day) is earlier in the
year will pay its benefits first. If the parents of a dependent child are divorced
or legally separated, the plan of the parent with custody of the child pays
its benefits first. If the parent with custody remarries, the order of payment
is as follows:
- Natural parent with whom the child resides;
- Stepparent with whom the child resides;
- Natural parent not having custody of the child.
This order of payment can change if a court order specifically and unambiguously
requires one of the parents to be financially responsible for the child’s medical
expenses.
Special Rules Concerning Medicare
If you or your insured dependent has Medicare, Medicare will always pay before
this Plan, unless you or your insured dependents is entitled to Medicare solely
on the basis of end-stage renal disease (ESRD). If this
is the case, Medicare will pay after this plan for the first 30 months after
Medicare Part A eligibility or entitlement.
In determining benefits payable under Medicare, all the benefits to which
you or your insured dependent is entitled under Medicare shall be included without
regard to whether or not the individual has registered for Part A or enrolled
in Part B of Medicare.
RIGHT TO RECEIVE AND RELEASE INFORMATION
This Plan may, without the consent of or notice to any insured, release or obtain
from any insurance company, organization, or person, any information it deems
necessary to determine eligibility, and to process benefit claims. Whenever
payments which should have been made by this Plan have been made by any other
plan, this Plan will have the right to repay the plan the amount it determines
will satisfy the intent of the coordination of benefits
provision. Whenever this Plan pays out more than necessary, it has the right
to recover the excess payment from any person to whom such payments were made,
or any insurance company or other organization.
RIGHT OF RECOVERY
You or one of your dependents may receive benefits from this Plan for expenses
incurred due to an injury involving a third party. You also may receive payments
from the third party resulting from a lawsuit, settlement or otherwise. If this
occurs, the Plan shall have the right to reimbursement by you up to the amount
of benefits which it paid for the same expenses.
