HomeMy WebLinkAbout98-07050
)
~
\....
\.I
~
'It.
~
(~
!
I
i~
;
: \I
'~
~
~
~
tJ
tJ
~
~
~
,~
IV)
8
I. .-.1
-
.~
.~
f
...
\~
~
-
.::s
~
~
~
~
.
Hamaker's vehicle, whIch n!sulted in inJuries t.o .Julie Hamaker.
2. The cumberland County Complaint alleged that ERX
Logistics, Presidium, Inc., and Subrogation Advantage were
claimants to the $100,000 as a result of medical expenses paid by
them to or on behalf of ,Tulie Hamaker.
3. On April 14, 1999, ERX Logistics, Presidium, Inc. and
Subrogation Advantage filed a motion to withdraw from the action
and to substitute the Plan as the proper respondent, since it is
the Plan that paid all of the medical expenses. On April 19,
1999, Judge Edward Guido of the Cumberland County Court of Common
Pleas entered an order issuing a rule upon Petitioners to show
cause why the Respondents' motion to substitute parties should
not be gr'anted.
4. At a conference before the Judge Guido on April 30,
1999, all parties con~nted to the motion to substitute parties
and Judge Guido issued an order providing that ERX Logistics,
Presidium, Inc., and Subrogation Advantage are removed as parties
from this action, and ERX Logistics Employee Benefit Plan is
added as a respondent.
5. The Plan is an employee benef~t plan governed by the
provisions of the Employee Ret,rement Income Security Act of
J 974, as amended, ("EIHSJ\") ~ 9 U. S. C. 51101, f.'.L..~.\:-'l~
6. AS;1 re,;ult of the accident "nvolving Johnson and Julie
Iidmaker, th" F}."n pcnd Sll J, 787. J6 to or on L",hal f of .Julie
Hamaker.
7. The Plan ;vJreemt,nt contai:l<? a pr'ovl Slon provlding the
2-
(>2':J-r ;;0, f9??
ERIE INSURANCE EXCHANGE and
LINDA F. JOHNSON,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Petitioners
v.
ACTION IN EQUITY
JULIE HAMAKER, DONALD
HAMAKER, individually and as
husband and wi fe, and ERX
LOGISTICS EMPLOYEE BENEFIT
PLAN,
NO. 98-7050 EQUITY
Respondents
~OTICE OF NOTICE OF REMOVAL
Notice is hereby given that this action was removed to the
United States Distrlrt Court for the Middle District of
Pennsylvania on May 19, 1999 in ilccordance with the attilohed
Notice of Removal.
Respectfully submitted,
McNEES, WALLACE & NURICK
(71 -".-1-'V. ^"t
- onathan H. Ru d, Lsq.
Attorney 1.0. No. 56880
100 PIne Street
P.O. Box ]] 6 G
Bilrri ';!)U;-g, PA ] 7] 08 -]] 61)
(717) 23'1-540"
\
'. /
Attorneyn lor Respondent
E!~X 1'('(1! :_~t i C:3 Empl oy(~e
Ben.l"l::. Pl,111
I).jtv: t.~.iV Jo, } ~!~~~;
\
John M. Popilock, Esquire
Altorney 1.0. # 72671
Timothy I. Mark, Esquire
Attorney 1.0, # 27758
Thomas, Thomas & Hafor, LLP
305 North Front Streel
P. 0, Box 999
Harrisburg, PA 17108.0999
(717) 255-7629
Attorneys for Plaintiffs
ERIE INSURANCE EXCHANGE
and LINDA F. JOHNSON,
Petitioners
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
v.
ACTION IN EQUITY
JULIE HAMAKER, DONALD
HAMAKER, individually and as
husband and wife, ERX LOGISTICS,
PRESIDIUM, INC., and
SUBROGATION ADVANTAGE
Respondents
NO. ~r)!JL> ~1Jlt~10
ORDER
AND NOW, this _ day of , 1998, upon consideration of the
Complaint in Interpleader of Erie Insurance Exchange and Linda Johnson, and after
consideration of the matters set forth therein, it is hereby ORDERED and DECREED that:
1. Respondents, upon service of the Complaint in Interpleader, and a copy of this
Order, are directed to file with this Court, referencing the above term and number, any and all
claims to the interpleaded funds, said claims to be filed within thirty (30) days of the date of
service; further, with said claim, the Claimants are directed to indicate whether they object or
concur in the prayer of the Petitioners that upon payment of the insurance proceeds, the
Petitioners, Erie Insurance Exchange and Linda Johnson, should be discharged from any and
all liability relative to the subject action by virtue of general releases;
2. Respondents shall also file with the claim a statement: (a) identifying any
insurance company providing underinsured metorist coverage to the Respondents andlor
resident relative having a separate policy of insurance and the name 01 such insurance
company; (b) and an indication as to whether the Respondent is bound by the limited tort or full
tort option and if the limited tort option was selected, whether any exception applies thereto; (c)
and any entity known to have an ERISA qualifying lien against the proceeds of this Interpleader.
3. Following the time period referred to above in Paragraph 1 oltl1is Order, any
counsel representing any of the known Respondents may request a conlerence before one of
John M. Popilock, Esquire
Attomey 1.0. #72671
Timothy I. Marl<, Esquire
Attomey 1.0. #27758
Thomas, Thomas & Hafer, LLP
305 North Front Street
P. O. Box 999
Harrisburg, PA 17108-0999
(717) 255-7629
Attomeys for Plaintiffs
ERIE INSURANCE EXCHANGE
and LINDA F. JOHNSON,
Petitioners
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
v.
ACTION IN EQUITY
JULIE HAMAKER, DONALD
HAMAKER, individually and as
husband and wife, ERX LOGISTICS,
PRESIDIUM, INC., and
SUBROGATION ADVANTAGE
Respondents
NO. if.. 70 )-0 (Cg'U{_~~
COMPLAINT IN INTERPLEADER
The Petitioners, Erie Insurance Exchange and Linda F. Johnson, by their attorneys,
Thomas, Thomas & Hafer, LLP, bring this action for interpleader against the Respondents and
in support thereof, aver as follows:
1. Petitioner, Erie Insurance Exchange, is a reciprocal Insurance EX.change
organized under the Insurance Company Law of Pennsylvania with its home office and principal
executive offices located at 100 Erie Insurance Place, Erie, Pennsylvania, 16530.
2. Petitioner, Linda F. Johnson, is an adult individual residing at 221 Three Square
Ho!low Road, Newburg, Pennsylvania 17240-9213.
3. Respondents Julianne Marie Hamaker and Donald G. Hamaker, Sr., husband
and wife, are adult individuals w:th a last known address at 11 Lynn Avenue. Newburg,
Pennsylvania 17240. It is believed that Ms. Hamaker is being represented by Attorney Donald
Siaontz, 34 Market Place 3900, Baltimore, MD 21202.
4. Respondent, ERX Logistics, maintains a self-funded employee benefit plan and
has a principal place of business at Patterson Avenue. Grand Rapids, MI, 49505.
5. Respondent, Presidium, Inc., is a subrogation service organization and has a
principal place of business at P.O. Box 2305, Mt. Clemens, MI 48046-2305.
6. Respondent, Subrogation Advantage, is a subrogation service organization
maintaining a principal place of business at 2100 Ford Parkway, Suite 250, St. Paul, Minnesota,
55116.1813.
7. On or about March 7, 1997, Petitioner, Linda F. Johnson, was driving a 1986
Ford F150 with a vehicle identification number 1FTEF14YOGNA42272 in a northern direction on
Shippensburg Road in Hopewell Township, Cumberland County, Pennsylvania.
8. At that same time, Respondent Julianne Marie Hamaker was proceeding in a
southerly direction on Shippensburg Road driving a 1990 Plymouth Grand Voyager owned by
Donald G. Hamaker, Sr., and Julianne Hamaker, containing a Pennsylvania title number
42623992902.
9. At that time and location, Petitioner Linda Johnson caused an accident between
the two vehicles, and Julianne Marie Hamaker sustained serious injuries. including but not
limited to, a crush type injury with open fracture, dislocation to the right ankle.
10. At the time of the accident, Linda F. Johnson was the owner of the motor vehicle
involved in the accident and maintained insurance with Erie Insurance Exchange under policy
number 008-0111165. A copy of Ms. Johnson's declaration pages for this insurance are
attached hereto as Exhibit. A."
11. The aforementioned policy of insurance for Linda F. Johnson covering the
vehicle involved in the motor vehicle accident giving rise to the instant cause of action provided
for bodily injury limits of $100,000.00 for all damages caused to anyone person in a vehicular
accident and a totallimil of $300,000.00 per accident.
12. Based on information from Petitioner Johnson, at the time of the accident, Linda
F. Johnson did not have any other insurance, whether it be an excess policy or an umbrella
policy or otherwise that would provide additional coverage for damages to the Defendants as a
result of this accident. A copy of Linda F. Johnson's affidavit of no other insurance coverage is
attached hereto as Exhibit "B"
2
13. Petitioner Linda Johnson was operating her own car so the aforementioned Erie
insurance policy is exclusive for automobile liability. Petitioner Linda Johnson maintained no
other policy of insurance and resided with no one whose insurance policy would apply to her.
14. Although a formal cause of action has not yet been commenced in any court
against the Plaintiffs herein, Plaintiffs Erie Insurance Exchange and Linda F. Johnson believe
and therefore aver that Linda F. Johnson's insurance policy through Erie Insurance Exchange
providing $100,000.00 per person limitation and $300,000.00 per accident limitation would be
inadequate to satisfy all potential claims arising from the accident as described herein.
15. It is believed and therefore averred that ERX Logistics has a self-funded
employee benefit plan which ha:; made payments on behalf of their employee, Donald
Hamaker, which plan is formed under the provisions of federal law under ERISA. At this time,
the exact amount of any such ERISA lien is unknown.
16. It is believed and therefore averred that Respondent Presidium, Inc. maintains a
self-funded employee benefit plan for ERX Logistics who presently has a lien of $50,000.00. A
copy of a letter from Presidium, Inc. is attached hereto as Exhibit C.
17. It is believed and therefore averred that Respondent Subrogation Advantage has
been retained by ERX Logistics' stop loss carrier to pursue a subrogation recovery for the
medical benefits that have been paid. It is believed that Respondent Subrogation Advantage's
asserted lien is in the amount of $59,549.36. A copy of a letter from Subrogation Advantage is
attached hereto as Exhibit D.
18. It is believed that Respondents Julie and Donald G. Hamaker are presently
represented by Attorney Donald Siaontz, 34 Market Place, 3900, Baltimore, Maryland 21202.
19. Respondents ERX Logistics, Presidium, Inc. and Subrogation Advantage are
presently unrepresented in this action. However, Presidium, Inc.lCoreSource Subrogation
Services represents ERX Logistics on their self.funded employee benefits plan and may, in fact,
represent ERX Logistics in this proceeding.
20. Erie Insurance Exchange, on behalf of Petitioner Linda Johnson, hereby tenders
10 this Honorable Court Ihe $100.000 insurance policy limits al issue.
3
21. Petitioners cannot determine the appropriate apportionment of the claims of the
various Claimants and has no means other than these proceedings to determine the person(s)
to whom payment should be made and the amount of such payment(s).
22. It is proposed that Erie Insurance Exchange hold the $100,000 bodily injury
liability limits subject to final order of distribution by the Court and the execution of general
releases by all Respondents in favor of all Petitioners.
23. When the Court issues an Order directing payment by Erie Insurance Exchange
to the respondents in their respective shares of the insurance proceeds, Erie Insurance
Exchange, and its insured, Linda Johnson, shall be given general releases by the Respondents
and any other claimants discharging Petitioners from any and all liability relative to the subject
action.
24. Petitioners believe and therefore aver that Respondents may have available
coverage for underinsured motorist benefits and any such underinsured motorist benefit carriers
will have to give consent and waiver of subrogation rights before any policy limits can be
distributed; it is therefore requested that the Respondents identify any underinsured motorist
benefit carriers and/or resident relatives having separate policies of insurance and their
respective insurance companies so that these carriers can be put on notice of these
proceedings.
25. Petitioners believe and therefore aver that there may be other unknown entities
who have subrogation rights for medical payments, wages disability and the like who will have
to give consent and waiver of subrogation rights before any policy limits can be distributed; it is
therefore requested that the Defendants identify any such entity and their respective insurance
companies so that these carriers can be put on notice of these proceedings.
WHEREFORE, Petitioners, Erie Insurance Exchange and Linda Johnson, respectfully
request this Honorable COUl1to:
A. Grant its Complaint in Interpleader and direct the parties to provide their notice of
claim within thirty (30) days so that this Court can make a proper assessment as to the
apportionment of the claims of the various Claimants: and
4
',',. ,"', .~,', ',,' '",' :.l"W"~"".O"~"'~":'l.-,:~","-,;~".~~,,,,~.,......J<":".. ._::' .', !:iIII...,,~,( ,.' \,
. " '. ,,' ,I .'. "
B Direct Respondents to notify Petitioners within thirty (30) days of service hereof
of the identity of any entity providing underinsured motorist coverage of the pendency of
this action, and notify any entity known to have a ERISA qualifying lien. of the pendency
of this action; and
C. Issue an Order deciding the apportionment of the funds and directing
Respondents to execute general releases in favor of the Petitioners and discharging
Erie Insurance Exchange and Linda Johnson from any and all liability.
