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Home My WebLink About02-4983ELAINE M. KILLIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. : CIVIL ACTION - LAW : JURY TRIAL DEMANDED NOTICE TO: Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 YOU HAVE BEEN SUED 1N COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Notice to Defend Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (800)-990-9108 (717)-249-3166 Document #.. 243176.1 ELAINE M. KILLIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. : : CIVIL ACTION - LAW : : JURY TRIAL DEMANDED NOTICIA TO: Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siquientes paginas, debe tomar accion dentro de los proximos veinte (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion or remedio solicitado por el demandante puede ser dictado en contra suya pot la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Notice to Defend Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (800)-990-9108 (717)-249-3166 Document#:243176.1 ELAINE M. KILLIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. - : CIVIL ACTION - LAW : JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, Elaine M. Killian, by her attorneys, Metzger, Wickersham, Knauss & Erb, P.C., and complains against the Defendant Unum Life Insurance Company of America as follows: 1. The Plaintiff, Elaine M. Killian, is an adult individual residing at 430 South Fayette Street, Shippensburg, Cumberland County, Pennsylvania, 17257. 2. The Defendant is Unum Life Insurance Company of America, a corporation incorporated under the laws of the state of Maine, with an office at 2211 Congress Street, Portland, Maine, 04122, and is licensed to do business in the Commonwealth of Pennsylvania, and is engaged in the business of selling insurance in the Commonwealth of Pennsylvania and other states. 3. The Defendant sold to Lear Corporation, the employer of the Plaintiff, Group Insurance Policy, Number 551328 002, with an effective date of October 1, 2000; said insurance policy provides a long term disability plan..A copy of said insurance policy is attached hereto as Exhibit "A." 4. Pursuant to the terms of said policy, the employee is entitled to payment of long term disability (LTD) benefits when "you are limited from performing the material and Document #.. 243176.1 substantial duties of your regular occupation due to sickness or injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury." (LTD-BEN-1 [10/1/200]) 5. The Plaintiff last worked as a light machine operator on July 29, 2001. On August 1, 2001, she was seen by her fanfily physician, Rodney K. Hough, M.D., for increased fatigue, nausea, diarrhea, right heel pain, and urinary tract infection. The Plaintiff was hospitalized from August 21,2001, to August 24, 2001, rectal bleeding and diarrhea. 6. The Plaintiff continued to complain of persistent abdominal pain and was seen again in the emergency room of the Carlisle Regional Medical Center on September 1, 2001. A pelvic sonogram revealed three right ovarian cysts. 7. On October 23, 2001, the Plaintiffwas seen by Stanley C. Beachy, M.D., for evaluation of lower abdominal pain. The Plaintiff was seen again on November 19, 2001, and was still suffering from endometriosis. A diagnostic laparoscopy performed on November 19, 2001, revealed scarring from endometriosis, significant adhesions, and carcinoid tumor situated behind and attached to the appendix. The Plaintiff's appendix was removed and several aberrant cysts were discovered and removed on November 19, 2001. The Plaintiff continues to undergo treatment, including the administration of medical menopause, and, in the opinion of Rodney K. Hough, M.D., her family physician, she will continue to have abdominal pain until she has a hysterectomy and has her endometriosis surgically solved. The letter of Dr. Hough to Carol Braley, Senior Customer Care Specialist of Unum Life Insurance Company of America, dated May 20, 2002, is attached hereto as Exhibit "B." Document #: 243176.1 2 8. In the opinion of Rodney K. Hough, M.D., the Plaintiff's physician, the PlaintiWs endometriosis, carcinoid tumor, and appendicitis rendered her totally disabled. 9. On January 13, 2002, the Plaintiff injured her right knee when she tripped down steps, and on February 22, 2002, she underwent an arthroscopic chondroplasty by David C. Baker, M.D., an orthopedic surgeon. As a result of the injury, the Plaintiffhas developed degenerative arthritis of the right knee. 10. On February 27, 2002, the Defendant notified the Plaintiffthat she was approved for LTD Benefits in the amount of $1,137.29 per month. 11. Pursuant to said notice, the Plaintiff received LTD Benefits for the period from January 26, 2002, through March 25, 2002, whereupon benefits abruptly ceased. 12. By letter dated April 19, 2002, the Defendant denied the LTD claim. 13. On April 27, 2002, Plaintiff submitted a letter and additional medical information, and on May 10, 2002, she submitted a letter appealing the decision of denial. 14. By letter dated May 15, 2002, the Defendant once again denied the LTD claim. In addition, by letter dated May 28, 2002, the Defendant advised the Plaintiff that it had completed a review of the denial and had concluded that the decision of denial was appropriate. 15. The Plaintiff remains disabled from "performing the material and substantial duties" of her "regular occupation due to sickness or injury" as required by the policy. (LTD-BEN-1 [10/1/2000]) 16. The Plaintiff has performed all of the conditions of the group insurance policy (Exhibit "A") required to be performed on her part. Document#.243176.1 3 17. Despite repeated demands by the Plaintiff, the Defendant has refused to make payment of LTD Benefits. 18. Defendant has no legitimate or arguable reason to deny the claim of the Plaintiff for LTD Benefits. COUNT I Breach of Contract 19. The averments of Paragraphs 1 - 18 hereof are incorporated herein by reference. 20. Issuance by the Defendant of the policy (Exhibit "A") to the Lear Corporation created a contractual relationship between the Defendant and the Plaintiff. Defendant therefore was subject to the implied - in - law duty to act fairly and in good faith in order not to deprive the Plaintiff of the benefits of the policy. 21. Issuance by the Defendant of said policy to the Lear Corporation created a contractual relationship between the Defendant and the Plaintiff. 22. The Defendant has acted willfully, fraudulently, intentionally, and in bad faith in refusing to make payment of LTD Benefits. This was done knowingly, intentionally, and with the purpose of discouraging, avoiding, or reducing the payment due to the Plaintiff under the terms of said policy. 23. Defendant has rejected the Plaintiff's proof of disability and has produced no medical evidence disproving her disability. Document #: 243176. I 4 24. By refusing to accept the claim for LTD Benefits, the Defendant has acted in bad faith by denying benefits under said policy without any legitimate or arguable reason for refusing the claim. 25. Defendant's intentional refusal to pay the valid claim for LTD Benefits was a breach of the implied-in-law duty of good faith and fair dealing, and operated to unreasonably deprive the Plaintiff of the benefits of said policy. WHEREFORE, Plaintiff, Elaine M. Killian, requests judgment against the Defendant, Unum Life Insurance Company, for damages which exceed the limits of compulsory arbitration in Cumberland County, Pennsylvania, together with interest, cost of suit, and/or damages for delay as the law may allow. COUNT II Bad Faith 26. The averments of Paragraphs 1 - 25 hereof are incorporated inhere by reference. 27. The Plaintiff, Elaine M. Killian, has performed all of the conditions of said policy required to be performed on her part. 28. Pursuant to the terms of said policy, the Plaintiff has provided to the Defendant timely and proper proof of her long term disability. 29. Defendant breached the implied covenant of good faith and fair dealing under said policy by denying the Plaintiff's claim without a reasonable basis for such conduct. Document ii: 243176.1 5 30. Defendant's conduct has breached the implied covenant of good faith and fair dealing since Defendant has not produced any medical evidence disproving the Plaintiff's claim for LTD Benefits. WHEREFORE, Plaintiff, Elaine M. Killian, requests judgment against the Defendant, Unum Life Insurance Company, for damages which exceed the limits of compulsory arbitration in Cumberland County, Pennsylvania, together with interest, cost of suit, punitive damages, attorney's fees, and/or damages for delay as the law may allow. COUNT III Unfair Trade Practices and Consumer Protection Law 31. The averments of Paragraphs 1 - 30 hereof are incorporated herein by reference. 32. The transaction between the Plaintiff and the Lear Corporation and the Defendant as described above constitutes one under and subject to the provisions of the Unfair Trade Practices and Consumer Protection Law, 73 P.S. {}201-1, et seq. 33. By offering LTD Benefits under said policy when the Defendant knew, or should have known, that it would never accept the Plaintiff's proof of disability, the Defendant acted in a fraudulent manner, creating a likelihood of confusion or misunderstanding. 34. The Plaintiffhas sustained loss as a result of the Defendant's use of methods, acts, or practices declared unlawful under said statute by engaging in fraudulent conduct which creates a likelihood of confusion or of misunderstanding. Document #: 2431761 6 35. Defendant's conduct was in violation of the Unfair Trade Practices and Consumer Protection Law and was willful for which the Plaintiff seeks damages and such additional relief provided by such said statute or as the Court deems necessary and proper. WHEREFORE, Plaintiff, Elaine M. Killian, requests judgment against the Defendam, Unum Life Insurance Company, for damages which exceed the limits of compulsory arbitration in Cumberland County, Pennsylvania, and treble damages, costs, imerest, and/or damages for delay as the law may allow. Date: October I 0 ,2002 Respectfully submitted, METZGER, WICKERSHAM, KNAUSS & ERB, P.C. 1, Esquire · No. 01616 3211 North From Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiff Elaine ~ Killian Document #' 243176 1 7 Exhibit A UNUM. GROUP INSURANCE POLICY NON-PARTICIPATING POLICYHOLDER: Lear Corporation POLICY NUMBER: 551328 002 POLICY EFFECTIVE DATE: October 1, 2000 POLICY ANNIVERSARY DATE: January I GOVERNING JURISDICTION: Michigan Unum Life Insurance Company of America (referred to as Unum) will provide benefits under this policy. Unum makes this promise subject to all of this policy's provisions. The policyholder should read this policy carefully and contact Unum promptly with any questions. This policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. This policy consists of: all policy provisions and any amendments and/or attachments issued; employees' signed applications; and the certificate of coverage. This policy may be changed in whole or in part. Only an officer or a registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it. Signed for Unum at Portland, Maine on the Policy Effective Date. President Secretary Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 Copyright 1993, Unum Life Insurance Company of America C.FP-1 C.FP-1 (10/1/2000) TABLE OF CONTENTS BENEFITS AT A GLANCE ......................................................................................... B@G-LTD-1 LONG TERM DISABILITY PLAN ................................................................................ B@G-LTD-1 CLAIM INFORMATION ............................................................................................... LTD-CLM-1 LONG TERM DISABILITY .......................................................................................... LTD-CLM-1 POLICYHOLDER PROVISIONS ................................................................................. EMPLOYER-1 CERTIFICATE SECTION ........................................................................................... CC.FP-1 GENERAL PROVISIONS ........................................................................................... EMPLOYEE-1 LONG TERM DISABILITY .......................................................................................... LTD-BEN-1 BENEFIT INFORMATION ........................................................................................... LTD-BEN-1 OTHER BENEFIT FEATURES ................................................................................... LTD-OTR-1 OTHER SERVICES .................................................................................................... SERVICES-1 ERISA ........................................................................................................................ ERISA-1 GLOSSARY ............................................................................................................... GLOSSARY-1 TOC-1 (10/1/2000) BENEFITS AT A GLANCE LONG TERM DISABILITY PLAN This long term disability plan provides financial protection for you by paying a portion of your income while you are disabled. The amount you receive is based on the amount you earned before your disability began. In some cases, you can receive disability payments even if you work while you are disabled. EMPLOYER'S ORIGINAL PLAN EFFECTIVE DATE: October 1, 2000 POLICY NUMBER: 551328 002 ELIGIBLE GROUP(S): All Full-time Hourly Bargaining Employees of Lear Corporation, Carlisle, PA in active employment in the United States with the Employer MINIMUM HOURS REQUIREMENT: Employees must be working at least 40 hours per per year on a regularly scheduled basis. WAITING PERIOD: Members of UNITEt Union For employees in an eligible group on or before October 1, 2000:30 days of continuous active employment For employees entering an eligible group after October 1, 2000:30 days of continuous active employment Members of IUOE For employees in an eligible group on or before October 1, 2000:45 days of continuous active employment For employees entering an eligible group after October 1, 2000:45 days of continuous active employment REHIRE: If your employment ends andyou are rehired within 12 months your previous work while in an eligible group will apply towardthe waiting period. All other policy provisions apply. CREDIT PRIOR SERVICE-' Unum will apply any prior pedod of work with your Employer toward the waiting period to determine your eligibility date. WHO PAYS FOR THE COVERAGE: Your Employer pays the cost of your coverage. ELIMINATION PERIOD: 180 days Accumulation Period: 360 days Benefits begin the day after the elimination perlnd is completed. B@G-LTD-1 (10/1/2000) MONTHLY BENEFIT: 50% of monthly earnings to a maximum benefit of $3,000 per month. Your payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be covered or may have limited coverage under this plan. MAXIMUM PERIOD OF PAYMENT: Aae at Disability Maximum Period of Payment Less than age 60 To age 65, but not less than 5 years Age 60 60 months Age 61 48 months Age 62 42 months Age 63 36 months Age 64 30 months Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 and over 12 months No premium payments are required for your coverage while you are receiving payments under this plan. REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFIT: 10% of your gross disability payment to a maximum benefit of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while: - you are participating in the Rehabilitation and Return to Work Assistance program; and - you are not able to find employment. CHILD CARE EXPENSE BENEFIT: While you are pa~cipating in Unum's Rehabilitation and Return to Work Assistance program, you may receive payments to cover certain child care expenses limited to the following amounts: Child Care Expense Benefit Amount: $250 per month, per child Child Care Expense Maximum Benefit Amount: $1,000 per month for all eligible child care expenses combined TOTAL BENEFIT CAP: The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. OTHER FEATURES: Continuity of Coverage Minimum Benefit Pre-Existing: 3/12 Survivor Benefit Work Life Assistance Program The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section. B@G-LTD-2 (10/1/2000) CLAIM INFORMATION LONG TERM DISABILITY WHEN DO YOU NOTIFY UNUM OF A CLAIM? We encourage you to notify us of your claim as soon as possible, so that a claim decision can be made in a timely manner. Written notice of a claim should be sent within 30 days after the date your disability begins. However, you must send Unum written proof of your claim no later than 90 days after your elimination period. If it is not possible to give proof within 90 days, it must be given no later than 1 year after the time proof is otherwise required except in the absence of legal capacity. The claim form is available from your Employer, or you can request a claim form from us. If you do not receive the form from Unum within 15 days of your request, send Unum written proof of claim without waiting for the form. You must notify us immediately when you retum to work in any capacity. HOW DO YOU FILE A CLAIM? You and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum. WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM? Your proof of claim, provided at your expense, must show: - that you are under the regular care of a physician; - the appropriate documentation of your monthly earnings; - the date your disability began; - the cause of your disability; - the extent of your disability, including restrictions and limitations preventing you from performing your regular occupation; and - the name and address of any hospital or institution where you received treatment, including all attending physicians. We may request that you send proof of continuing disability indicating that you are under the regular care of a physician. This proof, provided at your expense, must be received within 45 days of a request by us. In some cases, you will be required to give Unum authorization to obtain additional medical information and to provide non-medical information as part of your proof of claim, or proof of continuing disability. Unum will deny your claim, or stop sending you payments, if the appropriate information is not submitted. TO WHOM WILL UNUM MAKE PA YMENTS? Unum will make payments to you. LTD-CLM-1 (10/1/2000) WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM? Unum has the right to recover any overpayments due to: - fraud; - any error Unum makes in processing a claim; and - your receipt of deductible sources of income. You must reimburse us in full. We will determine the method by which the repayment is to be made. Unum will not recover more money than the amount we paid you. LTD-CLM-2 (10/1/2000) POLICYHOLDER PROVISIONS WHAT IS THE COST OF THIS INSURANCE? LONG TERM DISABILITY The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s). WAIVER OF PREMIUM Unum does not require premium payments for an insured while he or she is receiving Long Term Disability payments under this plan. INITIAL RATE GUARANTEE AND RATE CHANGES Refer to the Rate Information Amendment(s). WHEN IS PREMIUM DUE FOR THIS POLICY? Premium Due Dates: Premium due dates are based on the Premium Due Dates shown in the Rate Information Amendment(s). The Policyholder must send all premiums to Unum on or before their respective due date. The premium must be paid in United States dollars. WHEN ARE INCREASES OR DECREASES IN PREMIUM DUE? Premium increases or decreases which take effect during a policy month are adjusted and due on the next premium due date following the change. Changes will not be pre-rated daily. If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pre-rated adjustment on the next premium due date. Unum will only adjust premium for the current policy year and the prior policy year. In the case of fraud, premium adjustments will be made for all policy years. WHAT INFORMATION DOES UNUM REQUIRE FROM THE POLICYHOLDER? The Policyholder must previde Unum with the following on a regular basis: - information about employees: · who are eligible to become insured; · whose amounts of coverage change; and/or · whose coverage ends; - occupational information and any other information that may be required to manage a claim; and - any other information that may be reasonably required. Policyholder records that, in Unum's opinion, have a beadng on this policy will be available for review by Unum at any reasonable time. EMPLOYER-1 (10/1/2000) Clerical error or omission by Unum will not: - prevent an employee from receiving coverage; - affect the amount of an insured's coverage; or - cause an employee's coverage to begin or continue when the coverage would not otherwise be effective. WHO CAN CANCEL OR MODIFY THIS POLICY OR A PLAN UNDER THIS POLICY? This policy or a plan under this policy can be cancelled: - by Unum; or - by the Policyholder. Unum may cancel or modify this policy or a plan if: - there is less than 75% participation of those eligible employees who pay all or part of their premium for a plan; or - there is less than 100% participation of those eligible employees for a Policyholder paid plan; - the Policyholder does not promptly provide Unum with information that is reasonably required; - the Policyholder fails to pedorm any of its obligations that relate to this policy; - fewer than 10 employees are insured under a plan; - the premium is not paid in accordance with the provisions of this policy that specify whether the Policyholder, the employee, or both, pay(s) the premiums; - the Policyholder does not promptly report to Unum the names of any employees who are added or deleted from the eligible group; - Unum determines that there is a significant change, in the size, occupation or age of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its employees; or - the Policyholder fails to pay any portion of the premium within the 31 day grace period. If Unum cancels or modifies this policy or a plan for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date or modification date. The Policyholder may cancel this policy or a plan if the modifications are unacceptable. If any portion of the premium is not paid during the grace period, Unum will either cancel or modify the policy or plan automatically at the end of the grace period. The Policyholder is liable for premium for coverage during the grace period. The Policyholder must pay Unum all premium due for the full pedod each plan is in force. The Policyholder may cancel this policy or a plan by written notice delivered to Unum at least 31 days prior to the cancellation date. When both the Policyholder and Unum agree, this policy or a plan can be cancelled on an earlier date. If Unum or the Policyholder cancels this policy or a plan, coverage will end at 12:00 midnight on the last day of coverage. If this policy or a plan is cancelled, the cancellation will not affect a payable claim. EMPLOYER-2 (10/1/2000) WHAT HAPPENS TO AN EMPLOYEE'S COVERAGE UNDER THIS POLICY WHILE HE OR SHE IS ON A FAMILY AND MEDICAL LEA VE OF ABSENCE? We will continue the employee's coverage in accordance with the policyholder's Human Resource policy on family and medical leaves of absence if premium payments continue and the policyholder approved the employee's leave in writing. Coverage will be continued until the end of the later of: 1. the leave period required by the federal Family and Medical Leave of Absence Act of 1993 and any amendments; or 2. the leave period required by applicable state law. If the policyholder's Human Resource policy doesn't provide for continuation of an employee's coverage during a family and medical leave of absence, the employee's coverage will be reinstated when he or she returns to active employment. We will not: - apply a new waiting period; - apply a new pro-existing conditions exclusion; or - require evidence of insurability. DIVISIONS, SUBSIDIARIES OR AFFILIA TED COMPANIES INCLUDE: NAME/LOCATION (CITY AND STATE) Lear Corporation Carlisle, Pennsylvania EMPLOYER-3 (10/1/2000) CERTIFICATE SECTION Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client. This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in asafe place. Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any .questions about any of the terms and provisions, please consult Unum's claims paying office. Unum will assist you in any way to help you understand your benefits. If the terms and provisions of the certificate of coverage (issued to you) are different from the policy (issued to the policyholder), the policy will govern. Your coverage may be cancelled or changed in whole or in part under the terms and provisions of the policy. The policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. When making a benefit determination under the policy, Unum has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy. For purposes of effective dates and ending dates under the group policy, all days begin at 12:01 a.m. and end at 12:00 midnight at the Policyholder's address. Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 CC.FP-1 (10/1/2000) GENERALPROVISIONS WHAT IS THE CERTIFICATE OF COVERAGE? This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you: - the coverage for which you may be entitled; - to whom Unum will make a payment; and - the limitations, exclusions and requirements that apply within a plan. WHEN ARE YOU ELIGIBLE FOR COVERAGE? If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of: - the plan effective date; or - the day after you complete your waiting period. WHEN DOES YOUR COVERAGE BEGIN? When your Employer pays 100% of the cost of your coverage under a plan, you will be covered at 12:01 a.m. on the date you are eligible for coverage. When you and your Employer share the cost of your coverage under a plan or when you pay 100% of the cost yourself, you will be covered at 12:01 a.m. on the latest of: - the date you are eligible for coverage, if you apply for insurance on or before that date; - the date you apply for insurance, if you apply within 31 days after your eligibility date; or - the date Unum approves your application, if evidence of insurability !s required. Evidence of insurability is required if you: - are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or - voluntarily cancelled your coverage and are reapplying. An evidence of insurability form can be obtained from your Employer. WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN? If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will begin on the date you return to active employment. ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING? If you are on a temporary layoff, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your temporary layoff begins. EMPLOYEE-1 (10/1/2000) If you are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins. WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT? Once your coverage begins, any increased or additional coverage will take effect immediately if you are in active employment or if you are on a covered layoff or leave of absence. If you are not in active employment due to injury or sickness, any increased or additional coverage will begin on the date you return to active employment. Any decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior to the decrease. WHEN DOES YOUR COVERAGE END? Your coverage under the policy or a plan ends on the earliest of: - the date the policy or a plan is cancelled; - the date you no longer are in an eligible group; - the date your eligible group is no longer covered; - the last day of the period for which you made any required contributions; or - the last day you are in active employment except as provided under the covered layoff or leave of absence provision. Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan. WHA T ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS? You can start legal action regarding your claim 60 days after proof of claim has been given and up to 3 years from the time proof of claim is required, unless otherwise provided under federal law. HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED? Unum considers any statements you or your Employer make in a signed application for coverage a representation and not a warranty. If any of the statements you or your Employer make are not complete and/or not true at the time they are made, we can: - reduce or deny any claim; or - cancel your coverage from the odginal effective date. We will use only statements made in a signed application as a basis for doing this. If the Employer gives us information about you that is incorrect, we will: - use the facts to decide whether you have coverage un.der the plan and in what amounts; and - make a fair adjustment of the premium. EMPLOYEE-2 (10/1/2000) HOW WILL UNUM HANDLE INSURANCE FRAUD? Unum wants to ensure you and your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution. It is a crime if you knowingly, and with intent to injure, defraud or deceive Unum, or provide any information, including filing a claim, that contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. Unum will pursue all appropriate legal remedies in the event of insurance fraud. DOES THE POLICY REPLACE OR AFFECT ANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE? The policy does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance. DOES YOUR EMPLOYER ACT AS YOUR AGENT OR UNUM'S AGENT? For purposes of the policy, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deemed the agent of Unum. EMPLOYEE-3 (10/1/2000) LONG TERM DISABILITY BENEFIT INFORMATION HOW DOES UNUM DEFINE DISABILITY? You are disabled when Unum determines that: - you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury~ After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. The loss of a professional or occupational license or certification does not, in itself, constitute disability. We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. We can require an examination as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Unum Representative. HOW LONG MUST YOU BE DISABLED BEFORE YOU ARE ELIGIBLE TO RECEIVE BENEFITS? You must be continuously disabled through your elimination period. The days that you are not disabled will not count toward your elimination period. Your elimination pedod is 180 days. In addition, if you retum to work while satisfying your elimination period, and are no longer disabled, you may satisfy your elimination pedod within the accumulation period. You do not need to be continuously disabled through your elimination period if you are satisfying your elimination period under this provision. If you do not satisfy the elimination period within the accumulation period, a new period of disability will begin. Your accumulation pedod is 360 days. CAN YOU SATISFY YOUR ELIMINATION PERIOD IF YOU ARE WORKING? Yes. If you are working while you are disabled, the days you are disabled will count toward your elimination period. WHEN WILL YOU BEGIN TO RECEIVE PA YMENTS? You will begin to receive payments when we approve your claim, providing the elimination period has been met. We will send you a payment monthly for any period for which Unum is liable. LTD-BEN-1 (10/1/2000) HOW MUCH WILL UNUM PAY YOU IF YOU ARE DISABLED? We will follow this process to figure your payment: 1. Multiply your monthly eamings by 50%. 2. The maximum monthly benefit is $3,000. 3. Compare the answer from Item I with the maximum monthly benefit. The lesser of these two amounts is your gross disability payment. 4. Subtract from your gross disability payment any deductible sources of income. The amount figured in Item 4 is your monthly payment. WILL UNUM EVER PA Y MORE THAN 100% OF MONTHLY EARNINGS? The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. WHAT ARE YOUR MONTHLY EARNINGS? "Monthly Earnings" means your gross monthly income from your Employer in effect just prior to your date of disability. It includes your total income before taxes, but does not include deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from commissions, bonuses, overtime pay, any other extra compensation, or include income received from sources other than your Employer. WHAT WILL WE USE FOR MONTHLY EARNINGS IF YOU BECOME DISABLED DURING A COVERED LA YOFF OR LEAVE OF ABSENCE? If you become disabled while you are on a covered layoff or leave of absence, we will use your monthly earnings from your Employer in effect just prior to the date your absence begins. HOW MUCH WILL UNUM PA Y YOU IF YOU ARE DISABLED AND WORKING? We will send you the monthly payment if you are disabled and your monthly disability earnings, if any, are less than 20% of your indexed monthly earnings, due to the same sickness or injury. If you are disabled and your monthly disability earnings are 20% or more of your indexed monthly earnings, due to the same sickness or injury, Unum will figure your payment as follows: During the first 12 months of payments, while working, your monthly payment will not be reduced as long as disability eamings plus the gross disability payment does not exceed 100% of indexed monthly earnings. 1. Add your monthly disability earnings to your gross disability payment. 2. Compare the answer in Item 1 to your indexed monthly earnings. If the answer from Item 1 is less than or equal to 100% of your indexed monthly earnings, Unum will not further reduce your monthly payment. LTD-BEN-2 (10/1/2000) If the answer from Item 1 is more than 100% of your indexed monthly earnings, Unum will subtract the amount over 100% from your monthly payment. After 12 months of payments, while working, you will receive payments based on the pementage of income you are losing due to your disability. 1. Subtract your disability earnings from your indexed monthly earnings. 2. Divide the answer in Item 1 by your indexed monthly earnings. This is your pementage of lost earnings. 3. Multiply your monthly payment by the answer in Item 2. This is the amount Unum will pay you each month. During the first 24 months of disability payments, if your monthly disability earnings exceed 80% of your indexed monthly earnings, Unum will stop sending you payments and your claim will end. Beyond 24 months of disability payments, if your monthly disability earnings exceed the gross disability payment, Unum will stop sending you payments and your claim will end. Unum may require you to send proof of your monthly disability earnings at least quarterly. We will adjust your payment based on your quarterly disability earnings. As part of your proof of disability earnings, we can require that you send us appropriate financial records which we believe are necessary to substantiate your income. After the elimination period, if you are disabled for less than I month, we will send you 1/30 of your payment for each day of disability. HOW CAN WE PROTECT YOU IF YOUR DISABILITY EARNINGS FLUCTUATE? If your disability earnings routinely fluctuate widely from month to month, Unum may average your disability earnings over the most recent 3 months to determine if your claim should continue. If Unum averages your disability earnings, we will not terminate your claim unless: - During the first 24 months of disability payments, the average of your disability earnings from the last 3 months exceeds 80% of indexed monthly earnings; or - Beyond 24 months of disability payments, the average of your disability earnings from the last 3 months exceeds the gross disability payment. We will not pay you for any month during which disability earnings exceed the amount allowable under the plan. WHAT ARE DEDUCTIBLE SOURCES OF INCOME? Unum will subtract from your gross disability payment the following deductible sources of income: 1) The amount that you receive or are entitled to receive under: LTD-BEN-3 (10/1/2000) - a workers' compensation law. - an occupational disease law. - any other act or law with similar intent. 2) The amount that you receive or are entitled to receive as disability income payments under any: - state compulsory benefit act or law. - automobile liability insurance policy. - other group insurance plan. - governmental retirement system as a result of your job with your Employer. 3) The amount that you, your spouse and your children receive or are entitled to receive as disability payments because of your disability under: - the United States Social Security Act. - the Canada Pension Plan. - the Quebec Pension Plan. - any similar plan or act. 4) The amount that you receive as retirement payments or the amount your spouse and children receive as retirement payments because you are receiving retirement payments under: - the United States Social Security Act. - the Canada Pension Plan. - the Quebec Pension Plan. - any similar plan or act. 5) The amount that you: - receive as disability payments under your Employer's retirement plan. - voluntarily elect to receive as retirement payments under your Employer's retirement plan. - receive as retirement payments when you reach the later of age 62 or normal retirement age, as defined in your Employer's retirement plan. Disability payments under a retirement plan will be those benefits which are paid due to disability and do not reduce the retirement benefit which would have been paid if the disability had not occurred. Retirement payments will be those benefits which are based on your Employer's contribution to the retirement plan. Disability benefits which reduce the retirement benefit under the plan will also be considered as a retirement benefit. Regardless of how the retirement funds from the retirement plan are distributed, Unum will consider your and your Employer's contributions to be distributed simultaneously throughout your lifetime. Amounts received do not include amounts rolled over or transferred to any eligible retirement plan. Unum will use the definition of eligible retirement plan as defined in Section 402 of the Internal Revenue Code including any future amendments which affect the definition. LTD-BEN-4 (10/1/2000) 6) 50% of the amount you receive under Title 46, United States Code Section 688 (The Jones Act). 7) The amount that you receive from a third party (after subtracting attorney's fees) by judgment, settlement or otherwise. With the exception of retirement payments, Unum will only subtract deductible sources of income which are payable as a result of the same disability. We will not reduce your payment by your Social Security retirement income if your disability begins after age 65 and you were already receiving Social Secudty retirement payments. WHAT ARE NOT DEDUCTIBLE SOURCES OF INCOME? Unum will not subtract from your gross disability payment income you receive from, but not limited to, the following: - 401(k) plans - profit sharing plans - thrift plans - tax sheltered annuities - stock ownership plans - non-qualified plans of deferred compensation - pension plans for partners - military pension and disability income plans - credit disability insurance - franchise disability income plans - a retirement plan from another Employer - individual retirement accounts (IRA) - individual disability income plans - salary continuation or accumulated sick leave plans WHAT IF SUBTRACTING DEDUCTIBLE SOURCES OF INCOME RESUL TS IN A ZERO BENEFIT? (Minimum Benefit) The minimum monthly payment is the greater of: - $50; or - 10% of your gross disability payment. Unum may apply this amount toward an outstanding overpayment. WHAT HAPPENS WHEN YOU RECEIVE A COST OF LIVING INCREASE FROM DEDUCTIBLE SOURCES OF INCOME? Once Unum has subtracted any deductible source of income from your gross disability payment, Unum will not further reduce your payment due to a cost of living increase from that source. LTD-BEN-5 (10/1/2000) WHAT IF UNUM DETERMINES YOU MA Y QUALIFY FOR DEDUCTIBLE INCOME BENEFITS? When we determine that you may qualify for benefits under Item(s) 1), 2) and 3) in the deductible sources of income section, we wilt estimate your entitlement to these benefits. We can reduce your payment by the estimated amounts if such benefits: - have not been awarded; and - have not been denied; or - have been denied and the denial is being appealed. Your Long Term Disability payment will NOT be reduced by the estimated amount if you: - apply for the disability payments under Item(s) 1 ), 2) and 3) in the deductible sources of income section and appeal your denial to all administrative levels Unum feels are necessary; and - sign Unum's payment option form. This form states that you promise to pay us any overpayment caused by an award. If your payment has been reduced by an estimated amount, your payment will be adjusted when we receive proof: - of the amount awarded; or - that benefits have been denied and all appeals Unum feels are necessary have been completed. In this case, a lump sum refund of the estimated amount will be made to you. If you receive a lump sum payment from any deductible sources of income, the lump sum will be pro-rated on a monthly basis over the time period for which the sum was given. If no time period is stated, we will use a reasonable one. HOW LONG WILL UNUM CONTINUE TO SEND YOU PA YMENTS? Unum will send you a payment each month up to the maximum period of payment. Your maximum period of payment is based on your age at disability as follows: Aqe at Disability Maximum Period of Payment Less than age 60 To age 65, Age 60 60 months Age 61 48 months Age 62 42 months Age 63 36 months Age 64 30 months Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 and over 12 months but not less than 5 years LTD-BEN-6 (10/1/2000) WHEN WILL PA YMENTS STOP? We will stop sending you payments and your claim will end on the earliest of the following: - during the first 24 months of payments, when you are able to work in your regular occupation on a part-time basis but you choose not to; - after 24 months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to; - the end of the maximum period of payment; - the date you are no longer disabled under the terms of the plan, unless you are eligible to receive benefits under Unum's Rehabilitation and Return to Work Assistance program; - the date you fail to cooperate or participate in Unum's Rehabilitation and Return to Work Assistance program; - the date you fail to submit proof of continuing disability; - after 12 months of payments if you are considered to reside outside the United States or Canada. You will be considered to reside outside these countries when you have been outside the United States or Canada for a total period of 6 months or more during any 12 consecutive months of benefits; - the date your disability earnings exceed the amount allowable under the plan; - the date you die. WHAT DISABILITIES HA VE A LIMITED PA Y PERIOD UNDER YOUR PLAN? Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness have a limited'pay period up to 24 months. Unum will continue to send you payments beyond the 24 month period if you meet one or both of these conditions: 1. If you are confined to a hospital or institution at the end of the 24 month period, Unum will continue to send you payments during your confinement. If you are still disabled when you are discharged, Unum'will send you payments for a recovery period of up to 90 days. If you become reconfined at any time during the recovery period and remain confined for at least 14 days in a row, Unum will send payments during that additional confinement and for one additional recovery pedod up to 90 more days. In addition to Item 1, if, after the 24 month period for which you have received payments, you continue to be disabled and subsequently become confined to a hospital or institution for at least 14 days in a row, Unum will send payments during the length of the reconfinement. Unum will not pay beyond the limited pay period as indicated above, or the maximum period of payment, whichever occurs first. Unum will not apply the mental illness limitation to dementia if it is a result of: - stroke; LTD-BEN-7 (10/1/2000) - trauma; - viral infection; - Alzheimer's disease; or - other conditions not listed which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment. WHAT DISABILITIES ARE NOT COVERED UNDER YOUR PLAN? Your plan does not cover any disabilities caused by, contributed to by, or resulting from your: - intentionally self-inflicted injuries. - active participation in a riot. - loss of a professional license, occupational license or certification. - commission of a crime for which you have been convicted under state or federal law. - pre-existing condition. Your plan will not cover a disability due to war, declared or undeclared, or any act of war. Unum wilt not pay a benefit for any period of disability during which you are incarcerated. WHAT IS A PRE-EXISTING CONDITION? You have a pre-existing condition if: - you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; or you had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months just prior to your effective date of coverage; and - the disability begins in the first 12 months after your effective date of coverage. WHAT HAPPENS IF YOU RETURN TO WORK FULL TIME AND YOUR DISABILITY OCCURS AGAIN? If you have a recurrent disability, Unum will treat your disability as part of your prior claim and you will not have to complete another elimination period if: - you were continuously insured under the plan for the period between your prior claim and your recurrent disability; and - your recurrent disability occurs within 6 months of the end of your prior claim. Your recurrent disability will be subject to the same terms of this plan as your prior claim. Any disability which occurs after 6 months from the date your prior claim ended will be treated as a new claim. The new claim will be subject to all of the policy provisions. LTD-BEN-8 (10/1/2000) If you become entitled to payments under any other group long term disability plan, you will not be eligible for payments under the Unum plan. LTD-BEN-9 (1011/2000) LONG TERM DISABILITY OTHER BENEFIT FEATURES WHAT BENEFITS WILL BE PROVIDED TO YOUR FAMILY IF YOU DIE? (Survivor Benefit) When Unum receives proof that you have died, we will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment if, on the date of your death: - your disability had continued for 180 or moro consecutive days; and - you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. in this case, no payment will be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim. WHAT IF YOU ARE NOT IN ACTIVE EMPLOYMENT WHEN YOUR EMPLOYER CHANGES INSURANCE CARRIERS TO UNUM ? (Continuity of Coverage) When the plan becomes effective, Unum will provide coverage for you if: - you are not in active employment because of a sickness or injury; and you were covered by the prior policy. Your coverage is subject to payment of premium. Your payment will be limited to the amount that would have been paid by.the prior carrier. Unum will reduce your payment by any amount for which your pnor carrier is liable. WHAT IF YOU HA VE A DISABILITY DUE TO A PRE-EXISTING CONDITION WHEN YOUR EMPLOYER CHANGES INSORANCE CARRIERS TO UNUM? (Continuity of Coverage) Unum may send a payment if your disability results from a pro-existing condition if, you were: - in active employment and insured under the plan on its effective date; and - insured by the prior policy at the time of change. In order to receive a payment you must satisfy the pre-existing condition provision under: 1. the Unum plan; or 2. the pdor carrier's plan, if benefits would have been paid had that policy remained in force. If you do not satisfy Item 1 or 2 above, Unum will not make any payments. LTD-OTR-1 (10/1/2000) If you satisfy Item 1, we will determine your payments according to the Unum plan provisions. If you only satisfy Item 2, we will administer your claim according to the Unum plan provisions. However, your payment will be the lesser of: a. the monthly benefit that would have been payable under the terms of the prior plan if it had remained infome; or b. the monthly payment under the Unum plan. Your benefits will end on the earlier of the following dates: 1. the end of the maximum benefit period under the plan; or 2. the date benefits would have ended under the prior plan if it had remained in force. HOW CAN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM HELP YOU RETURN TO WORK? Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will determine whether you are eligible for this program, at our sole discretion. In order to be eligible for rehabilitation services and benefits, you must be medically able to engage in a return to work program. Your claim file will be reviewed by one of Unum's rehabilitation professionals to determine if a rehabilitation program might help you return to gainful employment. As your file is reviewed, medical and vocational information will be analyzed to determine an appropriate return to work program. If we determine you are eligible to participate in a Rehabilitation and Return to Work Assistance program, you must participate in order to receive disability benefits. We will make the final determination of your eligibility for participation in the program. We will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. You must comply with the terms of the Rehabilitation and Retum to Work Assistance plan in order to receive disability benefits. The rehabilitation-program may include at our sole discretion, but is not limited to, the following services and benefits: - coordination with your Employer to assist you to return to work; - adaptive equipment or job accommodations to allow you to work; - vocational evaluation to determine how your disability may impact your employment options; - job placement services; - resume preparation; - job seeking skills training; or ~ education and retraining expenses for a new occupation. LTD-OTR-2 (10/1/2000) WHAT ADDITIONAL BENEFITS WILL UNUM PAY WHILE YOU PARTICIPATE IN A REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM? We will pay an additional disability benefit of 10% of your gross disability payment to a maximum benefit of $1,000 per month. This benefit is not subject to policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Inceme. However, the Total Benefit Cap will apply. In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while: - you are participating in the Rehabilitation and Return to Work Assistance program; and - you are not able to find employment. This benefit payment may be paid in a lump sum. WHEN WILL REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFITS END? Benefit payments will end on the earliest of the following dates: - the date Unum determines that you are no longer eligible to participate in Unum's Rehabilitation and Return to Work Assistance program; or - any other date on which monthl,) payments would stop in accordance with this plan. WHAT ADDITIONAL BENEFIT IS AVAILABLE FOR CHILD CARE EXPENSES IF YOU ARE PARTICIPATING IN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM? When you are disabled and incurring child care expenses for your dependent child(ren) and participating continuously in Unum's Rehabilitation and Return to Work Assistance program, we will pay the Child Care Expense Benefit Amount. The payment of the Child Care Expense Benefit Amount will begin immediately after you start Unum's rehabilitation program. CHILD CARE EXPENSE BENEFIT AMOUNT Our payment of the Child Care Expense Benefit Amount will: 1. be $250 per month, per child; and 2. not exceed $1,000 per month for all eligible child care expenses combined. CHILD CARE EXPENSE BENEFIT RULES The Child Care Expense Benefit will be provided to reimburse your expenses incurred for providing care for your dependent children who are: 1. under the age of 15; or 2. incapable of providing their own care on a daily basis due to their own physical handicap or mental retardation. LTD-OTR-3 (10/1/2000) To receive this benefit, you must provide satisfactory proof that: 1. you are incurring expenses for child care while participating in Unum's rehabilitation program; and 2. payments for child care have been made to the child care provider. Child Care Expense Benefits will end on the earlier of the following: 1. the date the dependent child(ren) attain the age of 15; 2. if the dependent child(ren) are mentally retarded or physically handicapped, the date they are no longer: a. incapacitated; or b. requiring daily care; 3. the date a charge is no longer made by the child care provider; 4. the date you no longer participate in Unum's rehabilitation program; or 5. any other date payments would stop in accordance with this plan. LTD-OTR-4 (10/1/2000) OTHER SERVICES These services are also available from us as part of your Unum Long Term Disability plan. IS THERE A WORK LIFE ASSISTANCE PROGRAM A VAIl_ABLE WITH THE PLAN? We do provide you and your dependents access to a work life assistance program designed to assist you with problems of daily living. You can call and request assistance for virtually any personal or professional issue, from helping find a day care or transportation for an elderly parent, to reseamhing possible colleges for a child, to helping to deal with the stress of the workplace. This work life program is available for everyday issues as well as crisis support. This service is also available to your Employer. This program can be accessed by a 1-800 telephone number available 24 hours a day, 7 days a week or online through a website. Information about this program can be obtained through your plan administrator. HOW CAN UNUM HELP YOUR EMPLOYER IDENTIFY AND PROVIDE WORKSlTE MODIFICATION? A worksite modification might be what is needed to allow you to perform the material and su§stantial duties of your regular occupation with your Employer. One of our designated professionals will assist you and your Employer to identify a modification we agree is likely to help you remain at work or return to work. This agreement will be in writing and must be signed by you, your Employer and Unum. When this occurs, Unum will reimburse your Employer for the cost of the modification, up to the greater of: - $1,000; or - the equivalent of 2 months of your monthly benefit. This benefit is available to you on a one time only basis. HOW CAN UNUM'S SOCIAL SECURITY CLAIMANT ADVOCACY PROGRAM ASSIST YOU WITH OBTAINING SOCIAL SECURITY DISABILITY BENEFITS? In order to be eligible for assistance from Unum's Social Security claimant advocacy program, you must be receiving monthly payments from us. Unum can provide expert advice regarding your claim and assist you with your application or appeal. Receiving Social Security benefits may enable: - you to receive Medicare after 24 months of disability payments; - you to protect your retirement benefits; and - your family to be eligible for Social Security benefits. We can assist you in obtaining Social Security disability benefits by: SERVICES-1 (10/1/2000) - helping you find appropriate legal representation; - obtaining medical and vocational evidence; and - reimbursing pre-approved case management expenses. SERVICES-2 (10/1/2000) ERISA Additional Summary Plan Description Information Name of Plan: Lear Corporation Name and Address of Employer: Lear Corporation 21557 Telegraph Rd. Southfield, Michigan 48034 Plan Identification Number: a. Employer IRS Identification #: 13-3386776 b. Plan #: 522 Type of Welfare Plan: Disability Type of Administration: The Plan is administered by the Plan Administrator. Benefits are administered by the insurer and provided in accordance with the insurance policy issued to the Plan. ERISA Plan Year Ends: December 31 Plan Administrator, Name, Address, and Telephone Number: Lear Corporation 21557 Telegraph Rd. Southfield, Michigan 48034 (248) 447-1500 Lear Corporation is the Plan Administrator and named fiduciary of the Plan, with aUthor ty to de agate its duties. The Plan Administrator may designate Trustees of the Plan, in which case the Administrator will advise you separately of the name; title and address of each Trustee. Agent for Service ~of Legal Process on the Plan: Lear Corporation 21557 Telegraph Rd. Southfield, Michigan 48034 Service of legal process may also be made upon the plan Administrator, and any Trustee of the Plan. ERISA-1 (10/1/2000) Funding and Contributions: The Plan is funded as an insured plan under policy number 551328 002, issued by Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122. Contributions to the Plan are made as stated under "WHO PAYS FOR THE COVERAGE" in the Certificate of Coverage. EMPLOYER'S RIGHT TO AMEND THE PLAN The Emp oyer reserves the right in its sole and absolute discretion, to amend, modify, or terminate, in whole or in part, any or all of the provis ons of this Plan (including any related documents and underlying policies), at any time and for any reason or no reason. Any amendment, modification, or termination must be in writing and endorsed on or attached to the Plan. EMPLOYER'S RIGHT TO REQUEST POLICY CHANGE The Employer can request a policy change. Only an officer or registrar of Unum can approve a change. The change must be in writing and endorsed on or attached to the policy. MODIFYING OR CANCELLING THE POLICY OR A PLAN UNDER THE POLICY The policy or a plan under the policy can be cancelled: - by Unum; or - by the Policyholder. Unum may cancel or modify the policy or a plan if: - there is less than 75% participation of those eligible employees who pay all or part of their premium for a plan; or - there is less than 100% participation of those eligible employees for a Policyholder paid plan; - the Policyholder does not promptly provide Unum with information that is reasonably required; - the Policyholder fails to perform any of its obligations that relate to the policy; - fewer than 10 employees are insured under a plan; - the premium is not paid in accordance with the provisions of this policy that specify whether the Policyholder, the employee, or both, pay(s) the premiums; - the Policyholder does not promptly report to Unum the names of any employees who are added or deleted from the eligible group; - Unum determines that there is a significant change, in the size, occupation or age of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its employees; or - the Policyholder fails to pay any portion of the premium within the 31 day grace period. If Unum cancels or modifies the policy or a plan for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date or modification date. The Policyholder may cancel this policy or a plan if the modifications are unacceptable. ERISA-2 (10/1/2000) If any portion of the premium is not paid during the grace period, Unum will either cancel or modify the policy or.plan automatically at the end of the grace period. The Policyholder is liable for premium for coverage during the grace period. The Policyholder must pay Unum all premium due for the full period each plan is in fome. The Policyholder may cancel the policy or a plan by written notice delivered to Unum at least 31 days prior to the cancellation date. When both the Policyholder and Unum agree, the policy or a plan can be cancelled on an earlier date. If Unum or the Policyholder cancels the policy or a plan, coverage will end at 12:00 midnight on the last day of coverage. If the policy or a plan is cancelled, the cancellation will not affect a payable claim. CLAIMS PROCEDURES Unum will give you notice of the decision no later than 45 days after the claim is filed. This time period may be extended twice by 30 days if Unum both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you of the circumstances requiring the extension of time and the date by which Unum expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information. If you deliver the requested information within the time specified, any 30 day extension periOd will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your ctaim without that information. If your claim for benefits is wholly or partially denied, the notice of adverse benefit determination under the Plan will: - state the specific reason(s) for the determination; - reference specific Plan provision(s) on which the determination is based; - describe additional material or information necessary to complete the claim and why such information is necessary; - describe Plan procedures and time limits for appealing the determination, and your right to obtain information about those procedures and the right to sue in federal court; and - disclose any intemal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request). Notice of the determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements. ERISA-3 (10/1/2000) APPEAL PROCEDURES You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made not later than 45 days following receipt of the written request for review. If Unum determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Unum will notify you in writing if an additional 45 day extension is needed. If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information. You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the adverse benefit determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. The review will be conducted by Unum and will be made by a person different from the person who made the initial determination and such person will not be the original decision maker's subordinate. In the case of a claim denied on the grounds of a medical judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Unum will provide you with the names of each such expert, regardless of whether the advice was relied upon. A notice that your request on appeal is denied will contain the following information: - the specific reason(s) for the determination; a reference to the specific Plan provision(s) on which the determination is based; a statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request); - a statement describing your right to bring a civil suit under federal law; - the statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, recOrds or other information relevant to the determination; and - the statement that "You or your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available ERISA-4 (10/1/2000) is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency". Notice of the determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements. Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim. YOUR RIGHTS UNDER ERISA As a participant in this Plan 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, all documents governing the Plan, including insurance contracts, 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 Pension and Welfare Benefits Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Prudent Actions 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 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. Enfome Your Riqhts If your claim 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 enfome 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 the materials ERISA-5 (10/1/2000) 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 Plan 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. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your dghts, you may seek assistance from 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 these costs and fees, if, for example, it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the 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 Plan Administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits 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 Pension and Welfare Benefits Administration. DISCRETIONARY ACTS In exemising its discretionary powers under the Plan, the Plan Administrator, and any designee (which shall include Unum as a claims fiduciary) will have the broadest discretion permissible under ERISA and any other applicable laws, and its decisions will constitute final review of your claim by the Plan. Benefits under this Plan will be paid only if the Plan Administrator or its designee (including Unum), decides in its discretion that the applicant is entitled to them. ERISA-6 (10/1/2000) GLOSSARY ACCUMULATION PERIOD means the period of time from the date disability begins during which you must satisfy the elimination period. ACTIVE EMPLOYMENT means you are working for your Employer for earnings that are paid regu arly and that you are performing the material and substantial duties of your regular occupation. You must be working at least the m n mum number of hours as described under Eligible Group(s) in each plan. Your work site must be: - your Employer's usual place of business; an alternative work site at the direction of your Employer, including your home; or - a location to which your job requires you to travel. Normal vacation is considered active employment. Temporary and seasonal workers are excluded from coverage. DEDUCTIBLE SOURCES OF INCOME means income from deductible sources listed in the plan which you receive or are entitled to receive while you are disabled. This income will be subtracted from your gross disability payment. DISABILITY EARNINGS means the earnings which you receive while you are disabled and working, plus the earnings you could receive if you were working to your maximum capacity. ELIMINATION PERIOD means a period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum. EMPLOYEE means a person who is in active employment in the United States with the Employer. EMPLOYER means the Policyholder, and includes any division, subsidiary or affiliated company named in the policy. EVIDENCE OF INSURABILITY means a statement of your medical history which Unum will use to determine if you are approved for coverage. Evidence of insurability will be at Unum's expense. GAINFUL OCCUPATION means an occupation that is or can be expected to provide you with an income at least equal to your gross disability payment within 12 months of your return to work. GRACE PERIOD means the period of time following the premium due date during which premium payment may be made. GROSS DISABILITY PAYMENT means the benefit amount before Unum subtracts deductible sources of income and disability earnings. HOSPITAL OR INSTITUTION means an accredited facility licensed to provide care and treatment for the condition causing your disability. GLOSSARY-1 (10/1/2000) INDEXED MONTHLY EARNINGS means your monthly earnings adjusted on each anniversary of benefit payments by the lesser of 10% or the current annual percentage increase in the Consumer Price Index. Your indexed monthly earnings may increase or remain the same, but will never decrease. The Consumer Price Index (CPI-W) is published by the U.S. Department of Labor. Unum reserves the right to use some other similar measurement if the Department of Labor changes or stops publishing the CPI-W. Indexing is only used to determine your pementage of lost earnings while you are disabled and working. INJURY means a bodily injury that is the direct result of an accident and not related to any other cause. Disability must begin while you are covered under the plan. INSURED means any person covered under a plan. LAW, PLAN OR ACT means the original enactments of the law, plan or act and all amendments. LAYOFF or LEAVE OF ABSENCE means you are temporarily absent from active employment for a period of time that has been agreed to in advance in writing by your Employer. Your normal vacation time or any period of disability is not considered a temporary layoff or leave of absence. LIMITED means what you cannot or are unable to do. MATERIAL AND SUBSTANTIAL DUTIES means duties that: - are normally requ red for the performance of your regular occupation; and cannot be reasonably omitted or modified, except that if you are requ red to work on average in excess of 40 hours per week, Unum will consider you able to perform that requirement if you are working or have the capacity to work 40 hours per week. MAXIMUM CAPACITY means, based on your restrictions and limitations: - during the first 24 months of disability, the greatest extent of work you are able to do in your regular occupation, that is reasonably available. - beyond 24 monthS of disability, the greatest extent of work you are able to do in any occupation, that is reasonably available, for which you are reasonably fitted by education, training or experience. MAXIMUM PERIOD OF PAYMENT means the longest period of time Unum will make payments to you for any one period of disability. MENTAL ILLNESS means a psychiatric or psycho!ogical condition regardless of cause such as schizophrenia, depression, manic depressive or bipolar illness, anxiety, personality disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment. GLOSSARY-2 (10/1/2000) MONTHLY BENEFIT means the total benefit amount for which an employee is insured under this plan subject to the maximum benefit. MONTHLY EARNINGS means your gross monthly income from your Employer as defined in the plan. MONTHLY PAYMENT means your payment after any deductible sources of income have been subtracted from your gross disability payment. PART-TIME BASIS means the ability to work and earn 20% or more of your indexed monthly earnings. PAYABLE CLAIM means a claim for which Unum is liable under the terms of the policy. PHYSICIAN means: - a person performing tasks that are within the limits of his or her medical license; and - a person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or - a person with a doctoral degree in Psychology (Ph.D. or Psy. D.) whose primary practice is treating patients; or - a person who is a legally qualified medical practitioner according to the laws and regulations of the governing jurisdiction. Unum will not recognize you, or your spouse, children, parents or siblings as a physiciar~ for a claim that you send to us. PLAN means a line of coverage under the policy. POLICYHOLDER means the Employer to whom the policy is issued. PRE-EXISTING CONDITION means a condition for which you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines for your condition during the given period of time as stated in the plan; or you had symptoms for which an ordinarily prudent person would have consulted a health care provider during the given period of time as stated in the plan. RECURRENT DISABILITY means a disability which is: - caused by a worsening in your condition; and - due to the same cause(s) as your prior disability for which Unum made a Long Term Disability payment. REGULAR CARE means: - you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and - you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards. GLOSSARY-3 (10/1/2000) REGULAR OCCUPATION means the occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location. RETIREMENT PLAN means a defined contribution plan or defined benefit plan. These are plans which provide retirement benefits to employees and are not funded entirely by employee contributions. Retirement Plan includes but is not limited to any plan which is part of any federal, state, county, municipal or association retirement system, SALARY CONTINUATION OR ACCUMULATED SICK LEAVE means continued payments to you by your Employer of all or part of your monthly earnings, after you become disabled as defined by the Policy. This continued payment must be part of an established plan maintained by your Employer for the benefit of all employees covered under the Policy. Salary continuation or accumulated sick leave does not include compensation paid to you by your Employer for work you actually perform after your disability begins. Such compensation is considered disability earnings, and would be taken into account in calculating your monthly payment. SELF-REPORTED SYMPTOMS means the manifestations of your condition which you tell your physician, that are not verifiable using tests, procedures er clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy. SICKNESS means an illness or disease. Disability must begin while you are covered under the plan. , SURVIVOR, ELIGIBLE means your spouse, if living; otherwise your children under age 25 equally. TOTAL COVERED PAYROLL means the total amount of monthly earnings for which employees are insured under this plan. WAITING PERIOD means the continuous period of time (shown in each plan) that you must be in active employment in an eligible group before you are eligible for coverage under a plan. WE, US and OUR means Unum Life Insurance Company of America. YOU means an employee who is eligible for Unum coverage. GLOSSARY-4 (10/1/2000) NOTICE OF PRIVACY PRACTICES UnumProvident Corporation and its subsidiaries Unum Life Insurance Company of America First Unum Life Insurance Company Provident Ufe & Accident Insurance Company Provident Life & Casualty Insurance Company Colonial Life & Accident Insurance Company Paul Revere Ufe Insurance Company Paul Revere Vadable Life Insurance Company Congress recently passed the Gramm-Leach-B, liley (GLB).A. ct, w~hich d, ea s~in part .with how, i!isn~nns~rialn- institutions treat nonpublic personal financial ir~ormation, unum~rovioem uorporat~on ano ~ g subsidiaries have always been committed to maintaining customer confidentiality. We appreciate this opportunity to clarify our privacy practices for you as a result of this new law. - As part of our insurance business we obtain certain "nonpublic personal fmanclal information" . about you, which for ease of reading we will refer to as "information" in this notice. This information nc udes nformation we mcei~,e from you on applications or other forms, information about your. transactions with us, our affiliates or others, and nformation we receive from a consumer reporting agency. - We restrict access to the information to authorized individuals who need to know this information to provide service and products to you. - We maintain physical, electronic, and procedural safeguards that protect your information. We do not disclose this information about you or any former customers to anyone, except as permitted by law. - Employees share this information outside the company only as authorized by you or for a specific business purpose. - The law permits us to share this information with our affiliates, including insurance companies and insurance service providers. - The law also permits us to share this information with companies that perform marketing services for us, or other financial institutions that have joint marketing agreements with us. We may also sham other types of information with our affiliates, including insurance companies and insurance service providers. This information may be financial or other personal information such as employment history and it may not be directly related to our transaction.with you. Consistent with the Fair Credit Reporting Act, our standard authorizations permit us to sham this information with our affiliates. You do not need to cai or do anyth ng as a result of this notice, it is meant to inform you of how we safeguard your nonpublic personal financial nformation. You may wish to file this not ce with your insurance papers. If you want to learn more about the GLB Act, please visit our web sites at www. unumprovident.com or www. unumprovidant, com/colonial, or contact your insurance professional. We value our relationship with you and stdve to earn your continued trust. GLB-1 (10/1/2000) Exhibit B · . .. . . · . BROOKWOOD FAMILY MEDICINE - - RODNEY K. HOUGH, M.D. and ASSOCIATES _ 49 BrookwOOd Avenue carlisle, PA. 17013 717-243-8000 (PH) 717-243-3599 (FAX) RODNEY K. HOUGH, M.D., F.A.A.EP. ROBERT E SIGUENZA, M.D. - M. JOAN RICE, M.N., C.R.N.P. SARAH STURGIS, M.S.N., C.R.N.P. ZHANNA GRIGORYAN, M~S.N., C.1LN.P. SANDRA ABBEY, M.S~N., C.R.N.P. May 20, '2002 Carol Braley, Senior Customer Care Specialist ,Re; Elaine Killian Claim # 0099112567 SSN: 201-52-42~3 Policy # 551328 ' Dear Ms. Braley: I have read the letter you sent to my patient, Elain~ Killian, dated 4/19/02, with trepidation and some disdain· To review the situation, we must remembe~ that Elaine had a malignant tumor thatwas very difficult to .diagnose being situated behind her appendix. She also has endometnosis which, by itself, causes morbidity for many patients. I have known Elaine Killian for approximately-20 years. Elaine is a hard- working, edergetic, honest person who has an impeccable Work ethic. I have not grven the chronology in this letter because I understand ~)O'L~ do have a copy of my record regarding her. The fact that the patient was hospitalized on 8/20/01-8/24/01 indicates the severity of her pain Per your own notes, you stated the patient did have significant adhesions which are very difficult to diagnose. I'm surprised that fatigue was the only complaint listed. The patient also complained at that time of abdominal pain, hematuria, recta bleeding, and diarrhea. The patient's periods came early, anywhere from 16-28 days and lasted 3-5 days. Her pedods were heavy and associated with much pain and bleeding. I think this is probably the result of her continuing endometriosis~ Her malignant tumor was also situated in an unusual location which made it very difficult to find. If you take the patient's endometriosis, her tumor, and thegppendicitis this would equate to ~:justffied absence from work. If you feel otherwise, I would like to hear your documentation regar,ding that. BROOKWOOD FAMILY MEDIC~IE ' RODNEY K~ HOUGH, M~D.'and ASSOCIATES 49 Bro0kwood Avenue Carlisle, PA. 17013 · . .. 717-243-8000 (PH) 717-243-3599 (FAX) RODNEY lC HOUGH, M.D., F.A. ~A. EP. ROBERT E SIGUENZA, M.D. pM. JOAN RICE, M.N., C.ILN.P. age 2 _ '-_ Re: Elaine Killian SARAH STURGIS, M.S.N., C.1LN.P. ' ZHANNA GRIGORYA~[~, M.S.N., C.1LN.P. SANDRA ABBEY, M.S.N., C.ILN.P. I'm also concerned about the following statement that you put'~r~ your note, "The restrictions and limitations were provided by a nurse practitioner, Sandy Abbey, not a physician; % Sandy Abbey ~s a very valuable and irreplaceable nurse practitioner who has had much 'experience and works with me on a daily basis. She is board certified in family practice. If Sandy Abbey stated the patient was unable to work and gave her restrictions, you can be assured that her judgement was solid and based on fact. I would also be interested to know what prompted you to make a slanderous remark about Sandy Abbey, a board certified nurse practitioner. I find it very difficult to accept the fact th'at Elaine Killian, who is a's~ngle parent, is struggling day by day to maintain her dignity with pain and does not seem to I~ave any help from the people who are supposed tO help her. I predict that the patien~ will continue to have abdominal pain until she has a hysterectomy and has her endometriosis surgically solved. I feel it is unfair End unjust that you do not reimbursement for time off for her documented and valid illnesses strongly plead that you consider her case and if necessary, I would be happy to testify on her behal[, against you if necessary. Sincer,e, ly, ~.~) RKH/hw VERIFICATION I, Elaine M. Killian, do hereby verify that the facts set forth in the foregoing Complaint are tree and correct to the best of my personal knowledge or information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unswom falsification to authorities. Date: Document/¢: 243176.1 ELAINE M. KILLIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLV32qIA No.02-4983 CIVIL ACTION NOTICE TO TI-I'E PROTHONOTARY OF CUMBERI,AND COUNTY OF NOTICE OF REMOVAL To: Prothonotary, Cumberland County, Pennsylvania Pursuant to 28 U.S.C. §1446(d), defendant hereby files a copy of the Notice of Removal filed in the United States District Court for the Eastern District of Pennsylvania on November '7 , 2002. Dated: November // , 2002 STEVENS & LEE E. Thomas; Henefer Attorney I.D. No. 55773 Kirk L. Wolgemuth Attorney I.D. No. 45792 111 North Sixth Street P.O. Box 679 Reading, Pennsylvania 19603 (610) 478-2000 Attorneys for Defendant UNUM Life Insurance Company of America SLI 306781vl/10305.115 Cerl;~ed from the uate , · ,~. 't::i, ary E. D ~,'~d..rea,. Clerk IN THE UNITED STATES DISTRICT COURT D°p~uIII FOR THE MIDDLE DISTRICT OF PENNSYLVANIA CIVIL ACTION Vo Plaintiff ~ LIFE INSURANCE COMPANY OF AMERICA, No. Defendant NOTICE OF REMOVAL FILED HARRISBURG, PA NOV O 7 2002 MARY E- .~REA, CLERK Per_ c~' Di~Uty Clerk -- Defendant UNUM Life Insurance Company of America ("UNUM"), files this Notice of Removal pursuant to 28 U.S.C. §1441 based on the District Court's jurisdiction under 28 U.S.C. §1331, and states',: 1. Defendant exercises its rights unde, r 28 U.S.C. §1441 to remove this civil action from the Court of Common Pleas, Cumberland County, Pennsylvania, in which this action is now pending, under the name of Elaine M. Killian v. UNUM Life Insurance Company of America., Docket No. 02-4983, to the United States District Court for the Middle District of Permsylvania. Removal is proper because, as outlined below, this case is governed by the Employee Retirement Insurance Security Act of 1994, 29 U.S.C. §§ 1001 -1461 ("ERISA"). 2. Pursuant to 28 U.S.C. §1446, UNUM has attached as Exhibit A to this Notice of Removal the Plaintiffs Complaint filed on October 15, 2002, with the Court of Common Pleas, Cumberland County, Pennsylvarfia, No. 02-4983. SL1 306781vl/10305.115 3. Plaintiff's Complaint alleges that ,,;he was insured under a group long term disability insurance policy (the "Policy") issued by UNUM. 4. Plaintiff's Complaint asserts claims for breach of contract, bad faith and for violation of the Unfair Trade Practices Act. 5. Plaintiffs complaint alleges that s]he was a beneficiary of a long term disability insurance policy (the "Plan") pursuant to which she seeks payment of benefits. The Plan was established by plaintiffs employer, Lear Corporation, an employer engaged in commerce and activities affecting commerce, as an employee benefit for its eligible employees. The benefits plaintiff seeks to recover are therefore provided pursuant to an employee welfare benefit plan as def'med by ERISA §3(1), 29 U.S.C. §1002(1), and plaintiffs only remedy for the recovery of such benefits is provided pursuant to ERISA §502, 29' U.S.C. §1132. 6. The Court therefore has original jurisdiction over this action because plaintiffs claims arise under ERISA and any state law claims plaintiff might assert would be preempted completely by ERISA. Metropolitan Life In,q, Co. v. Taylor, 481 U.S. 58 (1987). Accordingly, the claims asserted in this action arise under federal law and are removable as a matter of law. 7. Because this Court has jurisdiction under 28 U.S.C. §1331 and 29 U.S.C. § 1132(e)(1), this action may be removed without regard to the Citizenship or residency of the parties or the amount in. controversy. -2- SL1 306781vl/I0305.115 8. A Notice of Removal has been filed within thirty days of receipt of the Complaint by UNUM, which was the initial pleading setting forth the basis for the Court's jurisdiction. 9. Written notice of the filing of this Notice of Removal has been served on Plaintiffs counsel, and a true and correct copy of this Notice of Removal will be filed with the Prothonotary of the Court of Common Pleas, Cumberland County, Pennsylvania. WHEREFORE, UNUM respectfully requests that this action be removed to this Court. Dated: November 6, 2002 STEVENS & ]LEE By E. Thomas Henefer Attorney I.D. No. 55773 Kirk L. Wolgemuth Attorney I.D. No. 45792 111 North Sixth Street P.O. Box 679 Reading, Pennsylvania 19603 (610) 478-2000 Attorneys for Defendant UNUM Life Insurance Company of America -3- SLI 306781vl/10305.115 ELAINE M. KII,LIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant : IN Tltlg COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : : JURY TRIAL DEMANDED TO: NOTICE Unum Life ln,qurance Company of America 2211 Congress Street Portland, Ma/ne 04122 RECEIVED OCT 2, 2 2002. LAW DEPARTMENT YOU HAVE BEEN SUED IN COURT. If you wish to &~fend against the claims set forth in the following pages, you must take action within twenty (20) &~ys after this Complaint and Notice are served, by entering a written appearance personally or ]by attomey and filirtg in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other fights important ~o you. YOU SHOULD TAKE TI-ITS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Notice to Defend Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (800)-990-9108 (717) 249-3166 Document #: 243,176. l TRUE COPY FROM RECORD ~ !~..~ m said Co~[~ at Cariisle, 'Pa ELAINE M. KII,LIAN, Plaintiff UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant : IN TWE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. : : CML ACTION - LAW : : JURY TRIAL DEMANDED NOTICIA TO: Unum Life ln.qurance Company of America 2211 Congress Street Portland, Maine 04122 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las dernandas que se presentan mas adelante en las siquientes paginas., debe tomar action dentro de los proximos veinte (20) dias despues de la notification de esta Demanda y Aviso radicando personalmente o pot medio de tm abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de romar action como se describe anteriormente, el caso puede proceder sin usted y un fallo pot cualquier suma de dinero reclam;~la en la demanda o cnalquier otra reclamacion or remedio solicitado por el demandante puede set dictado en contra suya por la Corte sin mas aviso adiciona!. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU AZBOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DON-DE PUEDE ENCO~ ASISTENCIA LEGAL. Notice to Defend Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (800)-990-9108 (717)-249-3166 Document #: 245176.1 ELAINE M. IOI,LIAN, Plaintiff UNUM LI~E INSURANCE COMPANY OF AMERICA, Defendant IN THE. COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION - LAW JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, Elaine M. K_illian, by her attorneys, Metzger, Wickersham, Knauss & Erb, P.C., and complains against the De, fendant Unum Life Insurance Company of America as follows: 1. The Plaintiff, Elaine M. Killian, is an adult individuai residing at 430 South Fayette Street, Shippeusburg, Cumberland County, Pennsylvania, 17257. 2. The Defendant is Unum Life Insurance Company of America, a corporation incorporated under the laws of the state of Maine, with an office at 2211 Congress Street, Portland, Maine, 04122, and is licensed to do business in the Commonwealth of Permsylvania, and is engaged in the business of selling insurance in the Commonweaith of Permsylvania and other states. 3. The Defendant sold to Lear Corporation, the employer of the Plaintiff, Group Insurance Policy, Number 551328 002, with an effective date of October 1, 2000; said insurance policy provides a long term disability plan..A copy of said insurance policy is attached hereto as Exhibit "A." 4. Pursuant to the terms of said policy, the employee is entitled to paYment of long tem~ disability (LTD) benefits when "you are limited from perfo~xning the material and Document #: 243176.1 substantial duties of your regular occupation due to sickness or :injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury." (LTD-BEN-1 [10/1/200]) 5. The Plaintiff last worked as a light machine operator on July 29, 2001. On August 1, 2001, she was seen by her family physician, Rodney K. Hough, M.D., for increased fatigue, nausea, diarrhea, right heel pain, and urinary tract infection. The Plaintiff was hospitalized from August 21, 2001, to August 24, 2001, rectal bleeding and diarrhea. 6. The Plaintiff continued to complain of persistent abdominal pain and was seen again in the emergency room of the Carlisle Regional Medical Center on September 1, 2001. A pelvic sonogram revealed three right ovarian cysts. 7. On October 23, 2001, the Plaintiff was seen by Stanley C. Beachy, M.D., for evaluation of lower abdominal pain. The Plaintiffwas seen again on November 19, 2001, and was still suffering from endometriosis. A diagnostic laparoscopy performed on November 19, 2001, revealed scarring from endometriosis, significant adhesions, and carcinoid tumor'situated behind and attached to the appendix. The Plaintiff's appendix was removed and several aberrant cysts were discovered and removed on November 19, 2001. The Plaintiff continues to undergo treatment, including the administration of :medical menopause, and, in the opinion of Rodney K. Hough, M.D., her family physician, she will continue to have abdominal pain until she has a hysterectomy and has her endome~osis surt,qcally solved. The letter of Dr. Hough to Carol Braley, Senior Customer Care Specialist of Unum Life Insurance Company of America, dated May 20, 2002, is attached hereto as Exhibit "B." Document #: 243176.1 2 8. In the opinion ofRodney K. Hough, M.D., the Plaintiff's physician, the Plaintiff's endometriosis, carcinoid tumor, and appendicitis rendered her totally disabled. 9. On January 13, 2002, the Plaintiff injured her right knee when she tripped down steps, and on February 22, 2002, she underwent an arthroscopic chondroplasty by David C. Baker, M.D., an orthopedic surgeon. As a result of the injury, the Plaintiff has developed degenerative arthritis of the fight knee. 10. On February 27, 2002, the Defendant notified the Plaintiff that she was approved for LTD Benefits in the amount of $1,137.29 per month. 11. Pursuant to said notice, the Plaintiff received LTD Benefits for the period from January 26, 2002, through March 25, 2002, whereupon benefits abruptly ceased. 12. By letter dated April 19, 2002, the Defendant denied the LTD claim. 13. On April 27, 2002, Plaintiff submitted a letter and additional medical information, and on May 10, 2002, she submitted a letter appealing the decision of denial. 14. By letter dated May 15, 2002, the Defendant once again denied the LTD claim. In addition, by letter dated May 28, 2002, the Defendant advisexl the Plaintiff that it had completed a review of the denial and had concluded that the decision of denial was appropriate. 15. The Plaintift'remains disabled from "performing the material and substantial duties" of her "regular occupation due to sickness or injury" as required by the policy. (LTD-B~-I [10/1/2000]) 16. The Plaintiff has performed all of the conditions of the group insurance policy (Exhibit "A") required to be performed on her part. Document #: 245176.1 17. Despite repeated demands by the Plaintiff, the Defendant has refused to make payment of LTD Benefits. 18. Defendant has no legitimate or arguable reason to deny the claim of the Plaintiff for LTD Benefits. COUNT I Breach of Contract 19. The averments of Paragraphs 1 - 18 hereof are incorporated herein by reference. 20. Issuance by the Defendant of the policy (Exlfibit "A") to the Lear Corporation created a contractual relationship between the Defendant and the Plaintiff. Defendant therefore was subject to the implied - in - law duty to act fairly and in good faith in order not to deprive the Plaintiff of the benefits of the policy. 21. Issuance by the Defendant of said policy to the Lear Corporation created a contractual relationship between the Defendant and the Plalntift: 22. The Defendant has acted willfully, fi:audulently, :intentionally, and in bad faith in refusing to make payment of LTD Benefits. This was done knowingly, intentionally, and with the purpose of discouraging, avoiding, or reducing the payment due to the Plaintiff under the terms of said policy. 23. Defendant has rejected the Plaintiff's proof of disability and has produced no medical evidence disproving her disability. Document #: 243176.1 4 24. By refusing to accept the claim for LTD Benefits, the Defendant has acted in bad faith by denying benefits under said policy without any legitimate or arguable reason for refusing the claim. 25. Defendant's intentional refusal to pay the valid claim for LTD Benefits was a breach of the implied-in-law duty of good faith and fair dealing,, and operated to unreasonably deprive the Plaintiff of the benefits of said policy. WHEREFORE.Plaintiff, Elaine M. Killian, requests judgmem against the Defendant, Unum Life Insurance Company, for damages which exceed the limits of compulsory arbitration in Cumberland County, Pennsylvania, together with interest, CO:St of suit, and/or damages for delay as the law may allow. COUNT II Bad Faith 26. The averments of Paragraphs 1 - 25 hereof are incorporated inhere by reference. 27. The Plaintiff, Elaine M. Killian, has performed a2[l of the conditions of said policy required to be performed on her part. 28. Pursuant to the terms of said policy, the Plalntiff has provided to the Defendant timely and proper proof of her long tena disability. 29. Defendant breached the implied covenant of good faith and fair dealing under said policy by denying the Plaintiff's claim without a reasonable basis for such conduct. Document #: 245176.1 5 30. Defendant's conduct has breached the implied covenant of good faith and fair dealing since Defendant has not produced any medical evidence: disproving the Plaintiff's claim for LTD Benefits. WHEREFORE, Plaintiff, Elaine M. Killian, requests judgmem agaln~t the Defendant, Unum Life Insurance Company, for damages which exceed the limits of compulsory arbitration in Cumberland County, Pennsylvania, together with interest, cost of suit, punitive damages, attorney's fees, and/or damages for delay as the law may allow. COUNT IH Unfair Trade Practices and Consumer Protection Law 31. The averments of Paragraphs 1 - 30 hereof are incorporated herein by reference. 32. The transaction between the Plaintiff and the Lear Corporation and the Defendant as described above constitutes one under and subject to the pro'~isions of the Unfair Trade Practices and Consumer Protection Law, 73 P.S. §201-1, et seq. 33. By offering LTD Benefits under said policy when the Defendant knew, or should have known, that it would never accept the Plaintiff's proof of d~[sability, the Defendant acted in a fraudulent manner, creating a likelihood of confusion or misunderstanding. 34. The Plaintiff has sustained loss as a result of the Defendant's use of methods, acts, or practices declared unlawful under said statute by engaging in frandulent conduct which creates a likelihood of confusion or of misunderstanding. Document #: 243176.1 6 35. Defendant's conduct was in violation of the Unfitir Trade Practices and Consumer Protection Law and was willful for which the Plaintiff seeks damages and such additional relief provided by such said statute or as the Court deems necessary and proper. WHEREFORE, Plaintiff, Elaine M. Killian, requests judgment against the Defendant, Unum Life Insurance Company, for damages which exceed the :Limits of compulsory arbitration in Cumberland County, Pennsylvania, and treble damages, costs:, interest, and/or damages for delay as the law may allow. Respectfully submitted, METZGER, WICKERSI-DdVI, KNAUSS & ERB, P.C. oeSF. Carl, Esquire mey I.D. No. 01616 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiff Elaine M. Killian Date: October I 0 ~,2002 Document #: 243176.1 7 UNUM. GR;OU P INSURANCE POLICY NON-PARTICIPATING POLICYHOLDER: Lear Corporation POLICY NUMBER: 551328 002' POLICY EFFECTIVE DATE: October 1, 2000 POLICy ANNIVERSARY DATE: January I GOVERNING JURISDICTION:. Michigan Unum Life Insurance Company of America (referred to as Unum) will provide benefits under this policy. Unum makes this promise subject to all of this ix?licy's provisions. The policyholder should read this policy carefuily and contact Unum promptly with any ques.tions, This policy is deliver, ed in and is governed by thelaws of the governing judsoiction and to the extent applicable by the Employee Retirement Income Security ACt of 1974 (ERISA) and any amendments. This policy consists of: all policy provisions and any amendments and/or attachments issued; employees' signed applications; and · the certificate of coverage.. This policy may be changed in whole or in part. Only an officer or a registrar of Unum can approve a change. The approval must be in writingand endorsed on or attached to this policy. No'other person~ including an agent, may change this policy or waive any part of it. Signed for Unum at Portland, 'Maine on the Policy Effec~,e Date. President Secretary- Unum Life Insurance Company of America 2211 Congress Street ' Portland, Maine 04122 Copyright 1993, Unum Life Insurance CompaLny of America C.FP-1 C. FP-1 (10/1/2000) TABLE OF CONTENTS BENEFITS AT A GLANCE ........................................................................................... B@G-LTD-1 LONG TERM DISABILITY PLAN ............. ..; .................................................................. B@G-LTD-1 CLAIM INFORMATION ............................................................................................... LTD-CLM-1 LONG TERM DISABILITY ........................................................................................... LTD-CLM-1 POLICYHOLDER PROVISIONS ................................................................................. EMPLOYER-1 CERTIFICATE SECTION ........................................................................................... CC. FP-1 GENERAL PROVISIONS ........................................................................................... EMPLOYEE-1 LONG TERM DISABILITY .......................................................................................... LTD-BEN-1 BENEFIT INFORMATION ................................. ' ............. ~ ............................................ LTD-BEN-1 OTHER BENEFIT FEATURES ...................................................... ~ ............................ LTD-OTR-1 OTHER SERVICES ..... ~ ......................................................... ] .................................... SERVICES-1 ERISA ........................................................................................................................ ERISA-1 GLOSSARY ............................................................................................................... GLOSSARY-1 TOC-1 (10/1/2000) BENERTS AT A GLANCE LONG TERM DISABILITY PLA~! This long term disability plan provides financial protection fo~ you by paying a portion of your income while ~jare ,disabled. The amount you receive is based on the amount you earned before your disability an.. In some cases, you can receive disability payments even if you work while you are disabled. EMPLOYER'S ORIGINAL PLAN · EFFECTIVE DATE: October 1,2000 POLICY NUMBER: 551328 002 ELIGIBLE GROUP(S): Ali..Ful!-time Hourly Bargaining Employees of Lear Corporation, Carlisle, PA in active employment in me. united States with the Employer MINIMUM HOURS REQUIREMENT: Employees must be working at least 40 hours per per year on a regularly scheduled basis. WAITING PERIOD: Members of UNITEI Union For employees in an eligible group on or before October 1, 2000:30 days of continuous active employment ' For employees entering an eligible group after October 1, 2000:30 daYs of continuous active employment Members of IUOE .. For employees in an eligible group on or before October 1, 2000:45 days of continuous active employment For emplbyees entering an eligible group after October 1,2000:45 days of continuous active employment REHIRE: If your employment ends and you are reh red within 12 mon~'~s, your previous work while in an .eligible group will appl. y toward the waJ§ng period. All other policy provisions apply. CREDIT PRIOR SERVICE: Unum will apply any prior period of WOrk with your Employer toward the wailing period to determine your eligibility date. WHO PAYS FOR THE COVERAGE: Your Employer pays the cost of your coverage. ELIMINATION PERIOD: 180 days Accumulation Period: 360 days Benefits 'begin the day after the elimination period is completed. B@ G-LTD-1 (!0/1/2000) MONTHLY BENEFIT: 50% of monthly eamings to a maximum benefit of $3,000 per month. Your payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be c?vered or may have limited coverage; under this plan. · MAXIMUM PERIOD OF PAYMENT: Age 60 . Age 61 Age62 Age 63 Maximum Period of Pavmenl~ To age 65, but not less than 5 years 60 months 48 months 42 months 36 months Age 64 30 months Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 and over 12 months No premium payments are required for your coverage while you are receiving payments under thi~ plan. REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFIT: 10% of your gross disability payment to a ma)dmum benefit of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while: - you are participating in the Rehabilitation and Return to Work Assistance program; and you are no{ able to find employment. CHILD CARE EXPENSE BENEFIT: While you are participating in Unum's Rehabilitation and RettJm to WorkAssistance program, you. may receive payments to 'cover certain 'child care expenses limited to the following amounts: Child Care Expense Benefit Amount:. $250 per month, per ci~'ld Child Care Expense Maximum Benefit Amount: $1;000 per month for all eligible child care exp~.nses cOmbined .TOTAL BENEFIT CAP: Tl~e total benefit payable to you o~ a monthly basis (including all benefits prOVided under this ' plan) will no{ exceed 10(P/~ of your monthly earnings. OTHER FEATURES~ C~ntinuity of C~verage' Minimum Benefit Pre~Existing:. 3/12 . Survivor Benefit Work IJfe Assistance Program The abow · ~ Items are only highlights of ~is plan. For a full description~ of your coverage, continue reading your certificate of coverage section. · B@G-LTD-2 (10/1/2000) CLAIM INFORMATION LONG TERM DISABILITY WHEN DO YOU NoTIFy UNUMOF A CLAIM? We encourage you to notify us of your claim as soon as possible, so that a claim decision can be made in a timely manner. Wr'~ten notice of a claim Should be s~nt within 30 days after the date your disability begins. However, you must send Unum written proof of your claim no later than 90 days after your elimination period. If it is not' possible to.give proof within 90 days, it must be given' no later than 1 year after the time proof is otherwise required except in the absence of legal capacity. The claim form is available from your Employer, or you can request a claim form from us. If you do not receivethe form from Unum within 15 days of your request, send Unum Written proof of claim without waiting for the form. You must notify us immediately when you retum to work in any capacity. HOW DO YOU FILE A CLAIM? You and your E..mplo.),er m. ust fill out your own sections of the claim form and then give. it to your. attencang pnysician. Your physician .shc uld fill out his or her section, of the form and send it directly to Unum. WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM? Your proof of claim, 'provided 'at. your expense, must show: - that you are under the regular care of a physician; - the' appropriate documentation of your monthly eamiings; the date your disability began; ' - the cause of your disability; - the extent of your disability, inclUding.restrictions and limitations preventing you from performingyour regular occupation; and - the'name and address of any hospital or Institution where you received treatment, including all attending physicians. We. may request that you send proof of. continuing disability indicating that you are un(]er the regular care. of a physician. This Proof, provided at your expense, must be received Within 45 days of a request by us. In some cases, you will be required tO give Unum authorization to obtain additional medical information and to. provide non-medical information as part of your proof'of claim, or proof of continuing, disability. Un..um will denY your olaim, or stop sending · you payments, if the appropriate informatmn is not submitted. TO WHOM WILL UNUM MAKE PA YMENTS? Unum will make payments to you. LTD-CLM-1 (10/1/2000) WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM',? Unum has the' right to recover any overpayments due to: fraud; - any error Unum makes in processing a claim; and your receipt of deductible sources of income. · You must reimburse us in full. We will determine the method by which the repayment is to be made. Unum will not recover more money than the amount we paid you. LTD-CLM-2 (10/1/2000) POLICYHOLDER PROVISIONS WHAT IS THE COST OF THIS INSURANCE? LONG TERM DISABILI'rY The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s). WAIVER OF PREMIUM Unum does not require premium payments for an insured while he or she is receiving Long Term Disability payments upder this plan. INITIAL RATE GUARANTEE AND RATE CHANGES Refer to the Rate Information Amendment(s). WHEN IS PREMIUM DUE FOR THIS*POLICY? Premium Due Dates:. Premium due dates are based on the Premium Due Dates shown in the Rate Information Amendment(s). The Policyholder must send all premiums to Unum on or before their respective due date. The premium must be paid in United States; dollars. WHEN ARE INCREASES OR DECREASES IN PREMIUM DUE? Premium increases or decreases which take effect during a policy month are adjusted and due on the next premium due date following the change. Changes will not be pre-rated daily. If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustmen~t'on the next premium due date. Unum will.only adjust premium for the currentpolicy year and the prior policy year. In the case of fraud, premium adjustments will be made for all policy years; WHAT INFORMATION DOES UNUM REQUIRE FROM 'THE POLICYHOLDER? The Policyholder must provide Unum with the following on a regular basis: - information about employees: · who are eligible to become insured; · whose amounts of coverage change;-and/or · whose coverage ends; - occupational information and any other information that may be required to manage a claim; and - any other information that may be reasonably required; Policyholder records that, in Unum's opinion, have a beating on this policy will be. available for review by Unum at any reasonable time. EMPLOYER-1 (10/1/2000) Clerical error or omission by Unum will not: - prevent an employee from receiving' coverage; - affect the amount of an insured's coverage; or - cause an employee's coverage to begin or continue when the coverage would not otherwise be effective. WHO CAN CANCEL OR MODIFY THIS POLICY OR A PLAN UNDER THIS POLICY? Thispolicy or a plan unde[ this policy can be cancelleci: - by Unum; or - by the Policyholder. Unum may cancel or modify this.policy or a plan if: - there is less than 75% participation of those eligible employees who pay all or part of their premium for a plan; or - them is less than 100% participation of those eligible employees for a Policyholder paid plan; ' - the Policyholder does not'promptly provide Unum wiith information that is reasonably required; - the Policyholder fails to perform any of its obligations that relate to this policy; - fewer than 10 employees are insured under a plan; - the premiUm.is not paid in accordance with the provisions of this policy that specify whether the Policyholder, the employee, or both, pay(s) the premiums; - the Policyholder does not promptly report to Unum tihe names of any employees who are added or deleted from'the eligible group; - Unum determines that there is a significant change, in the size, occuPation Or age