Health & Welfare and Pension Funds
of Philadelphia and Vicinity

GENERAL PROVISIONS AND DEFINITIONS

Accidental Bodily Injury: For an injury to be considered an accident, the injury must have resulted from some external, violent and unforeseen happening.

Actual Charges: Shall mean covered charges up to the Usual, Customary and Reasonable charges as defined in this Section, and never to exceed the payment the provider of service accepted as payment in full from any other source.

Assignment: The Member or his/her Spouse have the right to authorize the Fund to pay a Family Member's benefits directly to the physician or hospital who provided the Family Member with covered care and treatment. Except for this, however, you may not assign, alienate, anticipate or commute any benefits which a Family Member is entitled to receive from the Plan and, further, except as may be prescribed by law, none of your benefits shall be subject to any attachments or garnishments of or for your debts and/or contracts, etc., except for recovery of overpayments made on a Family Member's behalf by the Fund, as described under the HOW SOON SHOULD YOU FILE YOU CLAIM paragraph in the How To File a Claim section of this Booklet.

Automobile Insurance: Where an injury is caused by an accident that is covered by a State-required Automobile Insurance Law, the coverage under this Plan is secondary and the automobile insurance or Assigned Claims Plan is responsible to pay the covered charges for that injury first. The Plan will then cover the balance of the covered charges that were not covered by the automobile insurance, up to the maximum benefit level set forth in the Summary of Benefits Schedule insert.

Special additional exclusions apply in the case of No-Fault insurance policies that are governed by the New Jersey No-Fault Law, as amended by the New Jersey Insurance Freedom of Choice and Cost Containment Act. Participants, dependents an beneficiaries who are injured in the course of an automobile accident and who are also covered by an automobile insurance policy governed by the New Jersey No-Fault Law, as amended by the New Jersey Automobile Insurance Freedom of Choice and Cost Containment Act, may only be reimbursed under the Plan by the Fund up to a maximum of $1,000 per accident for Covered Expenses and, in the case of an eligible member, only up to a Weekly Disability maximum of $62.50 per week up to the Plan maximum of twenty-six (26) weeks.

Benefit Period:  Benefit Period shall mean the Plan Year which begins on January 1 and ends on December 31 of each year.

Claim Forms: The Fund, upon receipt of a written notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proof of loss. If such are not furnished within 30 days after the giving of notice, the claimant shall be deemed to have complied with the requirements of the Fund for submitting proof.

Claim Review Procedure: See "Your Rights and Protections under ERISA" in this Booklet.

Collective Bargaining Agreement: As a requirement of which the employer is obligated to make contributions to the Fund on behalf of the employees covered by that Collective Bargaining Agreement.

Contributing Employer: An employer whose signed Collective Bargaining Agreement requires the employer to make contributions to the Fund on behalf of the employees covered by the terms of that Collective Bargaining Agreement.

Coordination of Benefits (C.O.B.): The Teamsters Health and Welfare Fund's Plan provides for Coordination of Benefits. This means that should a Family Member be entitled to any medical, dental, vision, disability or pharmacy benefits from another source, benefits under this Plan may be reduced to an amount, which together with all such other coverage under any other plan or policy, will not exceed 100% of any Usual, Customary and Reasonable item of expense covered under this Plan or any other such plan. The Fund has special rules for coordinating benefits with respect to automobile insurance. These rules are explained under the heading "Automobile Insurance" which is defined earlier in this section.  In all other cases in which a Family Member, on whose behalf a claim is submitted, is covered under one or more group plans for health benefits in addition to the Fund's Plan, benefits will be coordinated so that the member may receive up to 100% of the Reasonable and Customary Charges in accordance with the following priorities of payment:

 a.       If the other plan providing benefits for a person covered under the Fund's Plan does not have a coordination of benefits or duplication of benefits provision, benefits payable for covered expenses under the other plan will be paid in full before any benefits are paid by the Fund's Plan.

 b.       If the other plan providing benefits for a person covered under the Fund's Plan does have a coordination or non-duplication provision, the following rules will apply for determining whether the Fund or the other plan will provide primary coverage. For the purposes of these rules, the plan which provides "primary coverage" shall be obligated to provide benefits to the fullest extent of its coverage before any other plan is obligated to cover the benefits in question. The plan which provides "secondary coverage" shall not be obligated to provide benefits until the "primary coverage" is exhausted. 