Respectfully submitted,
THOMAS, THOMAS & HAFER, LLP
By: ~ 4'7. ,/;::/7'7
/..1 hn M. Popilock, E~quire
Attorney 1.0. # 72671
Timothy I. Mark, Esquire
Attorney 1.0. # 27758
305 North Front Street
P. O. Box 999
Harrisburg, PA 17108-0999
(717) 255-7629
Dated: December 11, 1998
:25847.1
5
, ". - ~' ty- " ' '" 1> ~ "".~ r,.J1l", ... \
. '~'. ._-",,'t,"" 1":,'"~;''''' '~''.~'"-.f-,,,,-,I';~''''!''\''l;'\;V'lr''''':'~,,'' ~t."""'''J "; "''''''~' "tt,~' ',,' ,11 ~ ' .
I :' '" ,,_ 'l':. f' " I, , ,'."',.,'. , '\ \ . '. " '. '
CONTINUATION NOTICE
PIONEER FAMILY AUTO POLICY
AA7401
CARL L CRAMER
08/01/96 TO 08/01/97
Q08 0111165 H
LINDA F JOHNSON
221 THREE SQUARE HOLLOW RD
NEWBURG PA 17240-9213
AGENT - CARL L CRfu~ER
*****
.'.GENT PHONE - (717) 423-5902
AS LISTED BELOW
4 E. MAIN STREET
NEWBURG PA 17240
****************~~*************************************~****~******
* FIRST ACCIDENT FORGIVENESS APPLIES. THE FIRST SURCHARGE FOR A *
* FUTURE AT-FAULT ACCIDEN'r WILL BE WAIVED. *
**************************.****************************************
ITEM
.'.UTO
1
2
4. AUTOS COVERED
YR MAKE
77 CHEVE MONTE CARLO
86 FORD XLT F-150
VIN ST
lH57L7B498945 PA
lFTEP14YOGNA42272 PA
TER SYM
27
27 :;
R-'.TING CLASS
.:>.lAS-MULTI
.'.2.!l.L-~!ULTI
DDP
ITEH 5. INSURANCE IS PRO'vIDED 'wHE:RE .'. PRn!lUM, OR ING., IS SHOViN FOR THE
COVERP.GE. COVER..^.GES, L1MITS JI.ND ;'.NNU,^.L PREMIUI-\S .>.RE ;'.5 FOLLOWS-
~l ~2
*~~~~GOOD DRIV~~ ~~T~S APPLY**~**
___ THE FULL TORT O;'TI811 ."PPLES '1'0 .>.LL PRI'';.'.~'o ?'.SSE~lGER VEEICLES. ---
LIABILITY PROTECTION-
BODILY INJURY SlOOM/PESSCN S300~!ACC
PROPERTY D;'J~.GE .s 1 OO~/ .:.CC
:IRST P.>.RTY EENEFITS-
MEDICl'.L EXPENSE 51 OOM
INCOME LOSS 5 lM/t.10NTH, 5 1 o~\ ~!J.o.:nHUM
.l\CCIDENT!'.L DEJI.TH SSM
FUNER-l\L EENEFIT 52.oM
UNINSURED MOTORISTS COVER..'.Gi':-
BOD INJ SlOOM/?ERSON 5300M/ACC-STACKED
LllIDERINSU?ED i.mTORISTS CO\i;:R.'.GE-
EOD IllJ S 100;.\/PERSON 5300;.\/,\CC-ST.'.CKED
?EYSIC:'\L DAl-\..'\CS CQ'lER..'\Gr:S-
, . 9
, " - .-
,- =
~': -
4 3 ~ 7
9 12
1 -
2 2
1 8 1 8
5 4 - ,
:)--:
'"
John M. Popllock, Esquire
Atlorney 1.0, 1172671
Timothy I. Mark, Esquire
Attorney 1.0. 1127758
Thomas, Thomas & Hafer, LLP
305 North Front Street
P. O. Box 999
Harrisburg, PA 17108.0999
(717) 255-7629
Attorneys for Plaintiffs
ERIE INSURANCE EXCHANGE
and LINDA F. JOHNSON,
Petitioners
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
v.
ACTION IN EQUITY
JULIE HAMAKER, DONALD
HAMAKER, individually and as
husband and wife, ERX LOGISTICS,
PRESIDIUM, INC., and
SUBROGATION ADVANTAGE
Respondents
NO. 98-7050 EQUITY
RULE TO SHOW CAUSE
AND NOW, this II~' day of ~ ' 19!J. upon consideration of the
Complaint in Interpleader of Erie Insurance Exchange and Linda Johnson, and after consideration
of the matter set forth therein, it is hereby ordered and decreed that:
1. Petitioners shall serve a copy of the Complaint in Interpleader, and a copy of this
Order, upon all Respondents identified in the Complaint.
2. Upon proof of service being filed with the Prothonotary of the Court of Common
Pleas of Cumberland County with regard to service of the Complaint in Interpleader, Respondents
are hereby ordered to show cause within thirty (30) days of the date of service why Petitioners'
Complaint in Interpleader shall not be granted.
3. Respondents shall also file with their concurrence or objection to the Complaint in
Interpleader a statement:
(a) Identifying any insurance company providing underinsured motorist
coverage to the Respondents and/or resident relative having a separate policy of insurance and
the name of such insurance company.
(b) An indication as to whether the Respondent is bound by the limited tort or
full tor1 option and, if the limited tort option was selected, whether any exception applies thereto.
02116-09
02/09/99
8. Admitted.
9. Admitted.
10-13. Neither admitted or denied, the means of proof being
wholly within the control of an adverse party. Strict proof
thereof, if relevant is demanded at trial.
14. It is admitted that respondents Julianne Hamaker and
Donald Hamaker have not yet instituted litigation. It is admitted
that, if indeed Erie's limit of liability is $100,000, that this
would be inadequate for the claims of answering Respondents.
15-17. Neither admitted nor denied. After reasonable
investigation answering Respondents are unable to determine the
truth or falsity of these averments and strict proof thereof, if
relevant, is demanded at trial.
18. Admitted.
19. Neither admitted nor denied, the means of proof being
wholly within the control of an adverse part. Strict proof
thereof, if relevant, is demanded at trial.
20. No response required.
2l. No response required.
22. No response required.
23. No response required.
24. Admitted in part. It is admitted that, as of the date of
the accident, answering Respondents were covered by an automobile
insurance policy issued by State Auto Insurance Company. The
details of the amount of underinsured motorist coverage available
are unclear at this time.
- 2 -
>-: Lfl
(~, l;-.
.~ ..
\.
U\(1 ('-I
0'. . '-~
r'C
.... c...
.L.iL
~( ('01
C': c;-.J
U."-' ';'.!
_.1\1 C'"
!:C... ....: : \ -~-
(" ~
.- ....s
,. C'
<.) G' (J
,
ERIE INSURANCE EXCHANGE
and LINDA F. JOHNSON,
Petitioner::;
V.
JULIE UAMAKER, DONALD
HAMAKER, individually
and as husband and wife,
ERX LOGISTICS PRESIDIUM,
INC., and SUBROGATION
ADVANTAGE,
Respondents
AND NOW, this
I ~ -0
IN THE COURT OF COMMON PLEAS OF'
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 98-7050 EQUITY TERM
CIVIL ACTION - EQUITY
QRDER OF COURT
day of APRIL, 1999, a Rule is issued
upon Petitioners to Show Cause why the motion of respondents to
substitute parties should not be gr.anted. Rulc returnablc tcn
(10) days after servicc.
Neil L. Albert, Esquire
22 South Duke Street
Lancaster, Pa. 17602
John M. Popilock, Esquire
305 North Front Street
P.O. Box 999
Harrisburg, Pa. 17108
Jonathan H. Rudd, Esquire
100 pine Strcet
P.O. Box 1166
Harrisburg, Pa. 17108
:sld
.:;; I'll tiz.) ~ s ~ .
EdWard E. Guido, J.
() \.0
C. u;;
.....
.., , .. ,...
f1l l .;..1
Z
(/J I, l.~-.'
"
-,
,.
,- .
, ..
c, o.
, :.-)
.. ~
..-: :~
--j
-. (;.)
"
'"
, ,
,1.1
:.;
rl
---'_.'~---
I..'('.'~ ',' I'
- .,V..'..", ',f'...,,'''' ',f'..-'
..,,'
~:iI'.f,I.,r\.:',;".
INTRODUCTION
This document is a description of ERX Logistics Employee Benelit Plan (the Plan). The Plan described
is designed to protect Plan Participants against catastrophic health expenses. This Plan will conform with
all federally mandated laws andlor regulations pertaining to Employee benelits.
When a pen;on is employed. that person'S salary pays the expenses of day-to-<.lay living. If a serious
illness or injury occurs, the cost involved could cause serious financial difficulties. This Plan can ease
such financial burdens by providing reimbursement for the great majority of covered expenses.
Coverage under the PI aD will take effect for an eligible Employee and designated Dependents when the
Employee and such DepeDdents satisfy the waiting period and all the eligibility requirements of the Plan.
The Employer fully intends to maintain this Plan indefinitely. However, it reserves the right through a
procedure described in the Plan Administration section to terminate. suspend, discontinue or amend the
Plan at any time upon advance notice to all Participants.
Changes in the Plan may occur in any or all partS of the Plan including benefit coverage, deductibles.
maximUlllS, copayments, exclusions, limi[;ltions. definitions, eligibility and the like.
If th~ Plan is terminated. the rights of Covered Persons are limited to covered charges incurred before
termination. If, for wh:ltever reason. the Plan Administrator is unable to fund the benefits provided, the
Covered Person may be liable for such costs.
This document s=rizes the Plan rights and benefits for covered Employees and their Dependents and
is divided into the following parts:
Eligibility, Funding, Effective Date and Termination. Explains eligibility for coverage under the Plan.
funding of the Plan and when the coverage takes effect and terminates.
Schedule of Benefits. Provides an outline of the Plan reimbursement formulas as well as payment limits
on certain services.
, ': - i~', ,l~ ..,
Iknefit Descriptions. Explains when the benefit applies ami the types of charges covered.
Iknefit Limits. Shows Ole limits applic;lble for certain conditions or treatment methods.
Cost Management Services. Explains the mClhoos used to curb unnecessary and excessive charges.
Defined Terms. Defines those Plan tenns that have a specific meaning.
General and Medical Plan Exclusions. Shows what charges are not covered.
Claim Provisions. Explains the rules for filing claims and the claim appeal process.
Coordination of Bencfits. Shows the Plan payment order when a person is covered under more than one
plan.
nurd Party Recovcry Provision. Explall1s the Pbn's rights to recover payment of charges when a
Covered Person has a claim againsl anolher pcrson because of injuries sustained.
COBRA Continuation Options. Explains when a person's coveragc under the Plan ceases and the
continuation options which ~rc avaibb1e.
ERISA Infon"'ltion. Explains the Pla:l's structure and lhe Participants' rights under the Plan.
----~._----~.., .
'~""""....,;l........",.." .'.
.. ,,,,,'I."""'~"''"''''''''''''''''"''''''''&~lr,,. J
ELIGillILlTY"l"fYNDING,/.EFFECTIVE DATE
AND TEKlVlINATIOro; PROVISIONS
ELIGIllILITY
Eligible Classes of Employces.
All Active Employees of the Employer.
Eligibility Requirements For Employee Covcragc. A person is eligible for Employee coverage from
the first day that he or she:
(1) is a Full-Time. Active Employee of the Employer. An Employee is considered to be
Full-Time if he or she normally works at least 32 hours per week and is on the regular
payroll of the Employer for that work.
(2) is in a class eligible for coverage.
(3) completes the employment waiting period of 90 days as an Active Employee.
Eligible Classes of Dcpendents.
Dcpendent is anyone of the following persons who lives in the United States:
(1) A covered Employee's Spouse and urnnarried childrcn from binh to the limiting age of
19 YC.1rs. However, a Dependent child will continue to be covered aftcr age 19, provided
the child is a full-time srudent enrolled for 12 or more credit hours at an accredited
schooi, primarily dependent upon the covered Employee for suppon and maintenance,
is ul1I11.1rried and under age 23. When the child reaches the limiting age, coverage will
end on the child's birthday.
The term "Spousc" shall mean thc Icgally rccognized marital panncr of a covcred
Employee. Common law spouses are eligible only in states whcrc Icgally recognized.
Thc Plan Administrator may require documentation proving a Icgal marital relationship.
The term "children" shall include namral childrcn, adopted childrcn or children placcd
with a covered Employee in anticipation of adoption, Step-childrcn and children undcr
legal guardianship who reside in the Employee's household may also be included.