of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its employees; or - the Policyholder fails to pay any portion of the premium within the 31 day grace period. If Unum cancels or modifies this policy or a plan for reasons other than the Policyholder's failure to pay premium, a wrilIen notice Will.be delivered.to the Policyholder at least 31. days pdor to the cancellation date or modification date. The Policyholder may cancel this policy Or a plan if the modifications are unacceptable. If anY portion of the premium is not paid dudng the gn[Ce per'~)d, Unum will either. cancel or modify the policy or plan automatically at thE; end of the grace, period. The 'Policyholder is liable for premium for coverage during the grace period. The. . Policyholder must.pay Unum all premihm due for the full period each plan is in force. uThe Policyholder may c~ncel this policy or.a plan by ~ritten notice delivered to num at least 31 days prior to the cancellation date. When both the Policyholder and Unum agree, this' policy or a plan can' be cancelled on an earlier date. If Unum er the Policyholder cancels' this policy or a plan, coverage will end at 12:00 midnight on the last day of coverage. If this policy or a'plan is Cancelled, the cancellation wil[I not affect a payable claim. EMPLOYER-2 (10/1/2000) ' WHAT HAPPENS TO AN EMPLOYEE'S CO VERAGE UNDER THIS POLICY WHILE HE OR SHE IS ON A FAMILY AND MEDICAL LEA VE OF ABSENCE? We will continue the employee's coverage in accordance with the policyholder's Human Resoui'ce policy on family and medical leaves of absence if premium payments continue and the policyholder approved' the ,employee's leave in writing. Coverage will be continued until the end of the later of: 1. the leave period required by the federal Family and Medical Leave of Absence Act of 1993 and any amendments; or 2. the leave period required by applicable state law. If the policyholder's Human Resource policy doesn't Provide for continuation of an employee's coverage during a family and medica! leave of absence, the employee's coverage will be reinstated when he or she returns to active employment. We will not: - apply a new waiting period; - appl.y a new pre-existing conditions exclusion; or - require evidence of insurability: DIVISIONS, SUBSIDIARIES OR AFFILIA TED COMPAN, WES INCLUDE: NAME/LOCATION (CITY AND STATE) Lear Corporation Carlisle, Pennsylvania EMPLOYER-3 (10/1/2000) CERTIFICATE SECTION Unum Life Ins~Jrance Company of America (referred to as 'Unum) welcomes you as a client. This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully.and keep it in a safe place. Unum has written your certificate of coverage in plain English. However, a few terms · and provisions are written as required by insurance law. I[f. you have any questions about any Of the terms and Provisions, please Consult Un~Jm's claims paying office. Unum will assist you in any way to help you understand your benefits. If the terms and provisions of 1~ certificate of coverage (issued to you) are different from the policy (issued to the policyholder)., the policy will govern. Your coverage may be.cancelled or changed in whole or in part under the terms and provisions of the policy. The policy is delivered in and is govemed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. When making a benefit determination under the policy, Unum has discretionary authority to. determine your eligibility for benefits and to interpret the terms and provisions of the policy. For purposes of effective dates and ending dates under the group policy~ all days begin at 12:01 a.m. and end at 12:00 midnight.at the Policyholders address. ' Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 CC.FP-1 (10/1/2000) GENERAL PROVISIONS WHAT IS THE CERTIFICATE OF COVERAGE? This certificate of coverage is a written statement prepared by Unum and'may include attachments. It tells you: - the coverage for which you may be entitled; - to whom Unum will make a payment; and - the.limitations, exclusions and requirements that apply within a plan. WHEN ARE YOU ELIGIBLE FOR COVERAGE? If you are working for YOur Employer in an eligible group, the date you are eligible for coverage is the later of' - the' plan effective date; or - the day after you complete your waiting period. WHEN DOES YOUR COVERAGE BEGIN? ,When your Employer pays 100% of the cost of your coverage under a plan, you will De covered at 12:01 a.m. on the date you are eligible for coverage. When you and your Employer share the cost of your coverage under a plan or when you pay 100% of the cost yourself, you will be covered.at 12:01 a.m. on the latest of: - the date you are eligible for coverage, if you apply for insuran .ce on or'before that '. date; - the date.you apply for insurance, if you apply within :3! days after your eligibility date; or - the date Unum approves your application, if evidence of insurability,!s required. Evidence of insurability is required if you: - are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or - voluntarily cancelled your coverage and are reapplying. An evidence of insurability form can be obtained from 'your Employer. WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN? If you.are absent fromwork due to injury, sickness, temporarylayoff Or leave of. absence, your coverage will begin on the date you return to active employment. ONCE YOUR COVERAGE BEGINS, WHAT ~IAPPENS j~F YOU ARE TEMPORARILY NOT WORKING? If you are on ~ temporary layoff; and if premium is' paid, you will be covered through the end of the month mat immediately follows the mop,th in which your temporary layoff begins. ' EMPLOYEE-1 (10/1/2000) If yod are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins. WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT? Once your coverage begins, any inCreased or additional coverage will take effect immediately if you are in active employment or if you ~,re on a covered layoff or leave of absence. If you are not in active employment due to injury or sickness, any increased or additional coverage will begin on the datE; you return to active 'employment. Any decrease in coverage will take.effect immediately but will not affect a payable claim that occurs prior to the decrease. WHEN DOES YOUR COVERAGE END? Your coverage under the policy*or a plan ends on the'earliest of: - the date the policy ora plan is cancelled; - the date you no longer are. in an eligible group; - the date your eligible group is no Ionger'covered~ - the' last day of the period for which you made any required contributionS; or - the last day you are in active employment except as provided under the covered layoff or leave of absence provision. Unum will provide.coverage for a Payable claim which occurs while you are covered' under 1he Policyor plan. WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS? You can start legal action regarding your claim 60 days after proof of claim haS been given and up to 3 years from the time proof of claim is required, unless otherwise provided under federal law. HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED? Unum considers any statements you or your Emp!oyei make in a.signed, application.. for coverage a representation and not a warranty. If any of the statements you Or your Employer make are not complete and/or not true at the time they are made, we c~n: reduce or deny any claim; or - cancel your coverage from the original effective date. 'We will use only statements made in a signed application as a basis for doing this. If the Employer gives us information about you that is incorrect, we will: - use the facts to decide whether you have coverage un.der the plan and in what amounts; and - make a fair adjustment of the premium. EMPLOYEE-2 (10/1/2000) HOW WILL UNUM HANDLE INSURANCE FRAUD? Unum Wants to ensure you and*your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution. It is a crime if you knowingly, and with intent to injure,'de[~aud or deceive Unum, or provide any information, including ~ing a. claim, that contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, will result in denial of your claim, and are Subject to prosecution and punishment to the full extent under state and/or federal law. Unum will pursue all appropriate legal remedies in the event of insurancefraud. · DOES THE POLICY REPLACE OR AFFECTANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE? The policy does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance. DOES YOUR EMPLOYER ACT AS. YOUR AGENT OR UNUM'S AGENT? For'purposes of the policy, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deen~;d the agent of Unum. EMPLOYEE-3 (10/1/2000) LONG TERM DISABILITY BENEFIT INFORMATION HOW DOES uNuM DEFINE DISABILITY? You are disabled when Unum determines that: - you are.limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your Indexed monthly earnings due to the same sickness or injury~ After 24 months of payments, you are disabled when ILJnum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. The loss of a professional or occupational license or certification does not, in itself, constitute disability. We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice.. Unum will pay' for thisexamination. We can require an examination as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Unum Representative. HOW LONG'MUST YOU BE DISABLED BEFORE YOU AREELIGIBLE TO RECEIVE BENEFITS? You must be continuously disabled through your elimination period. The days that you are not disabled will not count toward your elimination period. Your elimination period is 180 days. In addition, if you retum to work'while satisfying your elimination period, and are no longer disabled, you may satisfy your elimination period within the accumulation period. You.do not need to be continuously disabled through your elimination period if you are satisfying your eliminatiOn period under this provision. If you do not satisfy the elimination period within the aCCUmulation period, a new period of . disability will' begin. Your.accumulation period is 360 days. . CAN YOU SA TISFY YOUR ELIMINATION PERIOD IF YOU ARE WORKING? Yes. If you are working .while you are disabled, the days you are .disabled will count toward your elimination pedod. WHEN WILL YOU BEGIN TO RECEIVE PA YMENTS? You will begin tO receive payments when we approve your claim, providing the elimination, period'has been met. We will send'you a payment monthly for any pedod for which Unum is iiable. LTD-BEN-1 (10/1/2000) HOW MUCH WILL UNUM PA YYOU IF YOU ARE DISABLED? We will follow this pmcess to figure your payment: 1. Multiply your monthly eamings by 50%. . 2. The maximum monthly benefit Is $3,000. ' 3. Compa. re the answer from. Item 1 with the maximum monthly, benefit. The lesser of these two amounts is your gross disability payment. 4. Subtract from your gross disability payment any deductible sources of Income. The amount figured in Item 4 is your monthly payment. WILL UNUM EVER PA Y MORE THAN 100% OF MONTHLY EARNINGS? The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. WHAT ARE YOUR MONTHLY EARNINGS? "Monthly Earnings;' means your gross monthly income from your Employer in effect just prior to your date of disability. It includes your total income before taxes, but does not include deductions made for pre-tax contribLff~ons to a qualified deferred compensation plan, SeCtion 125 plan, or flexible spending accdunt. It does not include income received from commissions, bonuses, overtime pay, any other extra co. mpensation, or include income received fromsoumes other than your Employer. WHAT WILL WE USE FOR MONTHLY EARNINGS IF YOU BECOME DISABLED DURING A COVERED LA YOFF OR LEA VE OF ABSENCE? If you become disabled while you are on a covered layoff or leave of absence, we will use your monthlyeamings from your Employer in'effect just Prior to the date your absence begins. HOW MUCH WILL UNUM PA Y YOU IF YOU ARE DISABLED AND WORKING? dWie w. i.l! .send.yo.u the ..mOnthly payment if you are disabled and your monthiy samlity earnings, iT any, are less than 20% of your indexed monthly earnings, · due to the same sickness or injury. If you are disabled and your monthly disability eamings are 20% or more of your indexed monthly earnings, due to the same.sickness .or injury, Unum will figure your payment as follows: During the first 12 months.of payments, while working, your monthly payment will not be reduced as long as disability earnings plus the groSS disability payment does not exceed 100% of indexed monthly eamings. ' · ' 1. Add your monthly disability earnings to your gross disability payment. 2. Compare the answer in Item I to your indexed monthly earnings. If the answer from Item I is leSS than or equal to' 100% of your indexed monthly earnings, Unum will not further reduce your monthly payment. LTD-BEN-2 (10/1/2000) If the answer from Item I is more than 100% of your indexed monthly earnings, Unum will subtract the amount over 100% from your monthly'payment. After 12 months of payments, while working, you will receive payments based, on the percentage of income you are losing due to your disability. 1. Subtract your disability earnings from your indexed monthly eamings.' 2. Divide the answer in Item 1 by your indexed monthly earnings. This is your percentage of lost earnings. 3. Multiply your monthly payment by the answer in Item 2. This is the amount Unum will pay you each month. During the first 24 months of disability payments, if your monthly disability earnings exceed 80% of your indexed monthly earnings, Unum will stop sending you payments and your claim will end. Beyond 24 months of disability Payments, if.your monthly disability earnings exceed the gross disability payment, Unum will stop sending you payments and your claim will end. Unum may require you to send proof of your monthly disability earnings at least quarterly. We Will adjustyour payment based on your quarteriy disability earnings. As Part of your proof of disability earnings, we can require that you send us appropriate financial records which we believe are necessary to substantiate your income. After the elimination period, if you are disabled for les.,; than 1 mo. nth, we will send you 1/30 of your payment for each day of disability.. HOW CAN WE PROTECT YOU IF YOUR DISABILITY EARNINGS FLUCTUATE? if your disability earnings robfinely fluctuate widely.from month' to month, Unum may average.your disabili[y eamings over the most recent 3 months to determine if your claim should continue. If Unum averages your disability eamings, we will not terminate your claim unless: - During the first 24 months of disability payments, the average of your disability earnings from the last :3 months exceeds 80% of indexed rn~nthl~f earnings; o~ Beyond 24 months of disability payments, the .average of your dj§ability earnings from the last.3 month~ exceeds.the-gross disability payment~ We will nbt pay you for any month during which disabiility earnings exceed the amount .allowable under the plan. WHAT ARE DEDUCTIBLE SOURCES OF INCOME?* Unum will subtract from your gross disability payment the following deductible sources of income: 1) The amount that you receive or are entitled to receive, under. LTD-BEN-3 (10/1/2000) - a workers' compensation law. - an occupational disease law. - any other act or law with' similar intent. 2) The amount that you receive or are entitled to receive as disability income payments under any: - state compulsory benefit act or law. automobile liability insurance policy. - other group insurance plan. - governmental retirement system as' a result of your job with your Employer. 3) The amount that you, your' spouse and your children rE.~eive or are entitled to receive as disability payments because of your disability under: - the United States Social Security Act. - the Canada Pension Plan. - the Quebec Pension Plan. - af~y similar plan or act. 4) The amount that you receive as retirement payments or the amount your spouse and children receive as retirement payments because you are receiving retirement payments under: - the United States Social Secur'rty Act. - the Canada Pension Plan. - the Quebec Pension Plan. - any similar plan or act. 5) The amount that you: - receive as disability payments under your Employer's retirement plan. voluntarily elect to receive as retirement payments under your Employer's retirement plan. - receive as retirement Payments when you reach the later of age 62 or nof~-,al retirement age, as defined in your Employer's retirement plan. Disability payments under a retirement plan will be those benefits which are paid due to disability and do not reduce the retirement benefit which would have been paid if the disability had not occurred. Retirement payments will be those benefits which are bas .ed'on your Employer's COntribution to the. retirement plan. Disability benefits which reduce the retirement benefit under the plan w~l also be considered as a retirement benefit. '- ' Regardless of how the retirement funds from.~e retirement plan are distributed, Unum' will consider your and your Employer's oontrib[~ons to be distributed simultaneously throughout your lifetime. Amounts received do not include'amounts rolled over or transferred to any eligible retirement plan.. Unum will use the definition of eligiblle retirement plan as defined in Section 402 of the Internal Revenue Code including any future amendments which affect the definition. LTD-BEN-4 (10/1/2000') 6) 50% of the amount you receive under Title'46, United ;States Code Section 688 (The Jones Act). 7) The amount that you receive from a third party (after subtracting attorney's fees) by judgment, settlement or otherwise. With the exception of retirement payments, Unum will only subtract deductible sources of income which are payable as a result of thE; same disability. We *will not reduce your payment by your Social. Security retirement income if your disability begins after age 65 and you were already receiving Social Security retirement payments. WHAT ARE NOT DEDUCTIBLE SOURCES OF INCOME=.? Unum will not subtract from your gross disability payment income you receive from, but not limited to, the following: - 401(k) plans - profit sharing plans - thrift plans - 'tax sheltered annuities - stock ownership plans - non-qualified plans of deferred compensation - pension plans for partners - military pension and disability income plans - credit disability insurance ' - franchise disability income plans - a retirement plan from another Employer individual retirement accounts (IRA) - individual disability income plans - salary continuation or accumulated sick leave plans WHAT IF SUBTRACTING DEDUCTIBLE SOURCES OF' INCOME RESULTS IN A ZERO BENEFIT? (Minimum Benefit) The minimum monthly payment is the greater of: - $50; or , - 10% of your gross disability payment. Unum may apply this amount toward an outstanding overpayment. WHAT HAPPENS WHEN YOU RECEIVE A COST OF LIVING INCREASE FROM DEDUCTIBLE SOURCES OF INCOME? Once Unum has. subtracted any deduCtible source of income from your gross disability payment, Unum will not 'further. reduce your payment due'to a cost of.living increase trom that source. LTD-BEN-5 (10/1/2000) WHAT IF UNUM DETERMINES YOU MA Y QUALIFY FOR DEDUCTIBLE INCOME BENEFITS? When we determine that you may qualify for benefits under Item(s) 1), 2) and 3) in the deductible sources of income section, we will estimate your entitlement to these benefits. We can reduce your payment by the estimated amounts if such benefits: - have not been awarded; and have not been denied; or - have been denied and the denial is being aPpealed. Your Long Term Disability payment will NOT be reduc, ed by the estimated amount if you: - apply for the disability payments under Item(s) 1), 2): and 3) in the deductible sources of income section and appeal your denial t(~) all administrative levels Unum feels are necessary; and - sign Unum's payment option form~. This form states that you promise to pay us any overpayment caused by an award. If your payment has .been reduced by an estimated amount, your payment will be adjusted when we receive* proof: - of the amount awarded; or - that benefits have been denied and all appeals Unum feels are 'necessary have been completed. In this case, a lump sum refund of the estimated amount will be made to you. If y0'u receive a lump sum payment from any deductible soumes of income, the lump sum will be pro-rated on a monthly basis over the time period for which the sum was given. If no time pedod is stated, we will use a reasonable one. HOW LONG WILL UNUM CONTINUE TO SEND YOU PAYMENTS? Unum will send you a payment each month up to the maximum period of payment. Your maximum period of payment is based on your age at disability as follows: Aqe at Disability Maximum Period of Payment Less than age 60 To age 65, Age 60 60 months Age 61 48 months Age 62 - 42 months Age 63 36 months Age 64 30 months Age 65 24 months Age 66 . 21 months Age 67 .18 months Age 68. 