1. Member of the Fund: The Fund will provide primary coverage for Members of the Fund, and (in each case) the other plan will provide secondary coverage for such Members. This provision will not apply to pensioners under age 65 who are gainfully employed and covered by a plan provided by their employer; such individuals are covered by paragraph 4 below.
    

2. Dependent Spouses: In each case, the other plan will provide primary coverage for the dependent spouse, and the Fund will provide secondary coverage for the dependent spouse.  A spouse who (i) works full-time (defined as regularly scheduled to work 32 or more hours per week), and (ii) who is eligible to participate in group health coverage sponsored by his/her employer must enroll in that coverage except if the spouse must pay 100% of the premium for such coverage.  If the spouse is required to enroll in such coverage, but does not, the Fund will provide secondary coverage and only to the extent as if the other coverage was in effect as of the date services were rendered to the patient/spouse.
    

3. Dependent Children:

(a)     If a dependent child is gainfully employed and is covered by another plan as a result of that employment, then no coverage is available under the Fund's plan for such dependent child.

 (b)     If paragraph 3(a) above is not applicable and the member and the child's other parent are married to each other and not separated, then the "birthday rule" shall apply. Under the birthday rule, the Fund will provide primary coverage if the member’s birthday occurs before the spouse's birthday during the calendar year. For example, if the member was born in June and the spouse in September, then the Fund will provide primary coverage and the spouse's plan will provide secondary coverage. On the other hand, if the spouse's birthday occurred earlier in the calendar year than the member's birthday, then the spouse's plan will provide primary coverage and the Fund will provide secondary coverage. If the member and the spouse have the same birthday in the calendar year, then provision (5) below will apply.

 (c)     If paragraph 3(a) above is not applicable and the member and the child's other parent are either separated or divorced from each other, then the following rules shall apply.

 (i)                   If there is a court order which establishes or apportions the parents' respective obligations to provide for the medical, dental or other health care expenses of any such child, then benefits will be apportioned in accordance with the provisions of the court order, provided that such court order cannot grant benefits which are not otherwise provided by the Fund.

 (ii)                 In the absence of such a court order establishing such financial responsibility, the following shall be the order of payment of benefits for such dependent child: 

4.       The Fund's Plan will not provide any benefit if the person for whom the claim is made is a pensioner, or the dependent of a pensioner who is gainfully employed and his employer provides him with health insurance or the person for whom the claim is made is not a member, or an eligible dependent of a member. 

5. If the rules set forth above do not establish the order of benefit payment, the plan which covered the person for whom the claim is made for the longer period of time shall be considered the primary source of benefits.

 c.       Medicare Coverage- For Covered Expenses incurred by Members and/or Dependents age 65 through 69 years, except for dependents age 65 through 69 of Members over age 69, the coverage provided by the Fund is primary. In those cases where the Member is actively at work, the Fund’s coverage is primary.  In all other situations, Medicare coverage is primary and the Fund is secondary.

 d.       Under no circumstances will the Fund pay any benefits as the primary plan when a member or the dependent of a member has elected to make the Fund the primary plan by waving coverage under any other plan. This provision shall be effective regardless of whether the dependent waived enrollment in such other plan (when required to enroll in circumstances described in paragraph g. below) or, if enrolled, sought or secured services outside of the required network of providers of such other plan.

 e.       If a group plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be deemed a benefit payment.

 f.         Benefits otherwise payable under the Fund's Plan shall be reduced in accordance with the above priorities of payment to the extent necessary so that the sum of such reduced benefits payable under all group plans shall not exceed the total of the Usual, Customary and Reasonable charges for the service provided.

 g.       If a dependent spouse is employed full time (defined as being regularly scheduled to work 32 or more hours each week) and is eligible to enjoy group coverage through his/her employer at less than 100% of the cost to him/her, the spouse must enroll for such coverage (single coverage only).  Furthermore, if such coverage exists for the spouse, the spouse may not waive coverage in lieu of a salary increase or other financial remuneration.