As rcquired by the federal Onmibus Budget Reconciliation Act of ! 993 (OBRA). any
child of a Plan Panicipam who is an alternate recipient under a Qualified Medical Child
Support Order (QMCSO) shall be considered as having a right to Depcndent coverage
under this Plan with no Pre-Existing Conditions provisions applied.
The phrase "primarily dependent upon" shall mean dependent upon the covered Employee
for support and maintenancc as defined by the Internal Rcvenue Codc and the covered
Employec must declare the chIld as an income tax deduction. The Plan Administrator
may require documenr.ation proving dependency. including birth certificatcs, tax records
or initialion of legal proceedings severing parcntal rights.
(2) A covcred Dependcnt child who is incapable of self-sustaining employment by rcason of
mental rctardation or physical handicap. primarily dependent upon the covered Employee
for SUPPOrl and maintcn3nce, unmarried and covcred undcr the Plan when reaching the
limiting age. Thc Plan Administrator may require proof of the child's disability and
depcndency and reservcs the right to have such Depcndent ex:unincd by a Physician Qf
thc Plan Administrator's choice, at thc Pbn's expense. to delcmlinc the existence of such
incap3city.
'....' .. ......".,"',:"'..,,~~.+:t,:,,.;:....
. ,......,,...I:."'~it,'. .- ,,'.,. ..d..,
These persons ?r~ excluded as Dependents: other individuals living in (he covered Em 10 ee's home but
who arc not eligIble as defined; the legally separaled or divorced fanner Spouse of fh YE I .'
h . . d' .\. . e mp oyee any
person w 0 IS on active ury III any m! Ilary serv.ce of any coumry. '
If a person covered under this Plan changes status from Employee to Dependent or Dependem to
Employee, and Ihe person is covered continuously under this Plan before, during and after the change
in status, credit will be given for all amounts applied to maximums.
If both mother and father are Employees. their children will be cover<:d as Dependents of the mother
or the father. bur not of both.
If both husband and wife are Employees, they may be covered as either an Employee or as a Dependent,
but not both.
Eligibility Requirements ,,"or Dependent Coverage. A Dependent will become eligible for Dependent
coverage on the first day that the Employee is eligible for Employee coverage and the Dependent
satisfies the requirements for Dependent coverage.
At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a
Dependent as defined by this Plan.
FUNDING
Cost of the Plan.
ERX Logistics shares the cost of Employee and Dependent coverage under this Plan with the covered
Employees. The enrollment application for coverage will include a payroll deduction authorization. This
authorization must be filled out, signed and remmed with the enrollment application.
The level of any Employee contributions is set by the Plan Administracor. The Plan Administracor
reserves the right 10 change the level of Employee contributions.
ENROLLMENT
Enrollment Requirements. An Employee must enroll for coverage by filling out and signing an
enrollment application. The covered Employee is requirt'tl to enroll for Dependent coverage also,
including coverage for newborn children.
EnroUment Requirements for Employee andlOl' Dependents Who Initially Declined MediClI
Coverage. If an eligible Employee and/or their Dependents decline coverage because they are enrolled
under another group policy and if through no fault of their own that coverage is lost; the Employee
and/or their Dependents may enroll within 31 days of loss of that coverage. The Employee will be
required to submit proof of loss of the other group coverage at the time he or she enrolls for coverage
under this Plan.
If an Employee and/or their Dependents do not em 011 for Medical coverage within 31 days of eligibility,
satisfactory evidence of good health will be required. Coverage will become effective on the date
satisfactory evidence of good health is approved.
Enrollment Requirements for Employee and/or Dependents Who Initially Declined Dental Coverage.
If an Employee and/or their Dependents do not enroll for Dental coverage within 31 days of eligibility,
they may enroll anytime during the year with coverage effeclive the fits[ day of the following January.
3
"",110
TIMELY AND LATE ENROLLMENTS
An enrollment is either "timely" or "late":
(1) Timely EllrolllI1~'n.1 _ The enrollmelll will be 'timely" if the completed fonn is received
by the Plan Admll1lSlratOr no laler than 3 t days afler lhe person becomes eligible for the
coverage.
If twO Employees (husband alid wife) are covered under the Plan and the Employee who
is covering the Dependent childrellterminates coverage, the Dependent coverage may be
continued by the other Covered Employee with no wailing period as long as coverage has
been continuous.
(2) Late Enrollment _ An enrollment is "late" if it is not made on a "timely basis." In the
case of a late enrollment, the person will have to meet the Proof of Health Requirement
to bel:ome covered.
Proof of Health Requirement. When proof of heallh is a condition of a person's coverage:
(1) such proof must be submitted in the form required by the Plan; and
(2) the applicant must provide all proof required to decide if he or she is an acceptable risk.
A physical exam may be required as a part of this proof.
The requirement is met on the date that the Proof of Health is approved by the Plan Administrator.
EFFECTIVE DATE
ElTe<:tive Date of Employee Coverage An Employee will be covered under lhis Plan as of the first day
that the Employee satisfies all of the following:
(1) The Eligibility Requirement.
(2) The Actively at Work Requirement.
(3) The Enrollment Requilements of the Plan.
Employees Returning from a Layoff. An Employee who is recalled from temporary layoff within
twelve (12) months from the last day of work will have coverage reill5tated on the first day of work and
will not be subject to pre..existing limitations.
Rehiring Tenninated Employees. A terminated Employee who is rehired within six (6) months following
their termination will be covered the first day of work. Pre-existing limitations will apply.
Employees Hired from Elston-Rich:mls, Inc. When an Employee is hired from Elston-Richards. Inc.
within 91 d3ys of his/her break in service, the hire date with Elston-Richards, Inc. will be used to
detennine the waiting period and pre.existing limiutions for this Plan.
Acth'dy at Work Requirement.
Active Employees _ An Employee must be Actively at Work for coverage to take effect. An Employee
will be con.~idered Actively at Work if the Employee is performing the regular duties of employment on
that day either at the Employer's plJce oi business or at some location to which the Employee is required
to travel for the Employer's business.
An Employee is considertlj to be Actively at Work on <:.1ch day of a regular paid vacation and on each
regulJr non-work day on which lhe Employee is unable to perform the essential functions of his or her
job. if lhe Employee was Actively at Work on the last prece1ling regular work day.
.
"
. ..' ., "', ~ , . ,,',
An Employee is also con..~ldered tObe"Ai:t1~~iYiau'i:.'I~~~ ".', " '
MedIcal Leave Act of 1993, j ",t;,:;Jii7.Y'i;'.l'~" .f. i.". ',..
If an Employee is absent from work due to the inability to perform the essential ru;;ctlcinS'ofhlsor 11 r'
Job on the date thIS Plan would otherwise have been effective, the effective date will be deferred until the'
date. on which the Employee returns as an Active Employee.
Effe<:live Date of Dependent Co~erage. Subject to the Deferral Rule, a Dependent's coverage will13ke
effect on the day that the EligIbIlity ReqUirement IS met; the Employee is covered under the Plan; and
all Enrollment Requirements arc met.
Deferral Rule. If a Dependent, other than a newborn or newly adopted child, is a patient in a Hospital
or other Medical Care Facility, coverage will be deferred until the day following the date the Dependent
is discharged from the facility.
,t.-.....'... 1" ,j "If
TERMINATION OF COVERAGE
When Employee Coverage Terminates. Employee coverage willtenninate on the earliest of these dates:
(1) The date the Plan is terminated.
(2) The day the covered Employee ceases to be in one of the Eligible Classes, This includes
death or termination of employment of the covered Employee, (see COBRA Continuation
Options section).
(3) The end of the period for which the required contribution has been paid if the charge for
the next period is not paid when due.
However, Employees who initially elect dental coverage only, may not tenninate their dental coverage
unless they have been covered by the Plan for at least twelve (12) consecutive months. This provision
will not apply to persons who lose eligibility under the plan.
In certain circumstances, a covered Employee may be eligible for COBRA continuation coverage. For
a complete explanation of when COBRA continuation coverage is available, what conditions apply and
how to select it, (see COBRA Continuation Options section).
When Dependent Cover:lge Terminates. A Dependent's coverage will terminate on the earliest of:
(1) The date the Plan is terminated.
(2) The date that the Employee's coverage under the Plan terminates for any reason including
death, (see COBRA Continuation Options section).
(3) The date Dependent coverage is tenninated under the Plan.
(4) On the first date that he or she ceases to be a Dependent as defined by the Plan, (see
COBRA Continuation Options section).
Except in certain circumstances, a covered Dependent may be eligible for COBRA continuation coverage.
For a complete explanation of when COBRA continuation coverage is available, what conditions apply
and how to select it, (see COBRA Continuation Options section).
EXTE:-ISlON OF COVERAGE
Employees on !\lcdic:1l Leave. An Employee and their eligible Dependents may continue to receive all
benefit coverages, except Weekly Disability Income, for up to 90 days, upon making the required
contributions.
~
, .i' 't'.", '~",.. ....;..... rr :,': 'I' "'I' "
'; '," ,';~:,:{ I:'.:';".,. ';'''':'~'.,l:
Verilic:llion of Eligibility, (6 \6) 95,\-)300 or I (800) 766-9780. Call one of these numbers to v'erify eligibility
for Plan benefits t)4.~forc the char~~c is incurred,
NOTE: l'lea.,e refer to Mclkal..JkDsfilS .eetion of this Plan Document for a complete expl:lOation of Plan
henefits, coverl~1 charges, ::and limitations.
. = Deductible must be paid before the Plan pays.
t = Copayments do Dot apply toward Out-<lf-Poeket Maximum.
MEDICAL BENEFITS
rUN PARTICIPANT PAYS
PI..AN LlM1TS
Deductible
Per Covered Pel>on
Deductible must be paid before the Plan
pays unless noted othelVlise. Deductible
applies toward Out-of-Pocket Maximum.
5100
Per Family Unit
Out-of-Poekcl Maximum
Per Covered Pel>on
5400
5900
Once Out-of-Pocket Maximum is met,
benefilS are paid at 100%, unless noted
othenvisc.
Per Family Unit
52,800
5300t
Penalty docs not apply toward
Out-of-Pocket Maximum,
Pre-certification Penalty
PLAN BENEFITS
Lifetime Maximum
NAN PA YS
51,000,000
550,000
PLAN LIMITS
Mental Disorders & Subsunee Abuse
Lifetime Maximum
\00%
First 5300 payable at 100%, then payable
at 80%, Limited to treamlent within 90
days of an accident.
Supplemental Accident
80%.
Oflice Visit
Hospital Care
Inpatient
Outpatient
Pbysician Care
Inpatient
Outpatient
Surgery (lMc1uJt~S 1111 rdated charges)
Inpatient
Outpatient
Emcrl:ency J{o;;;;;-
Emergency
Non.Emer~ency
800/0.
800/0'
800/0.
80~'~'
80%'
gO~/O'
80~'o'
50%'
7
. H . ,_ ." .. -, "1
, ... . i\ ...' ;.!IIi'''' ,"";...."~, \~.;\",(;-~l"w.\>'O'l,"r..;l '~ . ~"" ---'
, ' ,,', ' ~"~' .r'."~"""'~"'!."'. '
,'" ',' ,',',', ,L", ",',,', ',.,,:-'-".~,,-: -:~"-,",' ,"~'_,,:" ,,"
. . .' ' .' .
Pf...IN IIENEFlTS
J>r~vcntativc Care
M;lInnlO!~r.UIl
PUN I'A YS
. ,..1' ....ql, .,'}.-,. ~f:~I'~'::1'~~k.'4irn.'t'f\~V'\7'.':' 1;::.;~I!-.l.i'll'."
NAN LIMITS
Limited 10 one exam ;lgCS 35-39; one exam
every two years ages .W~49; and one exam
per calendar year after age 50,
Limited to laboratory services only and one
lest per calendar ye3r.
Limited to one exam per calendar year
aller age 40,
Limited from birth tc age one,
Limited to six (6) visits from birth to age
one.
Benelits always payable at 80%,
Benefits always payable at 50%t,
Combined wilh Substance Abuse
Combined with Substance Abuse,
Limited to one (1) treatment program
while covcred by the Plan. Limited to 30
days per calendar year, Benefits always
payable at 80%t,
Limited to one (1) treatment program
while covered by the Plan,
Combined with Men131 Disorders,
Combined with Mental Disorders,
Limited to 30 visits per calendar year.
Limited to six (6) momh~ \,hilc covGed by
the t'bn,
;' ,.,....,.. I."~ ..'._, ' ,,,,..~,, .
. " . '\ . .~ .~"~" .' 1<.",,"""A"'.~ ~'"''''''''i''l'';;J,~...,(,'J~ ~...~,..........4"'>' ,~ .
",' __' "" ',','\' ',' ',' "':", ''':'':''~:'.'~~''' <:''':''~:: "::,,:,, ~",t~.: .:., ','" ,.:',
800/0.
