Eligibility

•    You start work in covered employment in January.
•    January 1 to March 31 You are paid for 270 Hours April 1 to June 30 You are paid for 250 Hours July 1 to September 30 You are paid for 350 Hours October 1 to December 31 You are paid for 130 Hours.
•    Total Paid hours 1000.
•    You allow for the waiting period of one calendar quarter from January 1 to March 31.
•    Your coverage becomes effective on April 1

.

•    your own or legally adopted children,
•    children in your custody while awaiting final legal adoption,
•    your stepchildren who are primarily dependent upon you for financial support, and
•    any other children related to you by blood or marriage who live with you in a regular parent-child ? relationship and are primarily dependent upon you for financial support

.

Medical Benefits

Hospital and Medical Benefits are provided by Anthem BlueCross BlueShield. A full and complete description of the hospital and medical benefits available are contained in the Anthem Blue Access EPO Guide in the Welfare Fund SPD which you can download in PDF format above.

Overview Of Health Care Provisions

The Steamfitters’ Industry Welfare Fund provides several types of health care benefits:

• Hospital and Medical Benefits
• Dental Care Benefits
• Prescription Drug Benefits
• Vision Care Benefits
• Hearing Aid Benefits

The above benefits are administered by either the Welfare Fund or by outside organizations designated by the Trustees.

Hospital And Medical Benefits

Hospital and Medical Benefits are provided by Anthem BlueCross BlueShield. A full and complete description of the hospital and medical benefits available are contained in the Anthem BlueCoss BlueShield Guide in the Welfare Fund SPD which you can download in PDF format above.

Hospital Benefits

Hospital and Medical Benefits are provided by Anthem BlueCross BlueShield. A full and complete description of the hospital and medical benefits available are contained in the Anthem Blue Access EPO Guide in the Welfare Fund SPD which you can download in PDF format above.

Dental Expense Benefits

Metlife Preferred Dentist Program Plus

The following benefits are provided to all eligible Welfare Fund participants and their qualifying dependents subject to the provisions of the program.

Schedule Of Benefits

Covered Percentage

Maximums

Please Note:

• Expenses for orthodontia, including any procedures necessary for such treatment, will be considered covered dental expenses only if the dependent child has not reached age 19.
• Covered dental expenses for orthodontia are not included in the Maximum Benefit per calendar year.
• The maximums for both orthodontic treatment and all other covered dental expenses apply to all expenses incurred whether treatment is provided by a Network Provider, a Non-Network Provider or a combination thereof.
• If a dental bill is expected to be $300 or more, see section F, Predetermination Of Benefits.

Dental Expense Benefits 

A. Definitions 

Covered Dental Expense means the charges based on the Preferred Dentist Program Schedule of Maximum Payments for the types of dental services shown in section C. These services must be:

1. performed or prescribed by a dentist who is: 

• a Network Provider; or
• a Non-Network Provider; and

2. necessary in terms of generally accepted dental standards. 

There may be more than one way to treat a dental problem. If, in MetLife’s view, an adequate method or material which costs less could have been used, the dental expense benefits will be based on the method or material which costs less. The rest of the cost will not be a covered dental expense. See section E for examples that show how this works.

Dentist means a person licensed by law to practice dentistry. A type of dental service which is performed or prescribed by a doctor will be considered for dental expense benefits as if it were performed or prescribed by a dentist.

Deductible Amount means the amount shown in the Schedule Of Benefits. The deductible amount during any one calendar year will not apply to covered dental expenses after:

1. you incur covered dental expenses for covered persons in your family; and

2. those expenses, when applied to the deductible amount, equal the family deductible amount.

Covered Percentage means the percentage shown in the Schedule Of Benefits.

Preferred Dentist Program Plus Schedule of Maximum Payments means MetLife’s fee agreement with a Network Provider in which such Network Provider has agreed to accept a schedule of maximum fees as payment in full for services rendered.

Preferred Dentist Program Plus means MetLife’s program to offer a covered person the opportunity to receive dental care from dentists who are designated by MetLife as Network Providers. When dental care is given by Network Providers, the covered person will generally incur less out-of-pocket cost for the services rendered.

Network Provider means a dentist who has been selected by MetLife for inclusion in the Preferred Dentist Program. These Network Providers agree to accept our Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.

Non-Network Provider means a dentist who is not a Network Provider.

Preferred Dentist Program Plus Directory means the list which consists of selected dentists who:

• are located in the covered person’s area; and
• have been selected by MetLife to be Network Providers and part of the Preferred Dentist Program. These Network Providers agree to accept our Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.

The list will be periodically updated.

B. Coverage 

1. When Benefits May Be Payable 

MetLife will pay dental expense benefits if you incur covered dental expenses:

• for a covered person during any calendar year; and
• while you are covered for the dental expense benefits for that covered person; and
• the covered dental expenses are more than the deductible amount when using Non-Network Providers.

An expense is "incurred" on the date the dental service is completed.