Counseling: It is not a covered benefit unless it is performed by a physician as defined in this Booklet. In addition, the counseling must be related to the patient being treated for a mental illness and/or functional nervous disorder, drug abuse and alcoholism. The counseling must also be performed in a non-group setting, unless the other participants are Family Members, in which case the Fund would still only provide a single individual benefit allowance per session.

Covered Expenses: Only actual charges for an item or service which is specifically listed as a covered benefit under a provision of the Plan which is covered by your specific Summary of Benefits Schedule which accompanies this Booklet.

Customary Charge: A fee is Customary when it is within the range of usual charges for a given service billed by most physicians or providers of service with similar training and experience within a given area.

Deductible: A specified amount of Covered Expenses for the Covered Services that is incurred by the Covered Person before the Fund will assume any liability.

Dependent: (See Eligibility Provisions in the front of this Booklet.)

Family Member: (See Eligibility Provisions in the front of this Booklet.)

Fraud: No benefits under this Plan will be paid if the person on whose account, or by whom the benefit is claimed, or the provider of service attempts to perpetrate a fraud upon or misrepresents a fact to the Fund with respect to any such claim. In the case of such conduct, the Board of Trustees, may, in its sole and exclusive discretion, pay no further benefits to the member, dependent or beneficiary involved as to the particular claim or as to any other claims arising during a period of not more than one year after the discovery of such fraud, attempted fraud or misrepresentation. The Fund shall have the right to fully recover any amounts, with interest, improperly paid by the Fund by reason of fraud, attempted fraud or misrepresentation of fact by a member, dependent, beneficiary or provider of service and to pursue all other legal remedies. The Board of Trustees shall have the right to finally determine whether or not a fraud has been attempted or committed upon the Fund or if a misrepresentation of fact has been made, and its decision shall be final, conclusive and binding upon all persons.

Fund: The Teamsters Health and Welfare Fund of Philadelphia and Vicinity.

Group Therapy: Is not covered unless the only other participants in the "group" are other Family Members. In addition the therapy must be performed by a physician as defined in this Booklet and be related to treatment of a mental illness, a functionaI nervous disorder, drug abuse or alcoholism. Regardless of the number of Family Members participating in the therapy session, only a single individual allowance will be made per session.

Group Therapy: Is not covered unless the only other participants in the "group" are other Family Members. In addition the therapy must be performed by a physician as defined in this Booklet and be related to treatment of a mental illness, a functionaI nervous disorder, drug abuse or alcoholism. Regardless of the number of Family Members participating in the therapy session, only a single individual allowance will be made per session.

Hospitals: An acute care institution which meets the following requirements:

1. Is Iicensed as a Hospital by the State in which it is located, and the primary function of the institution is providing inpatient medical care and treatment through medical diagnostic and major surgical facilities on its premises under the supervision of a staff of physicians, and with 24 hour a day nursing service, and

2. Is not owned or operated by the United States Government or by a State (or political subdivision thereof) unless there is an unconditional requirement that persons receiving care must pay for such care.

However, "Hospital" does not include a Nursing Home or an institution, or part of one, used primarily as a facility for convalescence, rehabilitation, treatment of mental illness or functional nervous disorders, a place for the aged, a rest home, a place for alcoholics, or place for drug addicts.

Inpatient: An individual who, while confined in a Hospital or Special Care Facility, is assigned to a bed in any department of the institution other than its outpatient department and for whom a charge for room and board is made.

Legend Drugs: Drugs, biologicals, and compounded prescriptions which, by Federal Law can be dispensed only pursuant to a prescription, and are required to bear the legend, "Caution: Federal Law prohibits dispensing without a prescription."