Pap Smear
100%
Prostate Cancer Screening Tests
80%'
Well Baby Cm
Immunizations
Routine Physical Exam
80%'
80%'
Maternity Care
Inpatient
Outpatient
Mental Disorders
Inpatient
Outpatient
Inpatient/Outpatient Calendar Year Maximum
Outpatient Calendar Year Maximum
Substance Abuse
Inpatient
800/0'
80%'
80%'
50%'t
S25,000
SS,OOO
80%'t
Outpatient
lOO~/o
Inpatient/Outpatient Calendar Year Ma.x,
Outpatient Calendar Year Maximum
Miscellaneou,
Ambulance
Chemotherapy
Chiropractic Care {Includes x-ray,}
Diagnostic Testing, X.rays & L3boratcry
Durable M,dical Equipment
Hemodialysis
Home Health Cu,
S25,000
$5,000
80~/O.
so~,~.
50%"t
80%-
800/0.
80~/O.
IOO~'.
Hospice Care
lOG~o
Occupational Thmpy
Physical Therapy'
80~o.
SO":'l.I.
s
PRE-EXISTING CONDITIONS
Pre-Existing Condition is a diagnosed or undiagnosed, symptomatic or asymptomatic, Injury or Sickness
that was lre.1ted within three (3) months ofthc person's coverage taking effect under this Plan. Trcatment
includes rc-ceiving medical care, services and supplies, including consultations, diagnostic tests or
prescribc-d medicines,
Covered charges incurred under Medical Benefits for Prc-Existing Conditions arc not payable unless
incurred after:
(1) the person has been frce from treatmcnt for at least six (6) consecutive months from the
effective date of his coverage; or
(2) the pcrson has been covered under this benefit for twelve (12) consecutive months,
AMOUNTS PAYABLE BY PLAN PARTICIPANTS
Deductible. A deductible is the dollar amount shown in the Schedule of Benefits that is paid once a
calendar year per covered person before any amount is paid by the Plan for any covered services, On
covered charges paid at 100% or where noted in the Schedule of Benefits, the deductible will be waived.
The deductible applies toward the out-of-pocket maximum.
Deductible Carry Over. Covered expenses incurred in and applied in October, November, and
December will be applied toward the deductible in the next calendar year.
Coverl-d Person Limit. When the dollar amount shown in the Schedule of Benefits has been reached
by a covered person toward their c.1lendar year deductible, the deductible of the covered person will be
considered satisfied for that year.
Family Unit Limit. When the dollar amount shown in the Schc-dule of Benefits has been reached by
members of a family unit toward their calendar year deductibles, the deductibles of all members of that
family unit will be considered satisfied for that year,
Copayments. A copayment is the amount of money a covered person pays that is not paid by the Plan,
Some copayments do not apply toward the out-of-pocket maximum and is noted in the Schedule of
Benefits.
BENEFIT PAYMLVf
Each calendar year, benefits will be paid for the covered charges of a covered person that are in excess
of the deductible. Payment will be made at the rate shown under "Plan Pays" in the Schedule of Benefits.
No benefits will be paid in excess of calendar year ma:dmurns, the lifetime maximum or the benefit limits
of the Pian,
OUT-OF-POCKET MA."{JMUM
Covered charges are payable at the percentages shown each calendar year until the out-of-pocket
ma.ximum shown in the Schedule of Benefits is reachcd. TIlcn, covered charges incurred by a covered
person will be payable at 100%, except where noted in the Schedule of Benefits, for the rest of the
calendar YC3r.
When a family unit reaches the out.{)f-pocket maximum, covered charges for that family unit will be
payable at 100%, except where noted in the Schedule of Benefits, for the rest of the calendar year,
12
,,,,.<,..'.
;0'. .
PRE-CERTIFICATION pENALTY
.. , II ',' ~ rl ~~1' "
:,0' .\ ,:' c.'r ~' l/'r;j!~'t: ',if..;
A eovercd person will be ,required to pay a ,pr~-certilication pen.,lty if they fail to call HHS, Ine, prior
to all non-cmcrgenc~ hospnaJ admIssIOns, wlthm48 hours of all emergency hospital admissions, on some
servIces and supplIes, and for Mental Dlsordcrs and Substancc Abuse hospitaliz.'lion, (see Cost
Management Services scct ion),
LIFETIME MAXIMUM
The lifetime maximum shown in the Schedule of Benefits is the total amount of benefits that will be paid
under the Plan for all medical covered charges incurred by a covered person while covered by the Plan,
COVERED CHARGES
Covered cbarges arc the Usual and Rcasonable Charges that are incurred for the following items of
service and supply. These charges are subject to the "Benefit Limits" of this Plan, A charge is incurred
on the date that the service or supply is perfonned or furnished, All charges will be subject to limitations
and payable as shown in tile Schedule of Benefits.
Office Visit. Charges for care, treatment and/or services perfonned in a Physician's office.
Hospital Care. Charges for inpatient care include services and supplies furnished by a Hospital or
Ambulatoty Surgical Center or a Birthing Center.
Charges for room and board will bc subject to the average semi.private room charge, except if a private
room is required for isolation,
Charges for an Intensive Care Unit stay are subject to the Hospital's lCU charge.
Charges for outpatient care is trcatment including services, supplies and medicines provided and used at
a Hospital under thc direction of a Physician to a person not admittcd as a registered bed patient; or
services rendercd in a Physician's office, laboratoty or x-ray facility, or an Ambulatory Surgical Ccntcr,
Physician Care. Charges for surgical or medical services perfonned by a Physician in the Physician's
office, home, hospital or outpatient facility.
Surgery. All related charges on the day surgcty is pcrfonned in a Physician's office, hospital, or
outpatient facility, (sce Cost Managcment Scrvices section).
The following types of surgery have specific limitations:
Cosmetic Surgery. Charges for cosmetic surgery will be limited W:
;
,
(1) correction of birth defects, if patient was covered by the plan at birth; i
(2) accidcntal injuries or traumatic SC3rs, if accident occurred while covered by the Plan: 01 !
(3) reconstructive surgery to correct deformities resulting from specified diseases or medical1:,
necessary surgery,
Oral Surgery/Services of a Dentist. Charge'S for the C3re and treatment of the mouth, teeth, gums an
alveolar processes will be covercd under Medical Benefits only if that care is for the following or;
surgical procedures:
(l) Charges will be I irnited to cJre and treatment by a Dentist for emergency repair due I 1
injury to sound natural teelh, This repair must be made within twelve (12) months frol ','
lhe date of an accidcnt and Ihe accident must have occurred while the person was coven "
under the Plan,
13
(3) Excision of tumors and cysts of the jaws, cheeks, lips. tongue, roof and Ooor of the
mouth,
(4) Excision of benign bony growths of the jaw and hard palate,
(5) External incision and drainage of cellulitis,
(6) Incision of sensoty sinuses, salivary glands or ducts.
Organ Transplant, Charges for the care and trcaunent of an organ or tissue transplant. Expenses
eligible for coverage:
(1) Transplant operation including pre and post surgic:Jl care for the transplant recipient.
(2) Anti-rejection drugs for the transplant recipient.
(3) If the donor is a Plan Participant donating an organ to a Phn Participant, the medical and
hospital expenses of the donor will be payable in cotIDection with the organ donation if
the donor's hospital admission is for the sole purpose of organ removal limited to
$10,000.
(4) If the donor is a Plan Participant donating an organ to a Non-Plan Participant, the medical
and hospital expenses of the donor will be payable in connection with the organ donation
if the donor's hospit:>.l admission is for the sole purpose of organ removal limited to
$10,000. If the transplant recipient's medical coverage provides donor coverage, then
this Plan will pay secondaty,
(5) If the donor is a Non-Plw Participant donating an organ to a Plan Participant, the medical
and hospital expenses of the donor will be payable in connection with the organ donation
if the donor's hospital admission is for the sole purpose of organ removal limited to
$10,000. If the donor has medical coverage, then this Plan will pay secondary.
(6) If the organ donation is from a cadaver. the organ removal, transportation, and storage
expenses will be payable in connection with the organ donation limited to $10,000.
Sterilization. Charges for sterilization procedures include the surgeon's fee, anesthesiology charges,
operation room and other services and supplies, but excludes inpatient hospital room and board
charg~.s .
Emergency Room. Charges for tre.lunent received in the hospital emergency room.
Medical Emergene)' is defined as a sudden onset of a condition with acute symptoms requiring immediate
medical care that threatens life or bodily functions and could result in serious bodily harm if not treated
inunediately. Such conditions include heart attacks, cardiovascular accidents, poisonings, loss of
consciousness or respiration, convulsions or other such acute medical conditions.
In addition, Medical Emergency includes a mental health or chemical dependency condition when the lack
of medical treauoent could reasonably be expected to result in the patient Iunning himself or herself
and/or other persons.
A Non-Medical Emergency is defined a.s treauoent received in the hospital emergency room that is not
life threatening,
Preventative Care. Charges for routine care md related testing by a Phj'sician that is not for an Injury
or Sickness,
1,\
VVell naby CAre, ChArgeft for l';'u,lne-c.a
that is not for an Injury or Slcknes:5.
Matcrnity Care. Chargcs for the care and treatment of pregnancy including pre and post delivery Co"e
for you or your covered spouse. Dependent Childrcn arc: not eligible for this benefit, Newborn expenses
are covercd if newborn is enrolled within 31 days of birth,
Mental Disordcrs. Charges for inpatient or outpatient care and treatment of Mcntal Disorders including
individual, family, marital. and group counseling. Inpatient care must be arranged through HHS, Inc"
(see Cost Management Services section).
Psychiatrists (M,D.), psychologists (Ph.D,) or counselors (Ph.D,) may bill thc Plan directly, Other
licensed mental health practitioners must bill the Plan through these professionals.
Substance Abuse. Charges for inpatient or outpatient care and treatment of Substance Abuse will be
paid upon completion of a licensed rehabilitation progratn which may be inpatient, outpatient, or a
combination of the two, Inpatient care must be arranged through HHS, Inc., (see Cost Managemen(
Services section).
Psychiatrists (M.D.), psychologists (Ph.D,) or counselors (Ph,D,) may bill the Plan directly. Other
licensed mental health practitioners must bill the Plan through these professionals.
Ambulancc. Charges for medically necessary professional land, air, or railroad transportation services
to and from a hospital or extended care facility where treannent can be rendered effectively,
Chcmothcr:lpy, Charges for chemotherapy for malignant diseases are limited to antineoplastic agents
that are not in an Investigational or Experimental stage,
Chiropr:lctie Care. Charges for chiropractic services for the diagnosis and treatmcnt of dislocations,
sUbluxations or misalignments of thc vertebrae, including x-rays.
Diagnostic Testing, X-Rays & Labor:l(ory. Charges for diagnostic testing. x-rays, and laboratory that
are part of the diagnosis of a condition due to Injuty or Sickness.
Durable Medical Equipment. Charges for rental or purchase of durablc medical equipment must be
approved by HHS, lnc" (see Cost Management Services section),
Hcmodialysis. All charges related to the use of an artificial kidney machine,
Home Hcalth Carc Services and Supplies. Charges for home health care services and supplies are
covered only for care and treatment of an Injury or Sickness when Hospital or Skilled Nursing Facility
confinement would otherwise by required. The diagnosis, care and treauoeot must be certified by the
attending Physician and arranged through HHS, Inc., (see Cost Management Services section).
Eligible expenses for benefit consideration includes:
(1) Care and services rendcred by a visiting nurse (RN, or LPN), certified home health aide,
or registered therapist. A home health care visit will be considered a periodic visit for
four hours of home health aide services,
(2) Physician calls in the office, home, or outpatient facility,
(3) Medications and supplies which would have been provided m the hospi13I, but not
including meals nonnally prepared in the horne,
(4) Rental or purchase of durable medical equipment, if approved in advance by HHS, Inc.
15
" ,f ~ ...,
,'. <,
",-". .. ,~,
,. 'I"~
'I ;.,'
Transportation to and rrom the Physician, therapist, or outpatient facility or other provider
for treatment, including ambulance (where the patient's condition mandates such
utilization) or ambucab (if the diagnosis makes an automobile unsuitable),
Hospice Care Services and Supplies. Charges for hospice care services and supplies arc covered only
when the allending Physician has diagnused the Covered Person's condition as being temlinal, determined
that the person is not expected to live more than six months and placed the person under a Hospice Care
Plan, Care must be arranged through HHS, (nc" (see Cost Management Services section),
(5)
Occupational Therapy. Charges for occupational therapy by a licensed occupationaltherapisl. Therapy
must be ordered by a Physician, result from an Injury or Sickness that occurred while covered under the
Plan and improve a body function.
Physical Therapy. Charges for physical therapy by a licensed physical therapist. Therapy must be
ordered by a Physician, result from an Injuty or Sickness that occurred while covered under the Plan and
improve a body function.