2. How Benefits Are Determined 

Benefits will be equal to the covered percentage of those covered dental expenses which are more than the deductible amount. However:

• The sum of all benefits for all covered dental expenses incurred for a covered person during any calendar year will not be more than the maximum benefit per calendar year; and
• The sum of all benefits for all covered dental expenses incurred for a covered person for orthodontic treatment during all calendar years will not be more than the applicable Aggregate Maximum Benefit.

In order to determine the amounts of covered dental expenses, MetLife may ask for x-rays and other diagnostic and evaluative materials. If they are not submitted, MetLife will determine covered dental expenses on the basis of the information which is available. This may reduce the amount of benefits which otherwise would have been payable.

3. How the Preferred Dentist Program Works 

A covered person is always free to choose the services of a dentist who is either:

• a Network Provider; or
• a Non-Network Provider.

Benefits will be determined and paid in either case, except that the covered person will generally incur less out-of-pocket cost if a Network Provider is chosen.

C. Dental Service Which May Be Covered Dental Expenses 

1. Type A Expenses 

a. Oral exams but not more than twice in any calendar year.

b. X-rays:

• full mouth x-rays but not more than once every 36 months; and
• bitewing x-rays but not more than twice in any calendar year.

c. Preventive treatment:

• cleaning and scaling of teeth (oral prophylaxis) but not more than twice in any calendar year; and
• topical fluoride treatment for a dependent child until their 19th birthday, but not more than twice in any calendar year.

d. Space maintainers for a dependent child through the year in which they turn 19(age 23 if a full-time student).

e. Two applications of sealant material for each molar tooth of a dependent child under age 16 for no more than twice in a lifetime.

f. Emergency palliative treatment.

2. Type B Expenses 

a. Fillings - amalgam, silicate, acrylic, synthetic porcelain or composite fillings

b. Extractions

c. Root canal treatment

d. Treatment of periodontal disease and other diseases of the gums and tissues of the mouth

e. Oral surgery

f. Injections of antibiotic drugs

g. Administration of general anesthesia, when medically necessary in connection with oral surgery, extractions (2 or more teeth), or other covered dental services

h. Relinings and rebasings of existing removable dentures but not more than once in any 36 month period

i. Repair or re-cementing of crowns; inlays or onlays; dentures; or bridgework.

3. Type C Expenses 

a. Those services needed to replace one or more natural teeth which are lost while dental expense benefits for the covered person are in effect for:

• Installation of fixed bridgework done for the first time.
• Installation for the first time of a partial removable denture or a full removable denture.
• Replacing an existing removable denture or fixed bridgework if it is needed because of the loss of one or more natural teeth after the existing denture or bridgework was installed; or it is needed because the existing denture or bridgework can no longer be used.
• Replacing an existing immediate temporary full denture by a new permanent full denture when the existing denture can not be made permanent; and the permanent denture is installed within 12 months after the existing denture was installed.
• Adding teeth to an existing partial removable denture or to bridgework when needed to replace one or more natural teeth removed after the existing denture or bridgework was installed.

b. Inlays, onlays and crown restorations

4. Type D Expenses 

Orthodontia, including appliance therapy for dependent children though the year in which they turn age 19 (age 23, if a full-time student). The Aggregate Maximum Benefit for orthodontia is shown in the Schedule Of Benefits.

D. Exclusions: Services Which Are Not Covered Dental Expenses 

1. Services or supplies received by a covered person before the dental expense benefits start for that person. 

2. Services not performed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for: 

• cleaning and scaling of teeth; or
• fluoride treatments.

3. Cosmetic surgery or supplies. However, any such surgery or supply will be covered if: 

• it otherwise is a covered dental expense; and
• it is required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or
• it is required for reconstructive surgery because of a congenital disease or anomaly of a dependent child which has resulted in a functional defect.

4. Replacement of a lost, missing or stolen crown, bridge or denture. 

5. Repair or replacement of an orthodontic appliance. 

6. Services or supplies which are covered by any workers’ compensation laws or occupational disease laws. 

7. Services or supplies which are covered by any employers’ liability laws. 

8. Services or supplies which any employer is required by law to furnish in whole or in part. 

9. Services or supplies received through a medical department or similar facility which is maintained by the covered person’s employer. 

10. Services or supplies received by a covered person for which no charge would have been made in the absence of dental expense benefits for that covered person. 

11. Services or supplies for which a covered person is not required to pay. 

12. Services or supplies which are deemed experimental in terms of generally accepted dental standards. 

13. Services or supplies received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while the dental expense benefits for the covered person are in effect. 

14. Adjustment of a denture or a bridgework which is made within 6 months after installation by the same dentist who installed it. 

15. Any duplicate appliance or prosthetic device. 

16. Use of materials to prevent decay other than fluorides and sealant material for the molar teeth of a dependent child under age 16.

17. Instruction for oral care such as hygiene or diet. 

18. Periodontal splinting. 

19. Services or supplies to the extent that benefits are otherwise provided under this plan or under any other plan which the employer (or an affiliate) contributes to or sponsors. 

