QUESTIONS AND ANSWERS
- To whom are benefits
payable?
- Will
the Fund automatically accept my physician's signed statement on my claim
form?
- May I select my own
physician?
- May
I go to any hospital or am I limited to certain ones?
- Can
I collect Weekly Disability Benefits and unemployment compensation at the
same time?
- If
my disability arose during the course of my employment, would it be all
right for me to submit a claim to the Fund?
- Exactly
what does the Major Medical deductible mean?
- If
I go to the doctor about two times a month for treatment, can I claim this
expense under my Major Medical Plan?
- I
have myself, my wife and four children and sometimes our medical bills are
too much. Do each of us have to satisfy the deductible?
- What is
the Fund's position on cosmetic surgery?
- My
wife and I just had a baby; when is our child eligible for coverage under
this Plan?
- I
went to a PPO provider and now I’m getting a bill. Why?
- Can I get
contact lenses instead of glasses?
- My
physician prescribed a medication, but my pharmacist said it wasn’t
covered under my Plan. Why isn’t it covered.
- Well,
l feel that l understand my coverage much better now, but if I have any
other questions, may I contact the Fund office?
(Return
to TOC)
1. Q. To whom are
benefits payable?
A. Your Death Benefit is payable to your beneficiary of record. Other
benefits are payable to you, the member, although you may assign your benefits
to the physician or hospital.
2.
Q. Will the Fund automatically accept my physician's signed statement on my
claim form?
A. Not always. The Fund reserves the right to ask for a medical examination
by its own appointed physician.
3. Q. May I select my
own physician?
A. Yes, as long as he is licensed to practice in accordance with all
applicable laws. Remember, however, you may have certain restrictions if you are
covered under the Keystone HMOÔ program. Also keep in mind that, under the
Personal ChoiceÔ program, higher deductibles and copayments apply if the doctor
you select is not in the Personal ChoiceÔ network.
4.
Q. May I go to any hospital or am I limited to certain ones?
A. Benefits are payable to any hospital which meets the definitions of
hospital contained in this Booklet. But please remember to comply with the
Fund's Pre-Admission Certification rules. For those enrolled in either the
Personal ChoiceÔ or Keystone HMOÔ programs, be sure to consult your Provider
Directory.
5.
Q. Can I collect Weekly Disability Benefits and unemployment compensation at the
same time?
A. No, collection of unemployment compensation shall be evidence that a
member is able and available for suitable work and, therefore, would not be
entitled to Weekly Disability Benefits.
6.
Q. If my disability arose during the course of my employment, would it be all
right for me to submit a claim to the Fund?
A. A claim for a disability that originates in the course of employment
should be filed with Workmen's Compensation because:
1. Charges for treatment of work related injuries are not covered under the
Plan, and
2. Workmen's Compensation Benefits are far more valuable than those under
the Fund, and
3. Should you first file your claim with the Fund and the Fund subsequently
denies payment because it is job related, the delay thus caused could affect
receipt of benefits under Workmen's Compensation.
4. On the other hand, should you file with Workmen's Compensation first,
and be denied by Referee decision, upon presentation of the Referee denial
from Workmen's Compensation to the Fund, your claim will be honored unless, of
course, your denial was for procedural reasons and not because the findings
were that the illness or injury was not job related.
7.
Q. Exactly what does the Major Medical deductible mean?
A. It is similar to the deductible you have with your car insurance. Prior to
any benefits being paid under your Major Medical Plan, you must first pay a
deductible amount out of your own pocket. This amount is shown in the Summary of
Benefits Schedule. Once you satisfy this out-of-pocket deductible the Fund pays
a large percentage of any Covered Expenses. Beyond this, you will continue to
pay a small portion of your Major Medical expenses until you satisfy your
co-payment amount as indicated in the Summary of Benefits Schedule Insert. At
that point the Fund will generally be covering 100% of your Major Medical
expenses, subject to the Plan maximums and limitations.
8.
Q. If I go to the doctor about two times a month for treatment, can I claim this
expense under my Major Medical Plan?
A. Yes. if you have office visits, clinic visits or consultations, these are
all covered under your Major Medical Plan. While no benefits will be paid until
you satisfy your deductible, as long as the claims are submitted, the charge
will be credited towards your deductible and once this is satisfied, the balance
of your claims will be paid at the appropriate percentage.
9.
Q. I have myself, my wife and four children and sometimes our medical bills are
too much. Do each of us have to satisfy the deductible?
A. Yes, but there is also a family clause in the Plan. If the family as a
whole has reached the family deductible maximum (see your Summary of Benefits
Schedule to determine what this maximum is), the Fund will begin to pay a large
percentage of all Covered Expenses.
10.
Q. What is the Fund's position on cosmetic surgery?
A. Generally speaking the Fund does not cover cosmetic surgery. When in doubt
as to whether a particular surgery is considered cosmetic or not, contact the
Fund prior to incurring any out-of- pocket expenses for which the Fund will not
reimburse you.
11.
Q. My wife and I just had a baby; when is our child eligible for coverage under
this Plan?
A. With the exception for the Death Benefit, which differs depending on the
age of the child, your child is eligible immediately for the first 31 days of
the child's life, assuming of course, that you are eligible and you participate
in one of the Fund's benefit programs that has dependent coverage. However, for
coverage to continue beyond this 31 day period, it is most important that you
notify the Fund of this new Family Member as soon as possible by filling out and
returning to the Fund a new Census Card. You must also send the Fund a copy of
the child's birth certificate.
12.
Q. I went to a PPO provider and now I’m getting a bill. Why?
A. If you went to a PPO provider for dental or vision benefits, this could
happen for several reasons. In the case of a dental claim, you could receive a
bill if you have already reached the yearly or lifetime dental maximum benefit
for that patient, or you received services sooner than allowed, or you received
non-covered services. Under the vision program, you may be billed the additional
fees for non-covered items, such as designer frames, sunglasses, transitional
lenses and invisible (or progressive) bifocal lenses. Remember: Although the
Fund strives to keep the provider directories current (they are updated
approximately every two months), check with the Fund office or the provider to
make sure the provider is still participating in the PPO panel. In some cases,
you will receive a bill from the provider for a major medical claim. You could
be billed for non-covered items, your deductible, your copayment, or for charges
which exceeded plan maximums.
13. Q.
Can I get contact lenses instead of glasses?
A. Yes. However, contact lenses are reimbursed by combining the allowances
for frames and single vision lenses.
14.
Q. My physician prescribed a medication, but my pharmacist said it wasn’t
covered under my Plan. Why isn’t it covered.
A. Although the vast majority of prescription drugs are covered under the
Prescription Drug Program, some drugs, such as vitamins, birth control bills,
drugs for weight reduction, drugs prescribed for cosmetic purposes, experimental
and/or investigational drugs (or drugs that are not experimental and/or
investigational, but are used for an experimental and/or investigational
purpose), are not covered.
15.
Q. Well, l feel that l understand my coverage much better now, but if I have any
other questions, may I contact the Fund office?
A. Yes, please do, but please keep this Booklet and the Summary of Benefits
Schedule Insert handy for future reference. Incidentally, should you find it
necessary to call the Fund, it is very helpful if you can provide us with the
member's social security number, the name of the provider of service and the
date the service was performed.
Health
& We
lfare
and Pension Funds