Pre-Admission Tests. Charges for diagnostic lab tests and x-ray exams when performed on an outpatient
basis prior to a hospital confinement; related to the condition which causes the confinement; and
performed in place of tests while hospital confined,
Prescription Drugs, Limited to drugs not covered under the Prescription Drug Benefits section of the.
Plan specifically stating covered under the Medical Plan,
Private Duty Nursing Care, Charges for private duty nursing care by a licensed nurse (R,N., L.P,N.
or L.V.N,). Care must be arranged through HHS, (nc" (see COSl Management Services section),
Covered charges for this service will be included to this extent:
(1) Inpatient Nursing Care, Charges are covered only when care is Medic.1lly Necessary
or not Custodial in nature and the Hospital's Intensive Care Unit is filled or the Hospital
has no Intensive Care Unit.
(2) Outpatient Nursing Care, Charges are covered only when care is Medically Necessary
and not Custodial in naTUre.
,
I
Prosthetics/Orthotics. Charges for the initial purchase, filling, repair and replacement of filled
prosthetic devices which replace body pam provided that the loss occurred while covered under the Plan,
Charges for the initial purchase, fining, repair and replacement of orthotic appliances such as braces,
splints or other appliances which are required for support for an injured or deformed part of the body
as a result of a disabling congenital condition or an Injuty or Sickness that occurred while covered under
the Plan.
Radiation Ther:lpy, Charges for treatment of disease by x-ray, gamma ray. accelerated particles,
mesons, neutrons, radium or radioactive isotopes,
Se<:ond Surgical Opinion. See Cost Management Services section,
Skilled Nursing Facility Care, Charges for room and board and nursing care furnished by a Skilled
Nursing Facility will be payable if care is arranged through HHS, Inc" (see Cost Management Services
section). and if and when:
(l) the patient is confined as a bed patient in the facility;
(2) the confinement starts inunediately following a HospItal confinement or a period of Home
Heallh Care utiIi7_1tion;
(3) the allending Physician cenifies that the confinement is needed for funher care of the
condition and that care carl nol be provided at home; and
Ii
16
c..:.:Ut)T l\fli\,NAVElYl.c:.NT bl:';'l<'Vl'-.,.:~~
HHS, Inc.
1 (800) 634-2712
A Covered Person or family member must call HHS, Inc, to receivc ccrtification of ccrtain cost
managemcnt services. This call must be madc in the following sinlations: I) in advance of a
non-emergency Hospitalization, 2) within 48 hours after an emergency Hospitaliz.1tion, 3) on somc
services and supplies, and 4) for Mental Disorders and Substance Abuse Hospitalization.
Failure to follow cost management procedures will reduce reimbursement received from the Plan
and will not accrue toward the 100% maximum out-{Jf-pocket payment,
UTILIZATION REVIEW
Utilization review is a program designed to help insure that all Covered Persons receive necessary and
appropriate health care while avoiding unnecessary expenses when a Hospital confinement is proposed.
The program consists of:
(I) Pre-<<rtification of the Medical Necessity for all non-emergency Hospital admissions
before Medical services are provided;
(2) Retrospective review of the Medical Necessity for all emergency Hospital admissions;
(3) Concurrent review, based on the admitting diagnosis, of the number of days of Hospital
confinement requesled by the attending Physician; and
(4) Certification of the length of confinement and discharge planning.
The purpose of the program is to detemune what is payable by the Plan. This program is not designed
to be the practice of medicine or to be a subSlitute for the medical judgment of the attending physician
or other health care provider,
Here's how the program works:
Pre-<ertilication. Before a Covered Person enters the Hospital on a non-emergency basis, HHS, lnc,
will, in conjunction with the attending Physician, certify the care as appropriate. A non-emergency
Hospitalization is one that can be scheduled in advance.
The utilization review program is set in motion by a telephone call from the Covered Person. Contact
HHS, Inc. in advance of a non-emergency admission with the following information:
-The name of the patient and relationship to the covered Employee
-The name, Social Security number and address of the covered Employee
-The name of the Employer
-TIle name and group number of any other group insurance coverage
-The name and telephone number of the attending Physician
-The name of the Hospital and proposed date of admission
-The diagnosis and/or type of surgery
-The proposed length of Hospital slay
If there is an I:mergency admission 10 the Ilospital, a Covered Person, family member, the Hospital or
attending physician must contact IlIlS, lnc, within 48 hours after the admission,
HHS, Inc., based on medical information received and recommendations from the Hospital or attending
Physician, will determine the number of days of Hospital confinement authorized fer paymem,
18
;, .1., ~,u I~~.... 'i<l;,y~J
, ",' . I ,,,, ' 'i \":, ' ' " Ii, '.I)' >.~,
Concurrent Stay Review and Discharge Planning. COnCUrTeri't'stay review and discharge ~1" , Ilg, re;'
parts of the utiliution review program, HHS, Inc, will monitor the Covered Person's Hospital stiy 'iUId'
coordinate with the allending Physician, Hospital and Covered Person either the scheduled release from
the Hospital or an extellsion of the Hospital admission,
If thc attending physician fecls that it IS Medically Necessary for the Covcrcd Person to stay in the
Hospital for a greatcr length of time than has heen preeertified, the allending physician must request the
additiona: days.
If a Covered Person does not receive the required authorization as explained in this section, then
the Covered Person would be required to pay a Pre<ertification Penalty of $300.
MANDATORY SECONDlTllIRD SURGICAL OPINION PROGRAM:
Benefits will be provided for a second opinion consultation to determine the Medical Necessity of an
elective surgical procedure, An elective surgical procedure is one that can be scheduled in advance; that
is, it is not an emergency or of a life-threatening nature.
As patterns of medical practice change, the specific procedures which require a second opinion also
change. Before a Covered Person has a surgery performed, the Covered Person must contact HHS, Inc,
to receive information on how to obtain a second opinion consultation to confinn thr. need for the
surgery .
These additional consult.1tions must be perfonned by Physicians who are:
(1) Board Certified Specialists in the area in which the operation is concerned; and
(2) not financially associated with the surgeon originally recommending surgery,
If the first and second opinion agrees, full Plan benefits will be paid if the Covered Person desires the
procedure.
If the second opinion disagrees with the first opinion, then a third opinion is required to confirm the need
for surgery,
If the third opinion confinns the need for surgety, full Plan benefits will be paid if the Covered Person
desires the procedure. If the third opinion does not confinn the need for surgety, Plan benefits will not
be paid if the Covered Person proceeds with the elective surgety.
SERVICES AND SUPPLIES
Some servi= and supplies received by a Covered Person must be coordinated through HHS, Inc.
Contact HHS, Inc. in advance of receiving the following services and/or supplies:
-Durable Medic.al Equipment
-Home Health Care Services and Supplies
-Hospice Care Services and Supplies
-Private Duty Nursing Care
-Skilled Nursing Facility Care
If a Covered Person dOL>>; not rcceive the required authorization, then the Covered Person would
be required to i>3Y a l're-c~:'tification Penalty up to $300.
19
.
..;~ c.
. -I''''
The following tern" have special meanings and when used in ;hlsPI~\vlll be' ';p(tll
",',r.t .,;".:'C:,,~
Active EmploYl'C is an Employee who perfonn.. all or the duties uf his or her job with the Employer on
a full-time basis,
Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery,
has a staff of Physicians, has continuouS PhysicIan aud uursing care by registered nurses (R. N ,s) and docs
not provide for overnight stays,
Birthing Center means any freestanding health facIlity, place, professional office or institution which is
not a Hospital or in a Hospital, where births occur in a home-like aunosphere, This facility must be
licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where
the facility is located.
The Birthing Center must provide facilities for obstetrical delivety and short-term recovery after delivery
(no more than 24 hours); provide care under the full-time supervision of a Physician and either a
registered nurse (R, N .) or a licensed nurse-midwife; and have a written agreement with a Hospital in the
same locality for inunediate acceptance of patients who develop complic.1tions or require pre- or
post-delivery confinement.
Calendar Year means Januaty 1st through December 31st of the same year.
Cbiropr:lctic Care means the diagnosis and treatment of dislocations, subluxations or misalignments of
the vertebrae,
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as atnended.
Cosmetic Surgery means medically unnecessaty surgical procedures, usually, but not limited to, plastic
surgery directed toward preserving beauty or conecting scars, burns or disfigurements.
Covered Person is an Employee or Dependent who is coverr.d under this Plan.
Custodial Care is care (including room and board needed to provide that care) that is given principally
for personal hygiene or for assistance in daily activities and can, according to generally accepted medical
standards, be perfonned by persons who have no medical training. Examples of Custodial Care are help
in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over mrdication
which could normally be self-administered,
Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within
the scope of such license.
Employee me.ms a person who is an Active, regular Employee of the Employer, regularly scheduled to
work for the Employer in an Employee/Employer relationship,
Employer is ERX Logistics,
ERISA is the Employee Retirement Income Security Act of 1974, as amended,
Experimental andior Investigational means services, supplies, care and traunent which does not
constirute accepted medical practice properly within the range of appropriate medical practice under the
standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant
segment of the ml"llical community or government ovetsight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental/nonexpcrimental
standings of specific, technologies, The Plan Administrator shall be guided by a reasonable interpretation
of Plan provisions, The deciSIOns shall be made in good faith and rendered following a detailed factual
20
';,\1
r".i,,'
if the drug or device cannot be lawfully marketed without approval orthe V,S. Food and
Drug Administration and approval for marketing has not becn given at thc time the drug
or device is furnished; or
(2) if the drug, device, medical treatment or procedute, or thc patient informed consent
document utilized with the drug, device, treatment or procedure, was reviewed and
approved by the treating facility's Institutional Review Board or other body selving a
similar function, or if federal law requires such review or approval; or
(3) if Reliable Evidence shows that the drug, device, medic:lI treatment or procedure is the
subjecl of on-going phase lor phase II clinical trials, is the research, experimental, study
or investigational ann of on-going phase III clinical trials, or is otherwise under study to
determine its maximum lolerated dose, its toxicity, its safety, its efficacy or its efficacy
as compared with a standard means of treatment or diagnosis; or
(4) if Reliable Evidence shows that the prevailing opinion among experts regarding the drug,
device, medical treatment or procedure is that further studies or clinical trials are
necessary [0 determine its maximum tolerated dose, its toxicity, its safety, its efficacy or
its efficacy as compared with a standard means of treatment or diagnosis.
Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific
literature; the written protocol or protocols used by the treating facility or the protocol(s) of another
facility studying substantially the same drug, device, medical treatment or procedure; or the written
informed consem used by the treating facility or by another facility studying substantially the same drug,
device, medical trealll1em or procedure.
Family Unit is the covered Employee and the Employee's covered Dependents under the Plan,
Groenc Drug meatlS a Prescription Drug which has the equivalency of the brand name drug with the
same use and metabolic disintegration, This Plan will consider as a Generic Drug any Food and Drug
Administration-approved generic pharmaceutical dispensed according to the professional standards of a
licensed phannacist and clearly designated by the pharmacist as being generic,
Hospicc Agency is an agency where its main function is to provide Hospice Care Services and Supplies
and it is licensed by the state in which it is located, if licensing is required,
Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice
Agency and supervised by a Physician,
Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice
Care Plan and include inpatient care in a Hospice Unit or other licensed facility, home care, and family
counseling during the bereavement period.
Hospice Unit is a facility or separate Hospital Unit, that provides treatment under a Hospice Care Pbn
and admits at least two unrelated persons who are expected to die within six momhs.
Hospital is an institution which is engaged primarily in providing medical care and treannent of sick alld
injured persons on an inpatient basis at the patient's expense and which fully meets these tests: it I:,
accredited as a Hospi13l by the Joint Commission on Accreditation of Healthcare Organizations; it is
.pproved by Medic.1re as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for
surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of
a staff of Physicia1lS; it continuously provides on the premis~s 24-hour-a-<lay nursing services by or under
the supervision of registered nurses (R,N ,s); and it is operated continuously with organized facilities for
operative surgety on the premises.
21
A facility operating primarily for the tre;Jtment of Substance Abuse if it meets thesc tests:
maintains pernlanent and full-lime facilities for bed care and full-time confinemelll or at
least 15 resident patients: has a Physician in rcgular attendancc; continuously provides
24-hour a day nursing service by a registered nurse (R.N ,); has a full-timc psychiatrist
or psychologist on the staff; and is primarily engaged in providing diagnostic and
therapeutic services and facilities for treatment of Substance Abuse.
Injury means an accidental physicallnjuty to the body caused by unexpected external means.
Inpatient Care is defined as the classification of a Covered Person when that person is admitted to
hospital, hospice unit, or skilled nursing facility for treatment, and charges are made for room and board
to the Covered Person as a result of such treatment.
Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within
a Hospital solely for the care and treatment of patients who are critically ill. This also includes what is
referred to as a "coronary care unit" or an "acute care unit." It has: facilities for special nursing care not
available in regular rooms and wards of the Hospital; special life saving equipment which is immediately
available at all limes; at least two beds for the accommodation of the critically ill; and at least one
registered nurse (R.N.) in continuous and constant attendance 24 hours a day.
lifetime is a word that appears in this Plan in reference to benefit ma.ximums and limitations. Lifetime
is understood to mean while covered under this Plan, Under no circumstances does Lifetime mean during
the lifetime of the Covered Person,
Medical Care Facility means a Hospital, a facility that treats one or more specific ailments or any type
of Skilled Nursing Facility,
ML>dical Emergency is defined as a sudden onset of a condition with acute symptoms requiring immediate
medical care that threatens life or bodily functions and could result in serious bodily harm if not treated
immediately. Such conditions include heart attacks, cardiovascular accidents, poisonings, loss of
consciousness or respiration, convulsions or other such acute medical conditions,
In lddition. Medical Emergency includes a ment31 health or chemical dependency condition when the lack
of medical treatment could reasonably be expected to result in the patient harming himself or herself
and/or other persons.
Medically Necessary care and treatment is recommended or approved by a Physician; is consistent with
the patient's condition or accepted slandards of good medical practice; is medically proven to be effective
treatment of the condition; is not perfonned mainly for the convenience of the patient or provider; is not
conducted for research purposes; and is the most appropriate level of services which can be safely
provided to the patient.
Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social
Security Act, as amende'll,
Mental DL~order means any disease or condition regardless of the cause that is classified as a Mental
Disorder in the current edition of !nternational Classification of Diseases, publishe.d by the U,S.
Depal1:nent of Health and Human Services,
Morbid Obesity is a diagnosed cundition in which the body weight exceeds the medica:Iy recommended
weight by either 100 pounds or is tWice the medic,ally reconuoended weight.
No. Fault Auto Insurance is the basic reparalion.~ provision of a law providing. for paymer.ts without
detennining fault in cOClnecti"n with automehlk accidents,
"
on-
threatening; , ,,!i,'~1r., '~ '
"" "<',1' "":;"', 1, 'I ",~'"~"-J,,, ~,.\,..',~ ..
Outpatient Care is treatment including services, supplies and medicines'p~oYlded'and use it p
under the direction of a Physician to a person not admitted as a registered bed patient; or services
rendered in a Physician's office. laboratory or X-ray facililY, an AmbulalOry Surgical Ccnter, or the
paticnt's home,
Phannacy means a Iicenscd establishment whcrc covered Prescription Drugs are fIllct! and dispensed by
a phannacist licensed under thc laws of the state where he or she practices,
Physician means a Doctor of Medicine (M,O,), Doctor of Osteopathy (0,0,), Doctor of Dental Surgery
(D,O.S.), Doctor of Podiatry (O.P,M.), Doctor of Chiropractic (O,C.), Psychologist (Ph,O,),
Psychiatrist (M.D,), who is licensed and regulated by a state or federal agency and is acting within the
scope of his or her license.
Care and services rendered under the direct supervision of a Physician by medical support personnel, such
as but not limited to, midwives, physical therapists, physiotherapists, audiologists and speech language
pathologists, will be considered for reimbursement by this Plan if the personnel are licensed by the state
in which they are practicing; they are practicing within the scope of their licenses; and they have billed
the Plan through a Physician or Hospital.
Plan Participant is any Employee or Dcpendent who is covered under this Plan.
Plan Year is the 12-month period beginning on either the effective date of the Plan or on the day
following the end of the first Plan Year which is a ShOll Plan Year,
Podiatry. Care, treatment, and supplies for the feet include, but not limited too, casted orthopedic
prescription devices, open cutting operations, and treatment of corns, calluses or toenails,
Pre-Existing Condition is a diagnosed or undiagnosed, symptomatic or asymptomatic, Injuty or Sickness
that was treated within thrce (3) months of the person's coverage I.1king effect under this Plan. Treannent
includes recciving medical care, services and supplics, including consultations, diagnostic tests or
prescribed medicines.
Pregnancy is childbirth and conditions associated with Pregnancy, including complications,
Prescription Drug means any of the following: a drug or medicine which, under fedcrallaw, is required
to bear the legend: .Caution: federal law prohibits dispcnsing without prescription"; injectable insulin;
hypodermic needles or syringes, but only when dispensed upon a written prescription,
Sickness is a person's illness, disease, or Pregnancy, including complications,
Skilled Nursing Facility is a facility that fully meets all of these tests:
(1) It is licensed to provide professiorul nursing services on an inpatient basis to persons
convalescing from Injury or Sickness, The service must be rendered by a registered nurse
(R,N,) or by a licensed practical nurse (L.P,N ,) under the direction of a registered nurse,
Services to help restore paticnts to self..care in essential daily living activities must be
provided,
(2) Its services arc providcd for compensation and under the full-time supervision of a
Physician,
(3) It provides 24 hour per day nursing scrvices by licensed nurses. umlcr the direction of
a full.timc registercd nurse,
(4) It maintains a complete medical record on each patient.
O'
..'
For all Plan IkncliL"i and l\lcdical Benefits, :1 cbargc for the rol1~wing is n'Ot coY~red:
(1) Care, trealment 01 ,upplks fur which a charge was incurred before a person was Covered
under this Plan,
(2) Services, treatments, and supplies which are not specified as covered under this Plan.
(3) Charges excluded by the Plan design as memioned in this document.
(4) Charges incurred for which the Plan has no legal obligation to pay,
(5) Care and treaunent of an Injuty or Sickness that is occupational - that is, arises from
work for wage or profit including self-employment.
(6) Care, treatment, services or supplies not recommended and approved by a Physician; or
treatment, services or supplies when the Covered Person is not under the regular care of
a Physician, Regular care means ongoing medical supervision or lreaunent which is
appropriate care for the Injuty or Sickness.
(7) Care and treatment for which there would not have been a charge if no coverage had
been in force.
(8) Care, treatmcm or supplies furnished by a progratn or agency funded by any government,
This does not apply to Medicaid or when otherwise prohibited by law,
(9) Care and treatment that is either Experimental/Investigational or not Medically
Necessary ,
(10) The part of an expense for care and treatment of an Injury or Sickness that is in ex,cess
of the Usual and Reasonable Charge,
(11) Charges for services received as a result of Injury or Sickness caused by or contributed
to by engaging in an illegal act or occupation; by committing or attempting to commit
any crime, criminal act, assault or other felonious behavior; or by participating in a riot
or public disrurbance.
(12) Any loss that is due to a declared or undeclared act of war.
(13) Any loss due to an intentionally self. inflicted Injury. while sane or insane.
(14) Professional services performed by a person who ordinarily resides in the Coveted
Person's home or is related to Ole Covered Persall as a Spouse, parent, child, brother or
sister, whether the relationship is by blood or exists in law.
(15) Services for educatiollal or vocational testing or training.
(16) Personal comfort items or other equipment, such as, but not limited to, air conditioners,
air-purification units, humidifiers, electric healing units, orthopedic mattresses, blood
pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and
medicines, and first.aid supplies and non-hospital adjust.1ble beds.
(17) Care, services or treatment for transsexualism, gender dysphoria or sexual reassignment
or change, including medications. implants, honnone therapy, surgery, medical or
psychi:mic treatment.
(18) Care and treatment for hair loss including wigs, hair transplants or any drug that
promises hair gro'" tb, ",hether or not prescribed by a Physician.
25
(21) Services or supplies which a covered Dependent could have received from a health
maintenance organization (HMO) as prim.1ry coverage,
(22) In Michigan _ care, services or supplies for the treatment of injuries received in an
accident involving a car or motor vehicle.
In all states except Michigan - c.1re, services or supplies for treaouent of injuries
received in an accident involving a car or other motor vehicle for which there is in effect,
or is required to be in effect, any policy of no-fault insurance. When coordinating
benefits, the auto insurance carrier will be primary and this Plan will be secondary.
(23) Services incurred outside the United States if the Covered Person traveled to such a
location for the primary purpose of obt.1ining medical services, drugs or supplies.
(24) Charges incurred while confined in a Government or Military Hospital.
(25) Abortion, unless the life of the mother is endangered by the continued Pregnancy,
(26) Charges for contact lenses and eyeglasses, except the initial contact lenses or eyeglasses
required following cataract surgery,
(27) Care and treatment provided for cosmetic reasons unless Medically Necessary as defined
in the Medical Benefits section.
(28) Services or supplies provided mainly as a rest cure, maintenance or Custodial Care.
(29) Charges for hearing aids and exan1S for their fitting.
(30) Care and treatment for infertility. artificial insemination or in-vitro fertilization,
(31) Charges for the care, treatment, or supplies of the feet for orthopedic shoes or non-casted
orthopedic prescription devices,
(32) Care and treatment of Pregnancy and Complications of Pregnancy for a dependent
daughter.
(33) Replacement of braces of the leg, arm, back, neck, or artificial anns or legs, unless there
is sufficient change in the Covered Person's physical condition to make the original device
no longer functional.
(34) Radial keratotomy or other eye surgety to correct near-sightedness,
(35) Charges for smoking cessation pr<lgrarns, classes, supplies, and aids.
(36) Charges for surgical sterilization reversal.
(37) Care and treatment of obesity, weight loss or dietary control whether or not it is, in any
case, a part of the treatment plan for another Sickness, except Morbid Obesity as defined
in the Defined Terms section
26
,
,..,,1\,",
" " 'PRESCR
pHARMACY DRUG CARD CHARGE
Participating phamlacies have contracted with the Plan to charge Covered Persons reduced fees for
covered Prescription Drugs, pes is the administrator of the phanTIacy card drug plan,
COPAYMENT
The copayment is applied to each covered phanTIacy card drug cllarge and is shown in the Schedule of
Benefits. The copayment amount is not a covered charge under the Medical Plan. Anyone prescription
is limited to the greater of a 34-day supply or a IOO-unit dose.
If a drug is purchased from a non-participating pharmacy, or a participating pharmacy when the Covered
Person's Employee Benefit Card is not used, the amount payable in excess of the copayment will be the
ingredient cost and dispensing fee.
MAIL ORDER DRUG OPTION
The mail order drug benefit optian is available for maintenance medications (those that are t:tken for long
periods of time, such as drugs sometimes prescribed for heart disease, high blood pressure, asthma. etc.).
Because of volume buying, SystemMed, the mail order pharmacy, is generally able to offer Covered
Persons savings on their prescriptions,
COPAYMENT
The copayment is applied to each covered mail order prescription charge and is shown in the Schedule
of Benefits. It is not a covered charge under the Medical Plan. Anyone prescription is limited to the
greater of a 9O-day supply or a 300-unit dose,
LIMITS TO TIllS BENEFIT
This benefit applies only when a Covered Person incurs a covered Prescription Drug charge, The covered
drug charge for anyone prescription will be limited to:
(1) Refills only up to the number of times specified by a Physician,
(2) Refills up to one year from the date of order by a Physician,
COVERED EXPENSES
A charge for any of the following wiU be covcred:
(1) Non-injectable legend drugs,
(2) Insulin on prescription.
(3) Disposable insulin syringes and needles on prescription.
(4) Compounded medication of which at least one ingredient is a prescription legend dru'
(5) Any drug which under the applicable state law may only be dispensed upon the WI ill'
prescription of a physician or other lawful prescriber.
27
, ,', ',. ,',.,"'.".., ..,~~.....'....,a.',I...'~',.,'~~..:1~'~.~''1fI'~~I'1'.-fjr,~j{"',1{I'~,,-!1~
EXl'ENSES NOT COVEltEI;: ' ,'," .,"'.. '1:' "~~~~:-r"rC"~I~\;";I~J,~fr'~fW~~1~lptn!!!l~'r.1J;~'~-1'r!aHlWf/l..IH l~,l'
.... .'.... 'r'-..,.'.,.,.....~-
A charge for any of the following will no' be covered:
(1) A charge excluded under General and Medical Plan Exclusions.
(2) A charge for contraceptives, oral or other whether medication or device, regardless of
intended use. (Covered Under Mail Order Drug Option,)
(3) Anorectics (any drug used for the purpose of weight loss),
(4) Any drug USL't! for cosmetic purposes (e.g, RClin-A used for wrinkles),
(5) Growth Honnones.
(6) Immunization agents or biological sera, blood or blood plasma.
(7) A charge for infertility medication.
(8) Non-legend drugs other than those listed above.
(9) Levonorgestrel (Norplant).
(10) Minoxidil (Rogaine) for the treatment of alopecia.
(11) Nicorelte (or any other drug containing nicotine or other smoking deterrent medication),
(12) Injectable drugs, except insulin. (Covered Under Medica' Plan.)
(13) Progesterone, all dosage fonns,
(14) Therapeutic devices or appliances, including needles, syringes, support garments and
other non-medical substances, regardless of intended use, except 'isted under covered
expenses.
(15) Charges for the administration or injection of any drug,
(16) Prescriptions which an eligible person is entitled to receive without charge from an,
Worker's Compensation Laws.
(17) A drug or medicine labelled: "Caution -limited by federal law to investigational use" 01
experimental drugs and medicines.