20. Myofunctional therapy or correction of harmful habits. 

21. Implantology. 

22. Initial installation of a denture or bridgework to replace one or more natural teeth lost before the dental expense benefits started for the covered person. 

23. Charges for broken appointments. 

24. Charges by the dentist for completing dental forms. 

25. Sterilization supplies. 

26. Services or supplies furnished by a family member. 

27. Treatment of temporomandibular joint disorders. 

E. Examples Of Alternate Benefits 

Dental expense benefits will be based on the materials and method of treatment which cost the least and which, in MetLife’s view, meet generally accepted dental standards.

1. Fillings: Inlays, Onlays and Crowns 

If a tooth can be repaired by a less costly method than an inlay, onlay or crown, dental expense benefits will be based on the adequate method of repair which costs the least.

2. Crowns, Pontics, and Abutments 

Veneer materials may be used for front teeth or bicuspids. However, dental expense benefits will be based on the adequate veneer materials which cost the least.

3. Bridgework and Dentures 

Dental expense benefits will be based on the adequate method of treating the dental arch which costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, the dental expense benefits will be based on the cost of a replacement denture unless adequate results can only be achieved with fixed bridgework.

These are not the only examples of alternate benefits. To find out how much your dental expense benefits will be, see section F.

F. Predetermination Of Benefits 

If a dental bill is expected to be $300 or more, before the dentist starts the treatment, a covered person can find out what dental expense benefits will be paid by MetLife. To do this, the covered person should send a claim form to MetLife in which the dentist states:

• the work to be done; and
• what the cost will be.

MetLife will then tell the covered person what dental expense benefits will be paid. If the covered person does not use this method to find out what dental expense benefits MetLife will pay, the decision will be final and binding with regard to what are covered dental expenses and what dental expense benefits will be paid. This method should not be used for:

• emergency treatment; or
• routine oral exams; or
• X-rays, cleaning and scaling, and fluoride treatments: or
• dental services which cost less than $300.

G. Impact Of Government Plans On Dental Expense Benefits 

To the extent that services or supplies, or benefits for them, are available to a covered person under a government plan, as defined below, they will not be considered for dental expense benefits under this benefit program. This provision will apply whether or not the covered person is enrolled for all government benefits for which they are eligible. This provision will not apply to a government plan if it requires that dental expense benefits under this benefit program be paid first.

A government plan is any plan, program or coverage, other than Medicare:

• which is established under the laws or the regulations of any government; or
• in which any government participates other than as an employer.

H. Dental Expense Coverage After Benefits End 

No benefits will be payable for covered dental expenses incurred by a covered person after the dental expense benefits for that person end. This will apply even if we have pre-determined benefits for dental services. However, benefits for covered dental expenses incurred for a covered person for the following services will be paid after dental expense benefits end:

1. For a prosthetic device if:

• the dentist prepared the abutment teeth and made impressions while dental expense benefits for the covered person were in effect; and
• the device is installed within 60 days after the date the dental expense benefits end; or

2. For a crown if: 

• the dentist prepared the tooth for the crown while the dental expense benefits for the covered person were in effect; and
• the crown is installed within 60 days after the date the dental expense benefits end; or

3. For root canal therapy if: 

• the dentist opened the tooth while the dental expense benefits for the covered person were in effect; and
• the treatment is finished within 60 days after the date the dental expense benefits end.

I. Payment Of Benefits 

Dental expense benefits will be paid to you. MetLife will pay benefits when it receives satisfactory written proof of your claim. Proof must be submitted not later than 90 days after the end of the calendar year in which the covered dental expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as the proof is given as soon as possible.

When Benefits End 

• All of your benefits will end on the date your coverage in the Welfare Fund ends. Your coverage ends when you fail to maintain eligibility. Please refer to the ELIGIBILITY section for details.
• If this benefit program ends in whole or in part, your benefits which are affected will end.
• All benefits on account of a qualifying dependent will end on the last day of the calendar year in which that qualifying dependent ceases to be your dependent.

The end of any type of benefits on account of a covered person will not affect a claim which is incurred before those benefits ended.

The dental expense benefits for a covered person may be continued in accordance with the Federal law called COBRA. Please refer to the answer to the question "What Happens If I Lose Coverage?" on page 2 under the ELIGIBILITY section of this booklet for details.

Prescription Drug Benefits

Express Scripts

Prescription drug benefits are available to all active and retired participants and their qualifying dependents who meet the Welfare Fund eligibility requirements. Your prescription drug benefits are administered by Express Scripts which covers almost all drugs prescribed by a licensed medical doctor, osteopath, dentist or podiatrist for their generally accepted medical use.

This program, which includes both a drug card and mail service plan, was instituted in an effort to increase benefits, alleviate the claim filing burden and reduce costs when you or your dependents require prescription drugs. At the time your coverage becomes effective, you will receive a plastic identification drug card and mail service order forms. The program works as follows:

Express Scripts Drug Program

Prescriptions filled at a local, retail pharmacy will have the following co-payments:

Prescriptions filled through the Express Scripts Delivery mail order program will have a $40 co-payment for a 90 day fill or re-fill.