15 months Age 69 and over 12 months but not less than 5 years LTD-BEN-6 (10/1/2000) WHEN 'WILL PA YMENTS STOP? We will stop sending you payments and your claim willl end on the earliest of the following: - during the first 24 months of payments, when you are able to work in your regular occupation 'on a part-time basis but you choose not to; - after 24 months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to; - the end of the maximum period of payment; the date you are no lOnger disabled under the 'terms of the plan, unless you are eligible to receive benefits under Unum's Rehabilitat'ion and Return to Work Assistance program; - the date you fail.to cooperate or participate in Unum's Rehabilitation and Return to Work Assistance program; - the date you fail to submit proof of continuing disability; - after 12 months of payments if you are considered to reside outside the United States or Canada. You will be considered to reside-outside these countries when you have been outside the United States or Canada fo~ a total period of 6 months or more during any 12 consecutive months of benefits; - the date your disability earnings exceed the amount allowable under the plan; - the date you die. WHAT DISABILITIES HA VE A LIMITED PA Y PERIOD LINDER YOUR PLAN? Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness have a limited.pay period up to 24 months. Unum will continue to send you payments beyond the 24 month' period if you meet one or both of these conditions.' 1. If you are confined to a hospital or institution at the end of the 24 month period, Unum will continue to send you payments during your confinement. If you are still disabled when you are discharged, Unum'will send you payments - for a recovery period of Up to 90 days. If you become reconfined at any time during the recovery period and. remain confined for at least !4 days in a row, Unum will send Payments d~iringthat additional confinement and for one additional recovery period up to 90.more days. 2. in addition to Item 1, if, after the 24 month period for which you have reCbived payments, you continue to .be disabled and subsequently become confined to a hospital or instifution for at least 14 days ina row, IL~num will send payments during, the length' of the reconfinement. Unum Will not pay beyond the limited pay period'as.indicated above, or the maximum period of payment, whichever occurs first. Unum will not apply the mental illness limitation to dementia if it is a result of: - stroke; LTD-BEN~7 (10/1/2000) - trauma; - viral infection; - Alzheimer's diseaSe; or - other conditions not. listed which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment. WHAT DISABILITIES ARE NOT COVERED UNDER YOUR PLAN? Your plan does not cover any disabilities caused by, contributed to by, or resulting from your. - intenti0na[ly self-inflicted injuries. - active participation in a riot. - loss of a professional license, OCCupational license or certification. - commission of a crime for which you have been convicted under state or federal law. i - pre-existing condition. Your plan will not cover a disability due to war, declared or undeclared, or any act of war. Unum will not pay a benefit for any period of disab~ity during which you are incarcerated. WHAT IS A PRE-EXISTING CONDITION? You have a pre-existing condition if: - you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of COverage; or you had symptoms for which an ordinarily prudent person would have consulted a health care provide,' in the 3 months just prior to · your effective date of COverage; .a~ - the disability begins in thefirst 12 months after your effective date of coverage. WHAT HAPPENS IF YOU RETURN TO WORK FULL TIME AND YOUR DISABILITY OCCURS AGAIN? .- If you have a recurrent disability, Unum will treat your disability as part of your prior claim and you will not have to Complete. another elimination period if:* - you were continuously insured under the plan for the period between your prior. claim and your recurrent disability; and ' ~ - your recurrent disability occurs within 6 months of tl~e end of your prior claim. Your recurrent disability will be subject to the same temps of this plan as your prior claim:. Any disability which OCcurs after 6 months from the date your prior claim ended will be treated as a new claim. The new claim wil! be subject to all of the policy pmvisi0ns. LTD~BEN-8 (10/1/2000) If you become entitled to payments under any other gr~OUp long term disability plan, you will not be eiigible for payments under the Unum plan. LTD-BEN-9 (10/1/2000) LONG TERM DISABILITY OTHER BENEFIT FEATURES WHAT BENEFITS WILL BE PROVIDED TO .YOUR FAMILY IF YOU DIE? (Survivor Benefit) When Unum receives proof that you have died, we will pay your eligible survivor a lump sum benefit equal to 3 months Of your gross disa!bility payment if, on the date of your death: .- your*disability had continued for 180 or more consecutive days; and - you were receiving or were entitled to receive payments under the Plan. If you have no eligible survivors, payment will be madE; to your estate, unless there is none. In this case, no payment will. be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim. WHAT IF YOU ARE NOT IN ACTIVE EMPLOYMENT WHEN YOUR EMPLOYER CHANGES INSURANCE CARRIERS TO UNUM? (Cont~inuity of Coverage) When the plan becomes effective, Unum will provide coverage for you if: - you ~e not in active employment because of a siclmess or injurY; and - you were covered by the prior.policy. Your coverage is subject to payment of premium. Your payment wilt be limited to the amount that would have been paid by.the prior carrier. Unum will reduce your payment by any amou,nt for which your prior carrier is liable. WHAT IF YOU HA VE A DISABILITY DUE. TO A PRE-F~(ISTING CONDITION WHEN YOUR EMPLOYER CHANGES INSYJRANCE CARRIERS TO UNUM? (Continuity of Coverage) Unum may send a payment if your disability results from a pre.existing condition if, you were: - in active employment and insured under the Plan on its effective date; and - insured by the'prior policy at the time of change. In order to receive a payment you must satisfy the pre-exiSting condition provision under: 1. the Unum plan; or 2. the prior carrier's plan, if benef:~s would have been paid had that policy.remained in force. If you do not satisfy Item I or 2 above, Unum will not make any payments. LTD-OTR-1 (10/1/20001) If you satisfy Item 1, we will determine your payments according to the Unum plan provisions. If you only satisfy Item 2, we will administer your claim according to the Unum plan provisions. However, your payment will be the lesser of: a. the monthly benefit that would have been payable under the terms of the prior plan if it had remained inforce; or b. the monthly payment under the Unum plan. Your benefits will end on the earlier of the fOllowing datles: 1. the end of the maximum benefit pedod under the plan; or 2. the date benefits would have ended Under the prior plan if it had remained in fome.· HOW CAN UNUM'S REHABILITA TION AND RETURN 7'0 WORK ASSISTANCE PROGRAM HELP YOU RETURN TO WORK? Unum has a vocational Rehabilitation and Return toWork Assistance program available to assist you in returning to worlc We will determine whether you are eligible for this program, at our sole discretion. In order to be eligible for rehabilitation services and benefits, you must be medically able to engage in a return to work program. Your claim file will be reviewed by one of Unum's rehabilitation professionals to determine if a rehabilitation program might help you return to gainful employment. As your file is reviewed,, medical and vocational inform,atio, n will be analyzed to determine an appropriate return to work program. If we determine you are eligible to participate in a Rehabilitation and Retum to Work · Assistance program, you must participate in order to receive disability benefrts. We will make the final determination of your eligibility for participation in the program. We will provide you with a written Rehabilitationand Fletum to Work Assistance plan developed specifically for you. You must comply with the terms of the Rehabilitation and Retum to Work Assistance plan in order'to receive disability benefits. The rehabilitation program may include at our sole discretion, but is not limited to, the following services and benefits: - coordination with your Empl'oyer'tO assist you to reborn to work; adaptive equipment or job accommodations tO allow you to work; - :vocational evaluation to determine how your disabiliity may impact your employment options; - job placement services; - resume preparation; - job seeking skills training; or' - education and retraining expenses for a new occupation. .LTD~OTR-2 (10/1/200011 WHAT ADDITIONAL BENEFITS WILL UNUM PA Y WHILE YOU PARTICIPATE IN A REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM? We will pay an additional disability benefit of 10% of your gross disability payment to a maximum benefit of $1,000 per month. This benefit is not subject to policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Income. However; the ' Total Benefit Cap will apply. In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while: - you are participating in the Rehabilitation and Return to Work Assistance program; and - you are not able to find employment. This benefit payment may be paid in a lump sum. WHEN WILL REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFITS END'? Benefit payments will end on the eadiest of the following dates: -'the date Unum determines that you are no longer eligible to participate in Unum's Rehabilitation and Return to Work Assistance program; or - any other date on which monthl~ payments would stop in aCCOrdance with this . plan. WHAT ADDITIONAL BENEFIT IS AVAILABLE FOR CHILD CARE EXPENSES*IF YOU ARE PARTICIPATING IN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM? When you are disabled and incurring child care expenses for your dependent - child(ren) and participating continuously in Unum's Rehabilitation and Return to. Work Assistance program, we will pay the Child Care Expense Benefit Amount. The payment of the Child Care Expense Benefit Amount will begin immediately after you stat: Unum's rehabilitation program. CHILD CARE EXPENSE BENEFIT AMOUNT Our payment Of the Child Care Expense Benefit Amount will: 1. be $250 'per month, per child; and. 2. not exceed $1,000 per month for all eligible child care expenses combined. CHILD CARE EXPENSE BENEFIT RULES · The Child Care Expense Benefit will be provided to reimburse your expenses incurred for providing care for your dependent children who are: 2' under the age of 15; or · incapable of providing their own care on a daily basis due to their own physical handicap or mental retardation. LTD-OTR-3 (10/1/2000) To receive this benefit, you must Provide satisfactory proof that: 1. you are incurring eXPenses for child care while partiicipating'in Unum's rehabilitation program; and 2. payments for child care have been made to the child care provider. Child Care Expense Benefits will end on the earlier of 1Ihe following: ~ 1. the date the dependentchild(ren) attain the age of '15; 2. if the dependent child(ran) are mentally retarded or physically handicapped, the date they are no longer: a. incapacitated; or. b. requ'a'ing daily care; 3. the date a charge is no Ion.~er made by the child ca~re provider; 4. the date you no longer participate in Unum's rehabilitation program; or 5. any other date payments would stop in accordance with this plan. LTD-OTR-4 (10/1/2000) OTHER SERVICES These services are also available from us as part of your Unum Long Term Disability plan. IS THERE A WORK LIFE ASSISTANCE PROGRAM A I/AILABLE WITH THE PLAN? We do provide you and your dependents access to a work Iife assistance program designed to assist you with problems of daily living. - · You can call and request assistance for virtually any personal or professional issue, from helping find a day care or transportation for an eldedy parent, to researching possible colleges for a child, to helping to deal with the stress of the workplace. This work life program is. available for everyday issues as well as crisis support. This service is also available, to your Employer. This program can be accessed by a 1-800 telephone number available 24 hours a day, 7 days a week or online through a'website. Information about this program can be'obtair~ed through your plan administrator. HOW CAN UNUM HELP YOUR EMPLOYER IDENTIFY AND PROVIDE WORKSrrE MODIFICATION ? A worksite modification might be what is needed to allow you to perform the material and su§stantial duties of your regular occupation with your Employer. One of our designated professionals will assist you and. your Employer to identify a modification we agree is likely to help you remain at work or return to work. This agreement will be in writing and must be signed by you, your Employe? and Unum. When this occurs, Unum will reimburse your Employer for the cost of the modification, up to the greater of: - $1,000; or - the equivalent of 2 months of your monthly benefit. This benefit is ava~able to you on a one time only basis. HOW CAN UNUM'S SOCIAL SECURITY CLAIMANT ADVOCACY PROGRAM ASSIST YOU WITH OBTAINING SOCIAL SECURITY r)ISABIUTY BENEFITS? In order to be eligible for assistance from Unum's Social Secur'~ claimant advocacy program, you must be receiving monthly payments from us. Unum can provide expert advice regarding Your claim and assist you wit~ your application or appeal. Receiving Social Security benefits may enable: - you to receive Medicare after 24 months of disabilil[y payments; - you to protect your retirement benef~s; and - your family to be'eligible for Social Security bener~s. We can assist you in obtaining Social Security disability benefits by: SERVICES-1 (10/1/2000) - helping you find appropriate legal representation; obtaining medical and vocational evidence; and. - reimbursing pre-approved case management expenses. SERVICES-2 (10/1/2000) ERISA Additional Summary Plan Description Info[marion Name of Plan: Lear Corporation Name and 'Address of Employer: Lear Corporation 21557 Telegraph Rd. Southfield, Michigan 48034 Plan Identification Number: a. Employer IRS Identification #: 13-3386776 b. Plan #: 522 Type of Welfare Plan: Disability Type of Administration: The Plan is administered by the Plan Administrator. Benefits are'administered by the insurer and provided in accordance with the insurance policy issued to the Plan. ERISA Plan Year Ends: December 31 Plan Administrator, Name, . Address, and Telephone.Number: Lear Corporation 21557 Telegraph Rd. Southfield, Michigan 48034 (248).447-1500 Lear Corporation is the Plan Administrator and named fiduciary of.the Plan, with authority to delegate its'duties. The Plan Administrator may designate Trustees of th.e Plan, in which case the Administrator will advise you .separately of the name; title and address of each Trustee. Agent for Service ,of Legal Process on the Plan: Lear Corporation 2! 557 Telegraph Rd. Southfieid, Michigan 48034 ~ Service of legal process may also be made upon 'the Plan Administrator, and any Trustee of the Plan. ERISA-1 (10/'1/2000) Funding and Contributions: The Plan is funded as an insured plan under policy number 551328 002, issued by Unum Life. Insurance ComPany of America, PPl~I Congress Street, Portland, Maine 04122. Contributions to the Plan are made as stated under 'WHO PAYS FOR THE COVERAGE' in the Certificate of Coverage. EMPLOYER'S RIGHT.TO AMEND THE PLAN The Employer reserves the right, in its sole and absolute discretion, to amend, modify, or terminate, in whole or in part, any or all of..the p, mv. ision.s, of this ,Plan (including any related documents and underlying policiies~, at any time anc~ Tor any reason or no reason. Any amendment, modification, or termination must be in writing and endorsed on or attached to the Plan. EMPLOYER'S RIGHT TO REQUEST POEICY CHANGE The Employer can request a policy change; Only an officer or registrar of Unum can approve a change. The change.must be in writing and endorsed on or attached to the poliCy. MODIFYING OR CANCELLING THE POLICY OR A PLAN UNDER THE POLICY · The policy or a plan under the policy can be cancelled: - by Unum; or - by the Policyholder. Unum may cancel or modify the policy or a plan if: - there is less than 75% participation of those eligible employees who pay all or part of their premium for a plan; or - there-is less than 100% participation of those eligible employees for a Policyholder paid plan; - .the Policyholder does not promptly provide Unum with information that is reasonably required; - the Policyholder fails to perform any of its obligations that relate to the policy; fewer than 10 employees are insured under a plan; . - the premium is' not paid in accordance with' the provisions of this .policy that specify' · whether the Policyholder, the employee, Or both, pay(s) the premiums; the Policyholder does not promptly report to Unum the names of any employees who are added or deleted from the eligible group; - Unum determines that there is a signirmant change, in the size, occupation or age of the eligible group as a result Of a corporate .transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its' employees; or - the Policyholder fails to. pay any portion of the premium.within the 31 day grace period. If Unum cancels or modifies the policy or a pian for reasons other than the . Policyholder's failure to pay.premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date or modification date. The Policyholder may cancel this policy or a plan if the·modifications are unacceptable. ERISA-2 (10/1/2000) any portion of the premium is not paid during the grace period, Unum will either lcfancel or modify the policy or plan automatically at the end of the grace period. The Policyholder is liable for premium for coverage dudng lfhe gr,ace period. The Policyholder must pay Unum all premium due for the full period each plan is in force. The PoliCYholder may cancel the policy or. a plan by w. ritten not_ice, de. liv.e.red to .Unum at least 31 days prior to the cancellation aate. When tx)th' the ~,o,cynolaer ana Unum agree, the policy or a plan can be cancelled on an earlier date. If Unum or the Policyholder cancels the policy or a plan, coverage will end at 12:00 midnight on the last day of coverage. If the policy or a plan is.cancelled, the cancellation wilt not affect a payable claim. CLAIMS PROCEDURES Unum will give you notice of the decision no later than~ 45 days after the claim is filed. This time period may be extended twice by 30 days if Unum both determines that such an extension is.necessary due to matters beyond the control.of the Plan and notifies you of the circumstances requiring the extension of time and the date by which Unum eXPects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension wil! specifically describe the required information, and you will be afforded at least 45 days from receipt o[the notibe within which to provide the specified · information. If you deliver' the requested information within the time specified, any 30 day extension periOd will begin after you have provided that information. If you fail to deliver the requested information within the tim'(; specified, Unum may decide your claim without that information. If your claim for benefits is whol!y or partially denied, 'the notice of adverse benefit determination under the Plan will: state the specific reason(s) for the determination; - reference specific Plan provision(s) on-which the determination is based; - describe additional matedal or information necessary to complete the claim and why such information is necessary; - describe Plan procedures and time limits for appea~ling the determination, and your right to obtain information about those procedures .and the right to sue in feder~J court; and - disclose any internal rule, guidelines,'protocol or similar, criterion relied On in making .the adverse determination (or state that such information will be provided free of charge upon request). Notice of the determination may be provided in v~fitten or electronic form. Electronic' notices will be provided in a form that complies with .any applicable legal requirements. ERISA-3 (10/1/2000) APPEAL PROCEDURES You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made not later than 45 days following receipt of the written request for review. If Unum determines that special circumstances require an extension of time for a decision on review, the review · period may be extended by an additional 45 days (90 (lays in total). Unum will notify you in writing .if an additional 45 day extension is needed. If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specilically describe the required info~','~ation, and you will be afforded at.least 45 days f~rom receipt of the notice to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal'per~)d will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information. You will have the opportunity to submit written comments, documents, or other information in support of' your appeal. You wal have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the adverse benefit determination will t.ake i~to'account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. .The review will be conducted by Unum and*will be ma,de by a person different from the person who made the initial determination and Such person will not be the original decision maker's subordinate. In.the case of a claim denied on the' grounds of a medica! judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during th(; initial determination or a subordinate, if the advice of a medical or vocational expert was obtained by the · Plan in connection with the denial of your claim; Unurn will provide you with the. names Of each such expert, regardless of whether.the advice was relied upon. A notice that your request on appeal is denied will contain the following information: - the specific reason(s) for the determination; - a reference to the specific Plan pmvisionis) on which the determination is based; - a statement disclosing any internal, rule, guidelines, protocol or similar'criterion relied on in making.the adverse determination (or a statement that such. information, will be provided free of charge upon' request); - a statement describing, your right to bring a civil suil: under federal law; - the statement that you are entitled to receive upon ref:luest, and without charge, reasonable access to or copies of all documents, .records or other information · relevant to the determination; and - the statement that "You or your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available ERISA-4 (10/1/2000) is to contact your local U.S. Department of Labor Office and your State insurance .regulatory agency". Notice of the determination may be provided in written ,or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements. Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim. YOUR RIGHTS UNDER ERISA As a participant in this Plan 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, all documents governing the Plan, including insurance contracts, 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 Pension and Welfare-Benefits Administration. Obtain, upon written request to the Plan Administrator, copies of documents goveming the operation of the Plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated summary plan .description. The Plan Administrator may make a reasonable charge for the copies. ~ Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Prudent Actions by Plan Fiduciaries In addition to creating riglits 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, halve a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your Employer or any other person, ma~y 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 Riqhts If your claim for a benefit is denied or ignored, in whole or in part, you ha~/e a ~ight to- know whythiS was done, to obtain, copies of docu. ments.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 Admin~istrat0r to provide the materials ERISA.5 (10/1/2000) and pay you up to $110 a ~lay until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan 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. 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 from 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 these costs and fees,, if, for example, it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the 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 Plan Administrator, you should contact the nearest office of 'the Pension andWelfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Tecl'inical Assistance and Inquiries, Pension and Welfare Benefits 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 Pension and Welfare Benefits Administration. DISCRETIONARy ACTS In exemising its discretionary POwers under the Plan, the Plan Administrat0r~ and. any designee' (which shall includeUnum as a claims fiduciary) will have the broadest discretion permissible under. ERISA and any other applicable laws, and its decisions will constitute final review of your claim by the Plan. Benefits under this Plan will be paid only if the Plan Administrator or its designee (including Unum), decides in its discretion that the applicant is entitled tO.them. ERISA-6 (10/1/2000) GLOSSARY ACCUMULATION PERIOD means the period of time from the date disability begins during which you must satisfy the elimination period. ACTIVE EMPLOYMENT means you are working for your Employer for eamin~s that ' are paid regUlarly and that you are performing the material and substantial duties of your regular occupation. You must be working at least the minimum number of hours as described under Eligible Group(s) in each plan. Your work site must be: - your Employer's usual place of business; - an alternative work site at the direction of your Employer*, including your home; or - a location to which your job requires you to travel. Normal .vacation is considered active employment. Temporary and seasonal workers are excluded from coverage. DEDUCTIBLE SOURCES OF INCOME means income from deductible sources listed in the plan which you receive or are entitled to receive while you-are disabled. This income will be subtracted from your gross disability payment. DISABILITY EARNINGS means the earnings which yOu receive 'while you are disabled and working, plus the'earnings you could receive if you were working to your maximum capacity. ELIMINATION PERIOD means a period of continuous, disability which must be satisfied before you are eligible to receive benefits from Unum. 'EMPLOYEE means'a person who is in active employment in the United States with the Employer. EMPEOYER means the Policyholder, and includes any dMsion, subsidiary or affiliated company named in the policy. EVIDENCE. OF INSURABILITY means a statement of your medical history which Unum will use to determine if you are apprOved-for COverage. Evidence.of insurability will be · at Unum's expense. GAINFUL OCCUPATION means an occupation that is'or can be expected to provide you with an income at least equal to your gross disability payment withih 12 months of your return to work. GRACE PERIOD means the pedod, of time following the premium due date dudng which premium' Payment may. be made. GROSS DISABILITY PAYMENT means the benefit amount before Unum subtracts deductible sources 'of income and disability earnings.. HOSPITAL OR INSTITUTION means an accredited facility licensed to provide care and treatment for .the condition, causing your disability. GLOSSARY-1 (10/1/2000) INDEXED MONTHLY EARNINGS means your monthly earnings adjusted on each .anniversary of benefit payments by the lesser of 10% or the current annual percentage tncrease in the Consumer Price Index. Your indexed monthly eamings may increase or remain the same, but will never decrease. The Consumer Price Index (CPI-W) is published by the U.S. Department of Labor. Unum reserves the right to use some other similar measurement if the DePartment of Labor changes or stops publishing the CPI-W. Indexing is only used to determine your percentage of lost earnings while you are disabled and working. INJURY means a bodily injury that is the direct result of art accident and not related to any other cause. Disability must begin while yOu are covered under the plan. INSURED means any person covered under a plan. LAW,. PLAN OR ACT means the original enactments of the law, plan or act and all amendments. LAYOFF or LEAVE OF ABSENCE means you are temporarily absent from active employment for a period of time that has been agreed to in advance in writing by your Employer. Your normal vacation time or any period of disability is not considered a temporary layoff or leave of absence. LIMITED means what you cannot or are unableto do. MATERIAL AND SUBSTANTIAL DUTIES means duties l~hat: -' are no.rmally required for the performance of your regular occupation; and - cannot be reasonably omitted, or modified, except that if you are required to work on average in excess of 40 hours par week, Unum will constder you able tO perform that requirement if you are working or have the capacity to work 40 hours per week. MAXIMUM CAPACITY means, based on your restrictions and limitations:' - during the first 24 months .of disability, the greatest extent of work you are able to do in your regular occupation, that is reasonably available. - beyond 24 months of disability, the greatest extent of ~rk you are able to do in any occupation, that is reasonabl, y available, for which you ca'e reasonably fitted by education, training or experience. MAXIMUM PERIOD OF PAYMENT means the longest period of time Unum will make payments to you for any one period of disability. 'MENTAL iLLNESS means a psychiatric or psychological condition regardless'of cause such as schizophrenia, depression, m~nic depressive or bipolar illness, anxiety, pers~)nality disorders and/or adjustment disorders or Other conditions. These conditions are usually treated by a.mental health Provider or other qualified'provider using psychotherapy, psychotropic drugs,'or other similar methods of treatment. GLOSSARY-2 (10/1/2000) MONTHLY BENEFIT means the total benefit amount for which an employee is insured under this .plan subject to the maximum benefit. MONTHLY EARNINGS means your gross monthly income from your Employer as defined in the plan. MONTHLY 'PAYMENT means your payment after any deductible sources of income have been subtracted from your gross disability payment. PART-TIME BASIS means the ability to work and earn 20% or mom of your indexed monthly earnings. PAYABLE CLAIM ~heans a claim for which Unurn is liablE; under the terms of the policy. PHYSICIAN means: -. a person performing tasks that are within the limits Of his or her medical license; and - a person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or - a person with a doctoral degree in Psychology (Ph.D. or Psy. D.) whose primary practice is treating patients~, or · - a person who is a legally qualified medical practitioner according tO the laws and regulations of the governing jurisdiction. Unum will not recognize'you, or your spouse, children, parents 0r siblings as a phYSiciar~ for a claim that you send to us. PLAN means a line of coverage under the policy.. POLICYHOLDER means the Employer to whom the pol!cy is issued. PRE-EXISTING CONDITION'means a condition, for which you received.medical treatment, consultation, care or services including diagno,,Aic measures, or took prescribed drugs or medicines for your COndition during the given period of time as stated in the plan; or you had symptoms for which an ordinarily prudent person would have consulted a health care provider during the given period of time as stated'in the plan. RECURRENT DISABILITY means a disability which is: - caused by a worsening in your COndition; and due to the same cause(s) as your prior disability for which Unum made a Long Term Disab~ity payment. REGULAR CARE means: - you personally visit a physician as frequently as is mediically required, acCOrding to gene. rally:a.ccept.ed medical standards, to e~ectively manage and treat your disabling COndition[s); ana . - you are receiving the most appropriate treatment and care which confo~r,~s with g.enerally accepted medical standards, for your disabling COndition(s) by a physician wnose~ specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical'standards. GLOSSARY-3 (10/1/2000) REGULAR OCCUPATION means the occupation you are routinely performing when your disability begins. 'Unum will' look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location. RETIREMENT PLAN means a defined contribution plan o~r defined benefit plan. These are plans which provide retirement benef~s to employees and are. not funded entirely by employee contributions. Retirement Plan includes but is' not limited, to any plan which is part of any federal, state, county, municipal or association retirement system. SALARY CONTINUATION OR ACCUMULATED SICK L~-'AVE means continued payments to you by your Employer of all or part of your monthly earnings, after you_ become disabled as defined by thePolicy. This continued payment must be part ot an established plan maintained by your Employer for the benefit of ali employees covered under the Policy. SalarY continuation or accumulated sick', leave does. not in.c. lude compensation 'lSald to you by your Employer for work you actually perform aner your disability begins.' Such compensation is considered disability eamings, and would be taken into account in calculating your monthly payment.'- SELF-REPORTED SYMPTOMS means the manifestations of your condition which you tell your physician, that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, nnglng in ears, dizziness, numbness and loss of energy. SICKNESS means an illness or disease. Disability must begin-while you are covered under the plan. , SURVIVOR, ELIGIBLE .means your spouse, if living; otherwise your children uhder age 25 equally. TOTAL COVERED PAYROLL means the total amount of monthly earnings for which employees are insured under this Plan. WAITING PERIOD means the continuous period of time (shown in each 'plan) that you must be in active employment in an eligible group before you are eligible for coverage under a plan. WE, US and OUR means Unum Life Insurance Company of America. YOU means an employee who is e!igible for Unum coverage. GLOSSARY-4 (10/1/2000) NOTICE OF PRIVACY PRAC'rlCES UnumProvident Corporation and its subsidiaries Unum LEe Insurance Company of America First Unum LEe Insurance Company Provident Life & Accident Insurance Company Provident LEe & Casualty Insurance Company Colonial LEe & Accident Insurance ComPany Paul Revere Life Insurance Company Paul. Revere Variable Life Insurance Cc~mpany Congress recently passed the Gramm-Leach-Blliey (GLB) Act, which deals in pert with how. financial institutions treat nonpubli~ personal financial information. UnumProvident Corporation ana its in.s~.r.i.ng subsidiaries have always been committed to maintaining customer confidentiality. We appreciate m~s opportunity to clarify our privacy praCtices for you as a result of this new law. - As part of our insurance business, we obtain certain "nonpublic: personal financial information' about you, which for ei~se of reading we will refer to es.'information' in this notice. This information includes inform~on we receive from you on applications or other forms, information about your transactions with Lis, our affiliates or others, and information we receive from a consumer reporting agency. - We restrict access to'the informalJon to authorized individuals ~M3o need to know this information to provide service and products to you. ·. · - We maintain physical, electronic, and procedural, safeguards that protect your intormation. We do not disclose this information about you or any former customers to anyone, except as permitted by law. - Employees share this information outside the company only as authorized by you orfor a specific business purpose. - The law permits us to share this information with our affi3iates, including insurance companies and insurance, service providers. - The law also permits us to sham this information with companies that perform marketing services for us, or other financial institutibns that have joint marketing agreemer~ts with. us. We may also share other types of information with our affiliates, including insurance, companies and insurance service providers. This information may be financial or other personal information, such as employment history and it may not be directly related to our transaction.with you..consistent with the Fair Credit Reporting ACt, our standard authorizations permit us to share this information with bur afflietes. You do not need to call, or do anything as a result'of this notice. It is meant to inf°rm you of bow we .safeguard your nonpublic personal financial'information~ You may wish to file this notice with your . insurance papers. If y.ou want to learn more about the GLB Act, please visit our web silvas at www. unumprovident.com or · www. unumprovident.com/colonfal, or contact your insurance professional. We value our relationship with you and strive to earn your continued trust. GLB-1 (10/1/2000) · .' . . . . ' ...; .:.' .:.. ' -...'.: ..," .. . .'". ... :. , ""' : Carol Brale~ n'i'Sr'Custome~ Cafe s e~iali.st "..: "' · ..' - ', Re?Elaine .Killia'n ." ... ' ." '." '... '. · · Claim ~.0099112567 :""':""" ' ::"' :' ' " " ..... : :..~.....:t......p.,,,~ M..':B~.~' - '. -,. --. ; ': .:' '.';'C'::.- ,.'::'-.; ' " "' " "' '"": .... ":' ' " ' ' ' : · .... ~.~ , .......-: .. :..... ;..'::-..:'..-.:'-.'-.....'-....;:... :,. .:: .-.: .... . -. '1 'have. [e~d .!he '!~er.:.YOU S~t..':tO my.,p~lie, nt, :EI.ain~ 'Kil.~ia~, 'd~d '~1.9/~,'-.~t~:': ":: trePidatmn and some'disdain.. To re~ie~.t~6'situatiofi, ~'~u~{ ~mbe~ ih'a~ Elaine". · . : -had a .maJig'~a~t tum~r'th~t:Wa~ ~y,d.iff cQlt'to.~iagnose b~idg"~itU'ated behind her. '. "' iFpendii'::"$fi~ al~o:has 'endometrio~is.W~i~h, ~y itself; ~aUSa's'tmOrbia[ty fbr ma~y: ' ' : giv'en the C~ohbl6gy'i~ t~i~ le~br '~'~cau'~e"r a~derstan~ ~)o'a do h~v~ ~ C~'py..~f ~y'. ' r~co~d reg~rdin'g her,:.The fact tha{~he 'patient was' ~o~pitalized On 8/20/01-8124/01 indicates th.e.seveHty of her pain..Per your own notes, you stated the"pa~ient did have ~ignificant'adhes on~ which' are veiy difficult 'to di'agno~e'.. I'm surprised that' fatigue . . was lhe pn~y.!!~p!aint, ii'i~ed.': Tbe pat~'e~t al~o complaihed at that ti'me of abdominal paifl, hematuria, rectal bleeding;".ahd ~'iarthea'.' Th~ patient'~'periodS'cam~ early'; anywhere" f.mm. 16:28.: day~ and'.lasted '3!5 .'d&ys..Her' .'pe[iods Were h'e~gy' and associated with much pain aad bleeding.-I .t~ink this'is'probably the .JeSuit df her continuing endometriosis~ 'Her .malignant tumor was also situated'in an unusual location, which made i~-'very' difficult to find..If you tak~ the 'patient's endometriosis, her tumo[, and the 9ppendicitis, this woald eqaate to ~:justified absence from work. If you feel otherwise, I' Would like to hear your documentation ~egar~ing that. . .': . : '.. ':...'":~_~.< .... ~.~-~.... ", :.,. .:.:.. - . '. ,..,. :.: ;.~-~~~..~, .~~,.. :'.:: ~:-../:-~~ · .. v'm' .~[go .e~n~e.roe~ ab'o'dt' th~: f°lio~ing-'stat~nt:that .~;ou '~Ut ~i~' you[ hole, ."The 'regtrictipns'.and limiiaii'~S'.w~re pr~v.ided b~.a'~urse ff~ac;t~ti0n'er, sandy.~bbey,.:not ' ' ~ physician;". Saddy'Ab~ey.i's.a'~vefY yaluhble' .and'""~rreCaceable"" ' : ' nurse."' ' "practlt" ....... oner whb .' -.: ha~ had ~c~ ~x~erience'and works With' m~'&n'a daii~basis. She is'.b0a(d certified in f~mily"pi~cti~e; If Sand~ ~bSe~Y ~t'a~ed'the~';tient W~.s'bp~b e to'work'and'ga~e her .: ~estrictio~s,'~.o.u can .be a~su~ed 'that-her judg'e~ent was solid and based 6n fact. I wobld-also .be inteCested to kn0W"what p[om. pted you...~o-make a slanderous remarE" ...- ~b0u~ .~andy'~Ab~ffyr~'.~oard Certified nurse practitioner;'.l fin'd it yew difficult to · ' aCcept the 'fict th'a~.~laine Ki!U~,..~ff0 is~a '~ n'g e pareht;is'~ffugg in~' day by day to · ' maintain· ~e~ ~gnit~ Wit~ pai'n ~ah'd does not seem t0 ~hve any help from t~e' people. · . .. ' ,solved. '1 f~el it i~ -unfair.~nd unjust that yqu'do hot reimburseme~ f&r'~ime off for her" ': : 'd~'cpmen~ea,.~:nd.val d~i in'e~s~'.--i "st~0ngty'p[ead'~6at'.y0u c°nsider her Cafe"and if ' ' .~.: nece'ssar¢, I Wbdld' Be h~ppY ~o' ~e{tify 6'& h'er'behalf against YOu if hecessary', VERIFICATION I, Elaine M. Killian, do hereby verify that the facts set forth in the foregoing Coml~laint are tree and correct to the best of my personal knowledge or infom:ation and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C,.S. §4904, relating to unswom falsification to authorities. Document #: 243176.1 CERTIFICATE OF SERVICE I, KIRK L. WOLGEMUTH, ESQUIRE, certify that I served a tree and correct copy of the foregoing Notice of Removal upon the following counsel of record, by depositing the same in the United States mail, postage prepaid, this i}~ Id-day of November, 2002, addressed as follows: James F. Carl, Esquire Metzger, Wickersham, Knauss & Erb, P.C. 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Date: November ~./-~2002 Kirk L. Wolgemuth SLi 3067glvl/10305.115 CERTIFICATE OF SERVICE I, KIRK L. WOLGEMUTH, ESQUIRE, certify that I served a tree and correct copy of the foregoing Notice to the Prothonotary of Notice of Removal upon the following individual and Plaintiff's counsel of record, by depositing the same in the United States mail, postage prepaid, this ___ day of November, 2002, addressed as follows: Prothonotary Court of Common Pleas Cumberland County One Courthouse Square Carlisle, PA 17013-3387 and James F. Carl, Esquire Metzger, Wickersham, Knauss & Erb, P.C. 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Date: November ff ,2002 Kirk L. Wolgemuth SLI 3067~1vl/10305.115 SHERIFF,S RETURN - CASE NO: 2002-04983 p COMMONWEALTH OF PENNSYLVANIA COUNTy OF CUMBERLAND U.S. CERTIFIED M-AIL KILLIAN ELAINE M VS. UNUM LIFE INS CO OF AMERICA R. Thomas Kline Sheriff of Cumberland County, Pennsylvania, who being duly SWorn according to law served the within named DEFENDANT ,UNUM LIFE INSURANCE COMPANy OF AMERICA '~ by United States Certified Mail postage prepaid, on the 16th day of October ,2002 at 0000:00 HOURS at 2211 CONGRESS STREET PORTLAND, ME 04122 and attested copy of the attached COMPLAINT & NOTICE with a true Together receipt card was signed by SIGNATURE ILLEGIBLE i0/i8/2002 Additional Comments: The returned on Sheriff,s Costs: Docketing 18.00 Cert Mail Affidavit 4.42 .00 Surcharge 10.00 .00 32.42 Paid by METZGER WICKERSHAM Sworn and subscribed to before me this L~ day D. o tary ' Sheriff of Cumberland County on ii/04/2002 · Complete items 1, 2, and 3. Also complete item 4 if Restflcted Delivery is desired. · Pdnt your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mallpiece, or on the front if space permits. 1. Article Addressed to: UnLF~ Life Insurance C~,pany of A~nerica 2211 Congress Street Portland, ME 04122 , ~.01 2510 0009 1017 B. iv~ ~ '~ ~ Certified Mail [] Expre~. ~ Mail ~ [] Registered [] Return I ¢{eCell ~[] In~ MeiJ D C.O.D. 8527 02_49,83 PS Form 3811, August 2001 Domestic Return Receipt