(18) Medic3tinn which is to be taken by or administered to the Covered Person. in whole 0
in part, while Hospital confined. This includes being confined in any institution that ha
a facility for the dispensing of drugs and medicines on its premises.
(19) Any prescription refilled in excess of the number specified by the physician, or any refil
dispensed after one year from the physician's original order.
(20) Amivirals, specifically related to HIV/AIDS, (Covered Under Medical Plan.)
(21) Immunosuppressants, primarily indicated for organ transplantation, (Covered Und(
Medical Plan.)
~ '
.11
This benefit applies when covered delllal charges are incurred by a person while covered under this Plan,
DEDUCTIBLE
Deductible Amount. This is an amount of dental charges for which no benefits will be paid, Before
benefits can be paid in a Calendar Year, a Covered Person must meet the deductible shown in the
Schedule of Benefits. On covered charges paid at 100%, the deductible will be waived.
BENEFIT PAYMENT
Each Calendar Year benefits will be paid to a Covered Person for the dental charges in excess of the
deductible. Payment will be made at the rate shown under 'Plan Pays' in the Schedule of Benefits. No
benefits will be paid in excess of the Calendar Year Maximum.
DENTAL CHARGES
Dental charges are the Usual and Reasonable Charges made by a Dentist or other Physician for necessary
care, appliances or other dental material listed as a covered denial service.
A dental charge is incurred on the date the service or supply for which it is made is performed or
furnished. However. there are times when one overall charge is made for all or part of a course of
treatment. In this case, the Claims Administrator will apportion that overall charge to each of the separate
visits or treatments, The pro rata charge will be considered to be incurred as each visit or treatment is
completed,
COVERED DENTAL SERVICES
Class A Services: Preventive and Dia"anostic Dental Procedures
The limit~ on Class A Services are for routine services. If denLll need is present, this Plan will consider
for reimbursement services performed more frequently thaIl the limits shown,
(1) Routine oral exams, This includes the cleaning and scaling of teeth. Limit of two (2)
exatnS per Covered Person each Calendar Year.
(2) One bitewing x-ray series two (2) times a Calendar Year.
(3) One full mouth x-ray evety three (3) Calendar Years,
(4) One fluoride treatment for covered Dependent children under age 19 each Calendar Year.
Class B Services: Basic Dental Procedures
(1) Dental x-rays not included in Class A.
(2) Space m.1intainers for covered Dependent children under age 19 to replace prim.'U')' teeth.
(3) Emergency palliative treatment for pain,
(4) Oral surgery, Oral surgery is limited to temoval of teeth, preparation of the mouth for
dentures and removal of tooth-generated cysts of less than 1/4 inch.
(5) Periodontics (gum treatments),
(6) Endodontics (root canals).
(7) Extractions, This service includes local anesthesia and routine post.operative care.
2<)
;.1,( '.'" ",.,' ,;
(8) Reccmcnting bridges. crowns or inlays.
(9) Fillings, other than gold,
(10) General anesthetics. upon demonstration of Medica] Necessity,
(11) Antibiotic drugs,
Class C Sei'Vices: Major Dental Procedures
(1) Gold restorations, including inlays, onlays and foil fillings, The cost of gold restorations
in excess of the cost for atn:1lgam, synthetic porcelain or plastic materials will be included
only when the teeth must be restored with gold,
(2) Insl.'lllation of crowns.
(3) Installing precision attachments for removable dentures.
(4) Installing partial, full or removable dentures to replace one or more natural teeth that
were extracted while the person was covered for this benefit, This service also includes
all adjusnnents made during a six-month period following the installation.
(5) Addition of clasp or rest to existing partial removable dentures,
(6) Initial installation of fixed bridgework to replace one or more natural teeth which were
extracted while the person was covered for these benefits,
(7) Repair of crowns, bridgework and removable dentures.
(8) Rebasing or relining of removable dentures.
(9) Replacing an existing removable partial or full denture or fixed bridgework; adding teeth
to an existing removable partial denture; or adding teeth to existing bridgework to replace
newly extracted natural teeth, However, this item will apply only if one of these tests is
met:
(b) The existing denture or bridgework was insl.'llled at least five years prior
to its replacement and cannot currently be made serviceable.
(c) The existing denture is of an immediate temporary nature. Further,
replacement by pennanent dentures is required and must take place
within 12 months from the date the temporal)' denture was installed.
Class D Services: Orthodontic Treatment and Appliances
This is treatment to move teeth bY means of appliances to corr~"Ct a handicapping malocclusion of the
mouth,
These services are available for covered Dependent children under age 19 and include preliminaty study,
including x-rays, diagnostic casts and treannent plan, active treatments and retention appliance.
Payments for comprehensive full-banded orthodontic treatments are made in installments.
(a) The replacement or addition of teeth is required because of one or more
narural teet.h being extracted after the person is covered under these
benefits '
30
ALTERNAT~: TREATMJ;:NT
Many dental conditions can be treated in more :han one way. This Plan has an "alternate lreatmelll"
clause which governs the amount of benefits the Plan will pay for treatments covered under the Plan, If
a patient chooses a more expensive treatment than is needed to correct a dental problem according to
accepted standards of dental practice, the benefit payment will be based on the cost of the treatment which
provides professionally satisfactory results at the most cost.effective level.
For example, if a regular amalgam filling is sufficient to restore a tooth to health, and the patient and the
Dentist decide to use a gold filling, the Plan will base its reimbursement on the Usual and Reasonable
Charge for an amalgam filling, The patient will pay the difference in cost.
EXTENSION OF BENEFITS
If your coverage under this Plan terminates, you may cont.inue to receive benefits for 30 days for the
following treatments:
(1) Prosthetic Devices _ if your dentist took the impression and prepared the supporting teeth
while you were covered by this Plall.
(2) Root Canal Therapy" if your dentist opened the tooth while you were covered under this
Plan.
(3) Crown _ if your dentist prepared the tooth for the crown while you were covered under
this Plan,
OPTIONAL PRETREATMENT ESTIMATE
If, before beginning a dental treatment program, you wish to have an estimate of the benefits that will
be paid by this Plan, your dentist should completl' a "Pretreatment Estimate" form, The completed foml
should be sent to CoreSource and they will provide you with a written estimate of covered expenses.
Forms may be obtained from the Local Personnel Administrator.
EXCLUSIONS
A charge for the following is not covered:
(1) Services that are excluded under Medical Plan Exclusions.
(2) Services that, to any extent, are payable under any medical expense benefits of the Plan
(3) Crowns for teeth that are restorable by other means or for the purpose of Periodont:
Splinting,
(4) Crowns, fillings or appliances that are used to emlOcct (splint) teeth, or change or alt,
the way the teeth meet, including altering the vertical dimension, restoring the bi
(occlusion) or are Cosmetic.
(5) Implants, including any appliances and/or crowns and the surgical insertion or remov
of implants,
(6) Replacement of lost or stolen appliances,
(7) Onhognathic surgery,
(8) Personaliution of dentures.
(9) Oral hygiene, p\Jque control prof\raJns or dietary instructions,
31
,..'.' ,.' ,',',,'\
,,. ."
SHORT TERlVI DISABILITY BENEFITS
This benefit applies when an Employee has a Total Disability that meets all of these tests:
(1) Total Disability startS while the Employee is covcred for this benefit.
(2) Total Disability is being continuGusly treated by a Physician,
(3) Total Disability is due to an lnjuty or Sickness, in either case, must bc covered by the
Medical Plan or nonoccupational (not arising from work for wage or profit).
Thc Employer shall reserve the option of requesting periodic physical exatninations from either the
current Physician on the case or a physician of the Employer's choice. Failure to provide requested
Physicians' st;ltements will result in termination of benefits. Employees are responsible for providing the
following information in a clearly understandable format:
(1) History regarding when symptoms first appeared or accident happened;
(2) D iagnos is;
< . . ' , ~.'
(3) Dates of treatment;
(4) Nature of treatment;
(5) Progress;
(6) Prognosis;
(7) Suitability for rehabilitation;
(8) Physician's signaturc and tax J.D, number.
Additional infonnation may be required based upon the indivicluallnjury or Sickness.
BENEFIT PAYMENT
Benefits will begin the first day of the Total Disability due to an Injuty and the eighth day of Total
Disability due to an Sickness and will be paid for up to 26 weeks per Total Disability period,
PERIOD OF TOTAL DISABILITY
Period ofTotal Disability is the period of time that an Employee is Totally Disabled. New periods do<
to thc same or related causes must be separated by return to Active Work for atleastlWO weeks in a row
New periods due to different causes must be separated by return to Active Work for at least one day.
COVERED WEEKLY EARNINGS
Covered weekly earnings is the Employee's rate of weekly earnings from the Employer in effect on tJ1
later of: (I) the Employee's effective date of coverage under the Plan; or (2) the start of the Tot~
disability.
Covered Weekly Earnings does not include these payments made by the Employer to the Employee f,
overtime pay, commissions, and bonuses.
EXCLUSION
Short Tenn Disability Benefits are not covcred in states where disability benefits are providcd
Slate,
33
When a Covered Person has a claim to submit for payment that person must:
(I) Obtain a claim form from the Local Personnel Administrator.
(2) Completc the Employee portion of the form. ALL QUESTIONS MUST BE
ANSWERED.
(3) Have the Physician complete the provider's portion of the fonn.
(4) For Plan reimbursements, attach bills for services rendered. ALL BILLS MUST SHOW:
-Name of Plan
-Group number of Plan
-Employee's name
-Name of patient
-Name, address, telephone number of the provider of care
-Diagnosis
-Type of services rendered, with diagnosis and/or procedure codes
-Date of services
-Charges
(5) Send the above to the Claims Administrator at this address:
CoreSource, Inc.
2600 Horizon Drive, SE
P.O, Box 1687
Grand Rapids, Michigan 49501
(616) 954-3300 or 1 (800) 766-9780
However, your physician, dentist, hospital, lab and other providers may submit fully itemized bills on
their own fonns, or they may use the Plan's claim fonn. Please be sure to use your Employee Benefit
C:ird when giving iofonnation to your physician, hospital, lab or other provider.
WHEN CLAIMS SHOULD BE FILED
Claims should be filed with the Claims Administrator within 90 days of the date charges for the service
were incurred, Benefits are based on the Plan's provisions at the time the charges were incurred. Charges
are considered incurred when a treaonent or care is given or a procedure performed. Claims filed later
than that date may be declined or reduced unless:
(1) it's not reasonably possible to submit the claim in that time; and
(2) the claim is submitted within one year from the dale incurred, This one year period will
not apply when the p'rson is not legally capable of submitting the claim.
The Claims Administrator will detennine if enough information has been submitted to enable proper
consideration of the claim. If not, more infonnation may be requested,
WUA T IL\PPENS WHEN A CLAIM IS HLED
After you submit claim, it will be reviewed and one of the following will occur:
(l ) You will receive a written explanation of the nature and amount of the claim and whether
or not it is approved for payment. If approved, the written explanation will indicate the
amount paid and the amount you owe (if any), If denied, you will receive an explanation
for the denial; or
(2) You will receive a request fm a,lditional information,
34
HOW CLAIMS ARE I'AlD
Payment will be made directly to your physician, dentist, hospi131. lab or other provider.
If. however, you have paid the bill, payment will be sent directly to you if you have submitted a paid
receipt.
RlGIIT OF EXAMINA nON
If neccsSaty to assist in making a benefit detennination, CoreSollrce may request that you or your
dcpendent be examined by a physician selected and paid by ERX Logistics, If you choosc not to comply
with this request, benefits will be denied.
DISPUTED CLAIMS PROCEDURE
In cases where a claim for benefits payment is denied in whole or in part, the claimant may appcal the
denial. This appeal provision will allow the claim:U1t to:
(1) Request from the Plan Administrator a review of the eligibility status for any claim
denied in whole or in part.
(2) Request from the Plan Admini~trator a review of any claim payment. Such request must
include; the name of the Employee, his or her Social Security number, the name of the
patient and the Group Identification Number, if any.
(3) File the request for review in writing, stating in clear and concise terms the reason or
reasons for this disagreement with the handling of the claim.
The request for review must be directed to the Plan Administrator or Claims Administrator within 60
days after the claim payment date or the date of the notification of denial of benefits,
A review of the denial will be made by the Plan Administrator and the Plan Administrator win provide
the claimant with a written response within 60 days of the date the Plan Administrator receives the
claimant's written request for review, If, because of extenuating circumstances, the Plan Administrator
is unable to complete the review process within 60 days, the Plan Administrator shall notify the claimanl
of the delay within the 60 day period and shall provide a final written response to the request for review
within 120 days of the date the Plan Administrator received the claimant'S written request for review,
The Plan Administrator's written response to the claimant shali, if the denial is upheld, cite the specific
Plan provision(s) upon which the denial is based.
ERROR DISCOVERY BONUS
As a special encouragement t,O your to carefully review your hospital bill, the Plan will pay you 20% 0
the amount of a billing error that you discover that is S10 or more. The maximum benefit is S200 pe
year.