Both retail and mail order prescriptions must be filled generically if a generic equivalent drug is available. If you have a prescription filled with a brand name drug when a genericis available FOR ANY REASON you will pay the brand name co-payment plus the difference between the cost to the Welfare Fund for the generic and the brand. Using a brand name drug when a generic is available will cost you a great deal of out-of-pocket expense.

Please keep in mind that if you have a prescription filled with a brand name drug when a generic drug is available the difference which you must pay does not accrue towards your annual deductible.

Utilization Management Program

Certain drugs require prior approval through Express Script's Utilization Management Program. You or your doctor can reach Express Scripts Utilization Management Program at 1-800-753-2851.

Covered Drugs

Prescription drugs available under both the Mail Service and the Card Program include:

• Federal Legend Drugs
• State-Restricted Drugs
• Compounded Medications [can be purchased through retail pharmacy only]
• Insulin and insulin syringes only

Exclusions

Drugs not covered by the program include:

• Contraceptives, oral or other, whether medication or devices, regardless of intended use.
• Non-Federal Legend Drugs including all "over the counter" items, regardless of whether they are prescribed.
• Charges for the administration or injection of any drug.
• Needles and syringes, support garments, and other non-medical substances (such items may be covered under your medical benefits coverage).
• Prescriptions which are entitled to receive without charge under any Workers' Compensation Laws or any municipal, state or federal program.
• Medication taken by, or administered to, a person while an inpatient in a licensed hospital, hospice, rest home, sanitarium, extended care facility, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceutical products.
• Drugs labeled "Caution - limited by federal use to investigational use" or experimental drugs.
• Blood, blood plasma or biological sera.
• Vitamins, except those which by law require a prescription.
• Any prescription filled in excess of the number specified by the physician, or any refill dispensed after one year from the physician's original order.

Vision Care Benefits

Vision care benefits are available for you and your qualifying dependents. This benefit will reimburse you for the cost of eye examinations, frames, and/or lenses, including contact lenses.

Vision care benefits are available in the maximum amount of $300 per person each calendar year. You must be covered under the Welfare Fund on the date of service or the purchase date. In addition, the date of service or the purchase date will determine whether you have reached the maximum benefit for the year.

Any unpaid balance of your or your qualifying dependents’ vision care expenses not covered by the Welfare Fund may be submitted to the Healthcare Reimbursement Account if you have available monies in that Fund.

Hearing Aid Benefits

Hearing aid benefits are available solely as a reimbursement towards the cost of purchasing a hearing aid. It is available to you and your qualifying dependents. Hearing aid benefits cannot exceed $2000 per person during any calendar year. The purchase date of the hearing aid is the applicable date, not the date you file the claim form. In addition, you must be covered on the purchase date. This benefit cannot be used for the cost of repairs to a hearing aid or for batteries.

Any unpaid balance of your or your qualifying dependents’ hearing aid purchase may be submitted to the Security Benefit Fund if you have available monies in that Fund.

General Background

Medicare, the federal health program provided for people 65 years and older, has two kinds of health insurance. Part A, the hospital insurance, helps you with the cost of hospitalization and related care; and Part B, the medical insurance, helps pay doctor bills and other health expenses. Medicare does not have dental insurance or vision benefits.

It is strongly recommended that each person covered in the Welfare Fund contact their local Social Security Administration office at least three months prior to their 65th birthday for information about Medicare benefits and enrollment requirements. The Welfare Fund will assume you have enrolled in both Part A and Part B on the earliest possible date in providing your benefits. Your Medicare eligibility commences the first of the month in which you will turn age 65 or the first day of the month after you have been receiving a Social Security Disability Award for a period of 24 months.

When either you or your spouse receives your Health Insurance (Medicare) Identification card, check it carefully to see that all of your personal information is recorded correctly. Also verify that at the bottom of the card coverage is indicated for both hospital insurance and medical insurance and that an effective date is indicated for each type of coverage.

The hospital insurance (Part A) portion of Medicare is provided to you at no cost. However, the medical insurance (Part B) portion of Medicare has a monthly premium associated with it. When you enroll, the premium will be deducted from your monthly Social Security check.

Significance Of Medicare Enrollment

If you do not apply for Medicare on a timely basis, your ability to receive Medicare benefits will be significantly delayed and the monthly Part B cost to you and your spouse will be higher.

Once you are eligible for both Medicare Part A and Part B and submit a copy of your Medicare card confirming your enrollment in both Medicare Part A and Part B, we will automatically enroll you in the Anthem Medicare Preferred PPO Plan (a Medicare Advantage plan which includes prescription drugs.

Additional Information

If you are over age 65, actively employed, and covered in the Welfare Fund due to your employment, for your hospital and medical benefits. Contact the Fund Office and they will explain to you what happens with your coverage.