Maternity Coverage:  Maternity coverage under the Plan available to female members and the female spouses of male members.  Under federal law, the Fund may not restrict benefits for any hospital length of stay in connection with child birth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.  However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).  In any case, the Fund may not, under federal law, require that a provider obtain authorization from the Fund for prescribing a length of stay not in excess of 48 hours (or 96 hours). 

Medically Appropriate or Medically Necessary: Means services or supplies that are:

1. appropriate for the symptoms and diagnosis or treatment of the Family Member's condition, illness, disease or injury; and

2. required for the diagnosis, or the direct care and treatment of the Family Member's condition, illness, disease or injury; and

3. in accordance with standards of good medical practice as generally recognized and accepted by the medical community; and

4. not primarily for the convenience of either the Family Member's family or a provider of medical services; and

5. the most efficient and economical supply or level of service that can safely be provided to the Family Member. When applied to hospitalization, this further means that the Family Member requires acute care as a bed patient due to he nature of the services rendered or the Family Member's conditions, and the Family Member cannot receive safe and adequate care in some other setting without adversely affecting the Family Member's condition or quality of medical care.

Medicare: To the extent permitted by law, Medicare benefits will be taken into account for any Member or Dependent while they are eligible to apply for Medicare, whether or not they actually apply. The Fund will determine a Family Member's benefit allowance, if any, based upon the applicable Medicare statutes and regulations.

 Member (or Eligible Member): An individual who has satisfied the eligibility requirements based on contributions made on his/her behalf by his Employer to the Fund and has qualified for the benefit program. Members include the following types of employees: (1) an employee covered by a collective bargaining agreement which requires his/her employer to contribute to the Fund on his/her behalf, (2) an employee of a Labor Union or trade association which contributes to the Fund on his/her behalf and (3) an employee of the Fund or the Teamsters Pension Trust Fund of Philadelphia and Vicinity who has contributions paid to the Fund on his/her behalf.

The masculine pronoun whenever used shall include the feminine pronoun and the singular shall include the plural where appropriate.

 Participating Local Union: A union with whom any of the contributing employers have entered into a signed Collective Bargaining Agreement, as a requirement of which, the employer is obligated to make contributions to the Fund on behalf of the employees covered by that Collective Bargaining Agreement.

 Physical Examination: The Fund reserves the right to examine at its own expense and as often as necessary, any person whose injury or sickness is the basis of a claim and, in the case of any death claim, to have an autopsy made.

 Physician: Means a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a doctor of chiropractic medicine (D.C.), a doctor of dental surgery (D.D.S.), a doctor of dental medicine (D.M.D.), a doctor of podiatric medicine (D.P.M.), and optometrist (O.D.). A clinical psychologist (Ph.D., M.S., or M.A. or L.S.W.), when providing treatment for mental illness or functional nervous disorders, shall also be considered a physician. 

Plan: Means this Booklet, the applicable Personal Choice or Keystone HMO booklet, the applicable Summary of Benefits Schedule and any modifications thereto published by the Teamsters Health and Welfare Fund of Philadelphia and Vicinity duly adopted by the Fund's Board of Trustees in accordance with their authority set forth in the Agreement and Declaration of Trust establishing the Fund. Additionally, the Trustees of the Fund, by unanimous action, may terminate, suspend, withdraw, amend or modify the benefits available under the Fund, in whole or in part, at any time and without any prior notice. Any such termination, suspension, withdrawal, amendment or modification of benefits shall not require the consent of any employer, union, Member or Dependent, nor shall such action require individual notice to any such person or organization .

 Prescription: A written order of a physician or where permitted by law, an oral order of a physician, for legend drugs to the extent that such order is within the scope of such physician's license.

Special Care Facility: An institute other than a Hospital (as defined in this Booklet) which: 

1. specializes in physical rehabilitation of injured or sick patients, or

2. specializes in the diagnosis and treatment of mental illness or functional nervous disorders, or

3. specializes in the diagnosis and treatment of alcoholism, drug addiction or mental and nervous disorders.