Coordination Of Benefits

Coordination of Benefits (COB) is a provision in group health and group dental contracts that prevents duplicate payments for the same covered medical or dental expenses. The COB provision applies only when a participant or eligible dependent is covered under more than one group health or dental program. When that is the case, the Welfare Fund will coordinate benefit payments with the other group plan. One group will pay its full benefit as the primary plan and the other group will pay secondary benefits (if necessary) to cover some or all of the remaining expenses. This COB provision prevents duplicate payments and overpayments. In no case should the benefits received from the two group plans in total be greater than the medical or dental allowed charges.

The rules to determine the order of payment under Welfare Fund coverage in those cases where there is coverage under more than one group plan are as follows:

A) If the other group plan does not have a COB provision similar to the Welfare Fund’s, then that group will be primary.

B)If both groups have a COB provision, the group covering the person as an employee is primary.

C)If a dependent child is covered under both parents’ group plan and the parents are not separated or divorced, the plan of the parent whose birthday falls earlier in the year will be primary. For purposes of determining the earlier birthday only the month and day are considered; the year of birth has no significance. If both parents have the same birthday, the plan which covered the parent longer will be primary. However, if the other group plan does not use the "birthday rule," but instead uses a rule based on the gender of the parent and as a result the two plans do not agree on which is primary, then the father’s group plan shall be primary.

D)If a dependent child is covered under both parents’ group plan and the parents are separated or divorced and there is no court decree which establishes financial responsibility for the child’s coverage, the plan of the parent who has custody (the custodial parent) shall be primary. However, if the custodial parent has remarried and the child is also covered as a dependent under the step-parent’s plan, the custodial parent’s plan will pay first, the step-parent’s plan second, and the non-custodial parent’s plan third.

E)If a court decree specifies which parent is to be responsible for the child’s coverage and that parent’s plan has actual knowledge of the decree, then that parent’s plan will be primary.

F)If a person is covered under one group as an active employee or as the dependent of an active employee and is also covered under another group as a retired employee or as the dependent of a retired employee, the group which covers that person as an active employee is primary. If the other group plan does not have this rule, and as a result the two plans do not agree on which is primary, then this rule will be ignored.

G)If none of the above rules determine which group plan is primary, the group plan covering the person for the longer period of time is primary.

Recovery Of Benefits From Alternative Sources

If a participant or qualifying dependent incurs covered medical expenses for which payment may be available from another source, a claim for these expenses may still be submitted for payment consideration by the Welfare Fund. The Welfare Fund may advance a benefit payment in order to assist the participant during a time of need. However, if another source is responsible for such expense under applicable provisions of the Welfare Fund and/or the law, the Fund retains the right to recover benefits paid from the responsible party despite any advance payment(s) it may make. In addition, the Welfare Fund will have the right to recover any payments which were made to the participant which duplicated another payment for the same expenses. The participant agrees to cooperate and assist the Welfare Fund in recovering any benefits for which other payment is available. Acceptance of benefits from the Welfare Fund automatically assigns to the Fund any right to recovery of alternate or duplicate payments.

In addition, if the participant recovers funds from another individual or insurer in connection with any covered medical expenses for which the Welfare Fund has already paid benefits, the Fund shall be entitled to recover the amount expended to or on behalf of the participant or his qualifying dependent(s) and by accepting benefits the participant agrees to reimburse the Welfare Fund.

Claim Filing Procedures

Hospital

Anthem BlueCross BlueShield

Should you or any of your dependents require emergency care or admission to a participating hospital, you should present your Empire identification card and Medicare card (where appropriate) at the time of service. The hospital will bill Empire for benefits payment. No claim forms are required for hospital coverage since all hospital benefits, excepting emergency care, must be pre-certified.

Medical Benefits

Anthem BlueCross BlueShield

There are no claim forms to file for medical benefits for services rendered by participating PPO providers. You simply identify yourself as a member of PPO by showing your identification card to the provider and make any required copayment. The providers are responsible for filing all claims for benefits directly Empire HealthChoice, Inc. Deluxe PPO.

Dental Benefits

MetLife Preferred Dentist Program

All necessary forms for dental and orthodontic work can be obtained by calling MetLife at 1-800-942-0854. Claim forms can be downloaded from the MetLife web site (www.metlife.com/dental). You must bring a claim form with you to your appointment. You must complete the employee portion of the claim and your dentist will complete the rest. Then, either you or your dentist can submit it to MetLife for processing. If your dentist uses his/her own computerized form, attach a copy to your MetLife claim form and send it to MetLife.

If you require treatment in excess of $300, you and your dentist should submit a pre-treatment estimate outlining the treatment plan and related charges. This way, you will know what services MetLife will cover and at what payment level. Services that usually require a pre-treatment estimate include crowns, bridges, inlays, onlays and periodontics.

Prescription Drug Program

No claim forms are required for prescriptions obtained through the mail service or card program. If you are required to purchase a prescription because of circumstances beyond your control, contact the Welfare Fund Office (212-465-8888) to obtain a Direct Reimbursement Claim form. Your reimbursement under this program will be significantly less than your purchase price of the prescription. After you and your pharmacist have completed the claim form, return it to the Fund Office for processing.

Vision Care Benefits & Hearing Aid Benefits

There is a special combined claim form for these benefits. Should you or any of your qualifying dependents require an application, contact the Fund Office (212-465-8888). After you have completed the application and followed its specific instructions, submit it to the Welfare Fund’s Medical Benefits Program for processing. An itemized receipt for the services rendered or products purchased must accompany the application

How To Appeal Denied Claims

Your request for a review of a denied claim should be made in writing and sent, within 60 days of the receipt of the denial, to:

The Steamfitters’ Industry Welfare Fund
27-08 40th Ave, 2nd Fl
Long Island City, New York 11101

You may examine plan records relating to your claim or submit comments on your claim in person or through a representative.

The Administrator will present your request for review to the appropriate provider of services, and/or the Trustees.

The provider or the Trustees will respond to your appeal within 60 days, unless special circumstances make it necessary for them to take an additional 60 days to review your request. You will be notified of the need for an additional 60 days before the end of the initial 60 day period.

If you feel that legal action concerning the Welfare Fund is necessary, legal process may be served upon the Administrator, or upon one or more of the Trustees at the addresses shown in the front of this booklet.

Miscellaneous Provisions

Assignability

Except as applicable law may otherwise require, no amount payable at any time hereunder shall be subject in any manner to alienation by anticipation, sale, transfer, assignment, bankruptcy, pledge, attachment, charge or encumbrance of any kind, and any attempt to alienate any amount, whether presently or hereafter payable shall be void, provided that benefits payable at any time may be used to make direct payments to health care providers upon written authorization of the participant. The Fund shall not be liable for or subject to the debts or liabilities of any person entitled to any amount payable through the Welfare Fund, or any part thereof.

Filing Of Information

Each eligible participant, qualifying dependent or other interested person shall file with the Welfare Fund such pertinent information as requested, including proof or continued proof of eligibility or dependency, and in such a manner and form as the Fund may specify or provide. Failure to file the requested information will result in the suspension of entitlement to any benefits hereunder until such time as said information is filed by the covered person or on behalf of the covered person.

Misstatements

In the event of any misstatement of fact(s) affecting coverage and/or benefits under the Welfare Fund, the true facts will be used to determine the proper coverage and the participant and qualifying dependent will be liable to repay the Fund for any excess coverage or benefits provided on the basis of the misstatement.

Overpayments

If a covered person has been paid benefits by the Welfare Fund that either should not have been paid or are in excess of the benefits that should have been paid, the Fund may cause the deduction of the amount of such excess or improper payment from any subsequent benefits payable to such covered person or other present or future amounts payable to such person, or recover such amount by any other legal method that the Fund, in its sole discretion, shall determine. Each covered person hereby authorizes the deduction of such excess payment for such benefits or other present or future compensation payments.

Payment To Other Than Participant

If it is determined that any person to whom benefits are payable is unable to care for personal affairs; is a minor; or has died, then any payment due the participant or his/her estate may be paid to the duly appointed legal representative, spouse, child, other relative or an institution maintaining or having custody of such person otherwise entitled to payment. In such a case, the Fund may, at its discretion, hold any such payments until a legal representative is appointed. Any such payment shall be a complete discharge of the liabilities of the Fund Office.

Privacy Provision

The following constitutes the Welfare Fund’s general policy regarding privacy:

1) Any information collected by the Welfare Fund will be treated as confidential except for certain specific disclosures. Those exceptions are as follows:

• Information required to administer benefit programs or to process a claim for benefits.
• Information relative to duplicate coverage.
• Information to be disclosed to determine whether medical services were reasonable and necessary.
• Information needed to comply with legal or regulatory requirements.

2) Any information which is on file with the Welfare Fund shall be available to the participant except as follows:

• If the information relates to civil or criminal proceedings.
• If such is of a medical nature, the information may be available only through the covered person’s physician.

3) The participant may request that any personal information be corrected, amended or deleted.

Right Of Information

For the purpose of determining the applicability of and implementing the terms of these benefits, the Welfare Fund may, without the consent of or notice to any person, release or obtain any information necessary to determine acceptability of any potential or current covered person who benefits from the Fund’s coverage. In so acting, the Welfare Fund shall be free from any liability that may arise with regard to such action. Any covered person claiming benefits shall furnish to the Welfare Fund information which may be necessary to implement this provision.