 In addition, to qualify as a Special Care Facility, an institution must be: 

a.       legally licensed to give medical treatment, and

b.       operated under the supervision of a physician, and

c.       offer nursing service by registered graduated nurses or licensed practical nurses.

However, the term "Special Care Facility" does not include an institution or part of one that is used mainly as a facility for rest, convalescence, or for the aged.

 Spouse: Means either your lawful wife or your lawful husband. The status of spouse shall be determined exclusively with reference to the laws of the Commonwealth of Pennsylvania regardless of the residence or domicile of the parties involved. Additionally, whether you are "separated" from your spouse will be determined with reference to the laws of the Commonwealth of Pennsylvania regardless of the residence or domicile of the parties involved.

 Subrogation/Reimbursement of Benefits: The following rule applies to any situation in which the Fund makes any full or partial payment to or on behalf of a Member or Dependent (other than for death benefits) who subsequently recovers from any other source additional payments or benefits in any way related to the accident, illness, or treatment for which the Fund made full or partial payment. Upon any such subsequent recovery by or on behalf of a participant or beneficiary, from any person or persons, party or parties, insurance company, firm, corporation, or government agency, whether by suit, judgment, settlement, compromise, or otherwise, the Fund, with or without the signing of a subrogation agreement, shall be entitled to immediate reimbursement to the extent of benefits paid to or on behalf of the Member or Dependent. The Fund shall be first reimbursed fully by or on behalf of such Member or Dependent to the extent of benefits paid from the monies paid by any person or persons, party or parties, insurance company, firm, corporation, or government agency and the balance of monies, if any, then remaining from such subsequent recovery shall be retained by or on behalf of the Member or Dependent.  The Member and/or Dependent shall hold, as a fiduciary in constructive trust for the benefit of the Fund, any monies so recovered that are subject to the Fund’s subrogation/reimbursement lien or these provisions.

 All Members and Dependents are obligated to cooperate with the Fund in its efforts to enforce its subrogation rights and to refrain from any actions which interfere with those efforts. This duty of cooperation includes (but is not limited to) the obligation to sign a subrogation agreement in a form prescribed by the Fund. The Fund shall have the right to take all appropriate actions necessary to enforce its subrogation rights in the event that a Member or Dependent refuses to sign a subrogation agreement, refuses to reimburse the Fund in accordance with the Fund's subrogation rights, or takes any other action inconsistent with the Fund's subrogation rights. In such situations, the Fund's options shall include, without limitation, the right in appropriate cases to deny benefits to an individual who refuses to sign a subrogation agreement; to institute legal actions to recover sums wrongfully withheld or to obtain other relief; and/or to offset wrongfully withheld sums against future benefit payments otherwise owed the individual who retains such sums. The Fund may pay counsel fees in an amount not to exceed 20% in order to protect the Fund's subrogation interests.

 Summary of Benefits Schedule: This is the Insert which accompanies this Booklet, and contains the actual allowances for your various benefits. In addition, you will also find a partial listing of covered dental allowances in this Insert. You may write the Fund office to learn the allowance of any covered procedure not listed. The maximum allowance may not exceed the fee actually charged for the procedure.

 Totally Disabled:

For Member:

You are prevented from engaging in your customary occupation solely because of injury or disease and are performing no work of any kind for pay or profit.

For Dependent:

Your dependent is prevented from engaging in substantially all of the normal activities of a person of like age and sex in good health solely because of injury or disease.

 Usual, Customary and Reasonable Allowance (or “UCR”): The benefit allowance for a procedure or service performed by a Physician or other medical service provider, taking into account the most consistent charge by an individual physician or provider of service to patients for a given service, the range of usual charges for a given service billed by most physicians or providers of service with similar training and experience within a given area, and the complexity of treatment of the particular case.

 Last Date Updated :  10/16/08