Subrogation

Subrogation means the Plan’s right to pursue the covered person’s claims for covered medical expenses that become the responsibility of a third party or other insurer. This subrogation right allows the Welfare Fund to pursue any claim which the covered person has against any third party or other insurer, whether or not the covered person chooses to pursue that claim. The Fund may make a claim directly against the third party or other insurer, but in any event, the Fund has a lien on any amount recovered by the covered person whether or not designated as payment for medical expenses. The covered person automatically assigns to the Fund any rights against any third party or other insurer when this provision applies and must repay the benefits paid on his or her behalf out of the recovery made from the third party or other insurer. The Fund will have priority over any funds paid by the third party or other insurer to a covered person relative to the injury or illness, including a priority over any claim for non-medical or dental charges, attorney fees, or other costs and expenses. The Welfare Fund’s subrogation and recovery rights, as well as the rights assigned to it, are limited to the extent to which the Fund has made, or will make, payments for covered medical expenses as well as any costs and fees associated with the enforcement of its rights. The covered person will execute and deliver all required instruments and papers as well as doing whatever else is needed to secure the Fund’s right of subrogation as a condition to having the Welfare Fund make payments. In addition, the covered person will do nothing to prejudice the right of the Fund to subrogate.

Definitions

When the following terms are used in this booklet, these definitions apply.

Accident

A non-occupational bodily injury that is caused by an event that is external, violent, sudden and not foreseen, exact as to time and place and independent of all other causes.

Calendar Quarter

A calendar quarter means a period of three consecutive months, commencing with any January 1, April 1, July 1, or October 1.

Cobra

Stands for the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Cosmetic Surgery

Refers to medically unnecessary surgical procedures, usually, but not limited to, plastic surgery directed toward preserving beauty or correcting scars, burns or disfigurements and not intended to restore a bodily function.

Covered Employment

Covered employment is work performed for any employer with respect to which the employer is obligated to make contributions to the Steamfitters’ Industry Welfare Fund (i) pursuant to the Collective Bargaining Agreement with Local Union 638 or (ii) pursuant to an existing reciprocal agreement between the Fund and another fund or (iii) pursuant to another agreement to make contributions to the Welfare Fund.

Covered Person

A participant who maintains the eligibility requirements and his or her qualifying dependents.

Custodial Care

The care, including room and board needed to provide such care, that is given principally for personal hygiene or for assistance in daily living activities which can be performed by persons who have no medical training.

Daily Living Activities

Includes those activities necessary to sustain daily living such as feeding, bathing, toileting, dressing, personal hygiene, transferring and ambulating.

Experimental Or Investigational

Those services, supplies, care and treatment which do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered.

Hospital

An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient’s expense and which fully meets all the tests set forth in (a) or (b) or (c) below:

a. It is a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations.

b. It is a hospital or psychiatric hospital as those terms are defined for Medicare insurance purposes, which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare.

c. It is an institution which fully meets all of the following tests:

• It maintains on the premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians; and
• It continuously provides on the premises 24 hour a day nursing service by or under the supervision or registered graduate nurses; and
• It continuously maintains organized facilities for operative surgery on the premises.

Hospital Services & Supplies

Services and supplies furnished to the individual and required for treatment, other than room and board, the services of any physician and any private duty, or special nursing services (including intensive nursing care by whatever name called), regardless of whether such services are rendered under the direction of the hospital or otherwise.

Maintenance Care

Those charges incurred after the patient has reached a maximum level of improvement; or for which no further medical improvement can be reasonably anticipated; or for the general conditioning of a body part.

Medically Necessary

Care and treatment that is recommended or approved by a physician; is consistent with the patient’s condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider; is not conducted for research purposes; and is the most appropriate level of services which can be safely provided to the patient.

Medicare

The program established by Title I of Public Law 89-88 (79 Statute 291), as amended, entitled Health Insurance for the Aged Act, and which includes both Parts A and B.

Mental Or Nervous Disorder

A neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. Personality disorders such as autism are included, as long as such condition has as its standard and accepted course of treatment the taking of prescription drugs. Presenile and arteriosclerotic dementias are not classified as mental or nervous disorders, but as any other illness. Learning disabilities, behavior problems or attention-deficient disorders are not classified as mental or nervous disorders, nor are they considered an illness. Psychiatric disorders resulting from specific external factors, such as grief, are classed as mental or nervous disorders. Senile dementia is, by itself, a non-covered illness. Alcoholism and substance abuse are not, by themselves, considered a mental or nervous disorder.

Morbid Obesity

A diagnosed condition in which the body weight exceeds the medically recommended weight by either 100 pounds or is twice the medically recommended weight in the most recent Metropolitan Life Insurance Co. tables for a person of the same height, age and mobility as the covered person.

No-Fault Auto Insurance

The basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Participant

A participant is (a) a member of the union or other employee on whose behalf contributions are required under an agreement between an employer and the union; (b) a steamfitter who is a salaried official of the union; (c) an employee of any of the related funds, provided that the union and the trustees of such related funds, respectively, have agreed to make contributions to the Fund on the employees’ behalf at the rate of contributions in effect for other employees or (d) retirees who meet the eligibility requirements.

Pharmacy

A licensed establishment where covered prescription drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices.

Physician

A legally licensed medical or dental doctor or surgeon, chiropractor, osteopath, podiatrist, chiropodist, optometrist, certified consulting psychologist, certified nurse anesthesiologist, or midwife, to the extent that same, under their license, are permitted to perform services provided for in this Plan. The term Physician shall not include the covered person or any person who is the spouse, parent, child, brother or sister, in blood or in-law, of the covered person.

Prescription Drug

Any of the following: a drug or medicine which, under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription"; and injectable insulin, but only when dispensed upon a written prescription.

Room & Board

Room, board, general duty nursing and any other services regularly furnished by the hospital as a condition of occupancy of the class of accommodations occupied, but not including professional service of physicians nor charges for intensive nursing care by whatever name called.

Total Disability With Respect To Health Insurance

You or your dependent’s complete inability to perform the normal activities of a person of like age and sex.

Well Baby/Child Care

Those charges made by the caring hospital, or similar institution, for the custodial and nursing care of a baby which is deemed to be free of any identifiable illness, disease or malfunction. It will also include any periodic check-ups in a clinic or physician’s office.

Life Insurance And Accidental

Death Or Dismemberment Insurance

What Is My Life Insurance Coverage?

MetLife has been designated by the Trustees to provide group life insurance benefits for any active participant who is eligible for coverage under the Welfare Fund. If you are an active participant and you die from any cause, your designated beneficiary will be paid $50,000.

Life Insurance and Accidental Death or Dismemberment Insurance are not available to retired participants, participants on return-to-work status and any active participant not eligible for coverage in the Welfare Fund.

Can I Continue Life Insurance If I Fail To Remain Covered Under The Group Plan?

If your Welfare Fund coverage terminates, you may apply, without medical examination or other evidence of insurability, for an individual life insurance policy through Metropolitan Life Insurance Company. Your application for conversion must be made within 31 days after the termination of your insurance. Contact the Fund Office for complete details.

Your group life insurance is payable if you die within the 31-day period following termination of insurance, whether or not you have applied for conversion to an individual policy.

What Is The Accidental Death Or Dismemberment Insurance?

If, while you are insured, you are injured in a non-employment related accident and the accident is the sole cause of the injury, the injury is the sole cause of the covered loss and the covered loss occurs within one year of the date of accident, you or your beneficiary will receive the following benefits:

Accidental dismemberment benefits are payable to the participant, but life insurance and accidental death benefits will be paid to your designated beneficiary.

Only one of the above amounts, the largest, will be paid on an Accidental Death or Dismemberment claim which results from one accident.

The benefit for Accidental Death is in addition to your basic life insurance benefit.

Exclusions

Accidental Death or Dismemberment insurance benefits will not be paid for any covered loss which in any way resulted from, or was caused or contributed to by any of the following means:

• an Occupational Injury; or
• physical or mental illness, diagnosis of or treatment for the illness; or
• an infection, unless it is caused by an external wound that can be seen and which was sustained in an accident; or
• suicide or attempted suicide; or
• injuring oneself on purpose; or
• the use of any drug or medicine; or
• a war, or a warlike action in time of peace, including terrorist acts; or
• committing or trying to commit a felony or other serious crime or an assault; or
• any poison or gas, voluntarily taken, administered or absorbed; or
• service in the armed forces of any country or international authority, except the United States National Guard; or
• operating, learning to operate, or serving as a member of a crew of an aircraft; or while in any aircraft operated by or under any military authority (other than the Military Airlift Command); or while in any aircraft being used for a test or experimental purposes; or while in any aircraft used or designed for use beyond the Earth’s atmosphere; or while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation).

It is essential that you keep your beneficiary information current. Contact the Fund Office if you wish to change or update your beneficiary information.

Failure to do so can delay or prevent payment of your group life and accidental death insurance benefits or result in payment which is not what you wished.

The Health Reimbursement Account

Your appeal must be made in writing and sent to the Fund Office within 180 days of the notification that your claim has been denied. Your appeal will be presented at the next regularly scheduled meeting of the Board of Trustees following receipt of your request for review provided the appeal has been received at least 30 days before such meeting. However, if your request for review is not received within 30 days of the next regularly scheduled meeting, your request for review will be considered at the second regularly scheduled meeting following receipt of your request.   In special circumstances a delay until the third regularly scheduled meeting following receipt of your request for review may be necessary.  Once a decision on review of your claim has been reached, you will be notified of the decision no later than five (5) days after the decision has been reached.    

Your Rights Under ERISA

As a participant in Steamfitters’ Industry Welfare Fund, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).  ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the plan administrator’s office and at other specified locations such as the union office, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Executive Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description.  The administrator may make a reasonable charge for the copies.

Receive a summary of the plan’s annual financial report.  The Executive Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Prudent Action by Plan Fiduciaries

In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan.  The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries.  No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claims for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights.  For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court.  In such a case, the court may require the plan administrator to provide materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.  If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court.   In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court.

If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance form the U.S. Department of Labor, or you may file suit in a Federal court.  The court will decide who should pay court costs and legal fees.  If you are successful the court may order the person you have sued to pay these costs and fees.  If you lose, the court may order you to pay the costs and fees if, for example, it finds your claim is frivolous.

Assistance with Your Questions

If you have questions about your plan, you should contact the Executive Plan Administrator.  If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Executive Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.  You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Summary Plan Description