35
Coordination of the benefit plans. Coordirtation of benefits sets out rules for the order of paymenl of
Covered Charges when two or marc plam - including Mcdicare - arc paying. When a Covered Pcrson
is covered by this Plan and another plan, or the Covered Person's Spouse is covered by this Plan and by
another plan or the couple's Covered children are covered under tWO or more plans, the plans will
coordinate hcnefits when a claim is received,
The plan that pays first according to the rules will pay as if there were no other plan involved. The
secondary and subsequent plans will pay the balance up to each one's plan fonnula, The total
reimbursement will neVer be more than the secondaty (or subsequent) plan's formula - 50% or 80% or
100% - whatever it may be. The balance due, if any, is the responsibility of the Covered Person.
Benefit plan. This provision will coordinate the medical and del1lal benefits of a benefit plan, The ternl
benefit plan means this Plan or anyone of the following plans:
(1) Group or group-type plans, including franchise or blanket benefit plans.
(2) Blue Cross and Blue Shield group plans.
(3) Group practice and other group prepayment plans,
(4) Federal government plans or programs, This includes Medicare.
(5) Other plans required or provided by law. This does not include Medicaid or any benefit plan
like it that, by its terms, does not allow coordination.
(6) No Fault Auto Insurance, by whatever name it is called, when not prohibited by law,
Allowable Charge, For a charge to be allowable it must be a Usual and Reasonable Charge and at least
pan of it must be covered under this Plan,
In the case of HMO (Health Maintenance Organization) plans: This Plan will not consider any charges
in excess of what an HMO provider has agreed to accept as payment in full. Also, when an HMO pays
its benefits first, this Plan will not consider as an allowable charge any charge that would have been
covered by the HMO had the Covered Person used the services of an HMO provider.
In the case of service type plans where services are provided as benefits, the reasonable cash value of
each service will be the allowable charge,
Automobile Limitations. When medical payments are available under vehicle insurance, the Plan shall
pay excess benefits only, without reimbursement for vehicle plan deduetibles. This Plan shall always be
considered the secondaty carrier regardless of the individual's election under PIP (personal injury
protection) coverage with the auto carrier.
This does not apply in the state of Michigan where care, service; or supplies for the treatment of injuries
received in an accident involving a car or motor vehicle is excluded under the Plan,
Benefit Plan Payment Order. When tWO or more plans provide benefits for the same allowable charge,
bene fir payment will follow these rules.
(1) Plans that do not have a coordinarion provision, or one like it, will pay first. Plans wirh such
a provision will be considered af1er those without one,
(2) Plans with a coordination provision WIll pay their benefits by these rules up to the allowable
charge,
(a) The benefits of the plan which covers the person as an employee, member or
subscriber (that is, other than as a dependent) arc determined before those of the plan
36
.',.'.',' "
,~r ..",...~,. 7 "
whldl ~ovcrs the person as a deperiden't; excep't 'that:, ~rso s s
bcneficlary, and 3S " rcsult or the rule established by Tille XVIII or
Security Act and implcmenting regulations, Medicarc is
(i) Secondary to the plan covering the person as a depcndent, and
(ii) Primary to thc plan covering the pcrson as othcr than a depcndent (e.g, a
retired employce), then the benefits of the plan covering the person as a
dependent are determined beforc those of thc plan covering that pcrson as
other than a dcpendent.
(b) The bencfits of a benefit plan which covers a person as an Employce who is neither
laid off nor rctired arc detennined before those of a bencfit plan which covcrs that
pcrs\JO as a laid.{)ff or Retired Employee. The bencfits of a bencfit plan which eovcrs
a person as a Depcndent of an Employee who is neither laid off nor retired are
detennined beforc those of a benefit plan which covers a person as a Dependent of
a laid off or Retired Employee. If the other benefit plan does not have this rule, and
if, as a result, tlle plans do not agree on the order of benefits, this rule does not
apply.
(c) When a child is covered as a Dependent and the parents are not separated or
divorced, these rules will apply:
(i) The benefits of the benefit plan of the parent whose birthday falls earlier in
a year are detennined before those of the benefit plan of the parent whose
birthday falls later in that year;
h
Ifboth parents have the same birthday, thc benefits of the bcnefit plan which
has covered the patient for the longer time are detennined before those of the
benefit plan which covers the other parent.
(d) When a child's parents are divorced or legally separated, these rules will apply:
(ii)
:,'
"
(i) This rule applies when the parent with custody of the child has not
remarried. The benefit plan of the parent with custody will be considered
before the benefit plan of the parent without custody,
(ii) This rule applies when thc parent with custody of the child has rcmarried.
Thc benefit plan of the parent with custody will be considered first, The
benefit plan of thc stcpparent that covers the child as a Dependent will be
considered next. The benefit plan of the parent without custody will be
considered last.
(iii) This rule will be in place of items (i) and (ii) above when it applies, A court
decree may state which parent is financially responsible for medical and
denIal benefits of the child. In this ca.~e, the benefit plan of that parent will
be considered beforc other plans that cover the child as a Dependent.
(iv) If the specific tenllS of the court decree state that the parents shall share joint
custody, without Staling that one of the parents is responsible for the health
care expenses of the child, the plans covering the child shall follow the order
of benefit determination rules outlined above when a child is covered as a
Dependent and the parents are not separated or divorced,
(e) If there is still a conf1ict after these rules havc been applied, the benefit plan which
has coverc,l the patient for the longer time will be considered first.
37
, -."
COIU{A CONTINUATION OPTIONS
Federal law givcs ce"ain persall, thc right to continue thcir health cafe bcnefits beyond the dalc that the
might otherwise temlinate, The entire cost (plus a reasonable administration fee) must be paid by th
continuing person, Coverage will end if the covered individual fails to make timely payment (
contributions or premiums (within a maximum of 30 days), This law is referred to as "COBRA", whic I
stands for the Consolidated OmnibUS Budgct Reconciliation Act of 1985. Generally, COBRA applies t
employers with 20 or more full and/or part-timc employecs. Employees should check with thcl
Employers to see if COBRA applies to them,
BENEFITS AFFECTED BY COBRA
There are two categories of benefits that may be continued under COBRA.
(I) "Core benefits" are Medical Benefits. Any COBRA continuance option must include cor
benefits for which thc person was covered just prior to the COBRA "qualifying cvelll
(an event which qualifies a person for continued coverage under COBRA),
(2) " Non-core benefits" include Dental Benefits, Vision Care Benefits and Flexible Spendin
Accounts under Section 125 (Cafeteria-type) plans.
If the "qualified beneficiary" (a person eligible for COBRA continuance) was covered b:
these non-core benefits prior to termination, the individual may, but is not required to
continue them under COBRA, Which non-core benefits, if any, are to be continued wil
be indicated by the qualified beneficiaty at the time of COBRA enrollment,
Life insurance, accidental death and dismemberment benefits and weekly income or long term disabilir:
benefits (if a part of the Employer's plan) are not considered for continuance under COBRA,
Maximum Time Periods. Continuation will be available for a qualified beneficiary up to the maximun
time period shown in item (1), (2) or (3) below. Combined qualifying events will not continue
beneficiary's coveragc for more than 36 months beyond the date of the original qualifying event, or whe,
thc qualifying event is "entitlement to Mcdicarc", the 36 month continuation period is measured from th,
date of Medicare entitlement.
(1) Up to 18 months for an Employee and his covered Dependem(s) when cove rag,
tenninatC5 due to reduction of hours worked, or termination of employment for reason
other than gross misconduct.
Note: An individual who is disabled on thc date of the qualifying event may have COBRi
coverage extended (and an extra fce charged) from 18 months to 29 months provided that:
(n) the individual is detennined as being disabled for Social Secudt
purposes on the date of the qualifying event; and
(b) the individual notifies the Plan Administrator within 60 days of th
qualifying event Of Social Security Administration's determination (
disability .
(2) Up to 36 months for:
(a) a covered child who cea,es to be an eligiblc Dependent;
(b) a covered Dependent of a dcce:lSed Employee;
(e) a former covered Spouse whose coverage cea!oes due to divorce or leg,
separation; or
40
RESPONsmn..rrms 1.OR PLAN ADMINISTRATION
PLAN ADMlNISTRA TOR. ERX Logistics Employee Benefit Plan is the benefit plan of ERX Logistics,
the Plan Administrator, also called the Plan Sponsor. It is to be administered by the Plan Administrator
in accordance with the provisions of ERISA. An individual may be appointed by ERX Logistics to be
Plan Administrator and serve at the convenience of the Employer, If the Plan Administrator resigns, dies
or is otherwise removed from the position, ERX Logistics shall appoint a new Plan Administrator as soon
as reasonably possible,
The Plan Administrator shall administer this Plan in accordance with its tenns and establish its policies,
interpretations, practices, and procedures. It is the e~press intent of this Plan that the Plan Administrator
shall have maximum legal discretionaty authority to construe and interpret the tenns and provisions of
the Plan, to make determinations regarding issues which relate to eligibility for benefits, to decide
disputes which may arisc relative to a Plan Participant's rights, and to decide questions of Plan
interpretation and those of fact relating to the Plan. The decisions of the Plan Administrator will be final
and binding on all interested parties,
DUTIES OF THE PLAN ADMINISTRATOR.
(1) To administer the Plan in accordance with iL~ tenns,
(2) To decide disputes which may arise relative to a Plan Participant's rights.
(3) To keep and maintain the Plan documents and all other records pertaining to the Plan.
(4) To appoint a Claims Administrator to pay claims.
(5) To perfonn all necessary reporting as required by ERISA.
(6) To establish and conununicate procedures to detcnnine whether a medical child support
order is qualified under ERISA Sec. 609,
PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation;
however, all expenses for plan administration, including compensation for hired services, will be paid
by the Plan.
FIDUCL\RY. A fiduciaty exercises discretior,ary authority or control over management of the Plan or
the disposition of its assets, renders investment advice to the Plan or has discretionary authority or
responsibility in the administration of the Plan,
FIDUCIARY DUTIES. A fiduciary must carry out his or her duties and responsibilities for the purpose
of providing benefits to the Employees and their Dependent(s), and defraying reasonable expenses of
2dministering the Plan. These are duties which must be C:lITied out:
(1) with care, skill, prudence and diligence undcr the given circumstances that a prudent
person, acting in a likc capacity and familial' with such maners, would use in a similar
siruation;
(2) by diversifying the investments of the Plan so as to minimize the risk of large losses,
unless undcr thc circumstances it is clearly prudent not to do so; and
(3) in accordance with the Plan documents to thc extent that they agree with ERISA.
THE NAMED FIDUCIARY. A "named fiduciaty" is thc one named in the Plan. A named fiduciaty car
appoint others to carry out fiduciary responsibilities (other than as a trustee) under the Plan. Thcsc othe:
persons become fiduciarics themselves and are responsible for their acts under the Plan, To the exten
that the named fiduciary allor.:ltes its responsibility to other persons, the named fiduciaty shall not bl
liable for any act or omission of such person unless either:
42
(I) lhe named liduciary has '1lolaH~tl il.'l ~tall~cI dlllll'S under ERJSA in appointing the
fiduciary, estahlishin[l the pnx:edlHes 10 appoint the fiduciary or continuing either the
appointment of the pnx:edurc.s; or
(2) the named fiduciary hreached it.~ fiduciary respolLsibility under Section 405(a) of ERISA.
CLAIMS ADMINISTRATOR IS NOT A FIIHJCIAItY, A Claims Administrator is not a tiduciary
under till' Plan by virtue of paying claims in acclltdance with the Plan's rules as established by the Plan
Administrator.
FUNDING TIlE I'LAN ANIlI'A YMlo:NT OF BENEFITS
TIle COSt of the Plan is fnllded as lilllows:
For l~mploYI'C Coveralle: FUllding is derivl~l from the funds of the Employer and contributions made
by Ihe cow red Employees,
I,'or DepI'llllcnl CovclOIllc: Fundin!\ is derived from the funds of the Employer and contributions made
by Ihe covered Employees,
The level of allY Employee cOlltributions will be set by the Plan Administrator. These Employee
cOlllributlllllS will be uscd in fundillg the cost of the Plan as soon as practicable after they have been
received from the Employee or withheld from the Employee's pay through payroll deduction.
Bellefits ale paid ,lireclly from the Plan through the Claims Administrator,
PLAN IS NOT AN EI\II'LOYI\IENT CONTRACT
The I'lall is lIot to be cllllStnled as a contract for or of employment.
CLEJUCAL EIUU.>H
AllY c1ericall'l'lor by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent
records or ,1 delay in making any changes will not invalidate coverage otherwise validly in force or
conlinue coverage validly terminated. An equitable adjustment of contributions will be made when the
error or delay is discovered,
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains a
contractual right to the overpayment. The person or institution receiving the overpayment will be required
10 return the incorrect amollnt of money, In the case of a Plan Panicipant, if it is requested, the amount
of overpayment will be deducted frnm future benefits payable,
AllmNIlING ANI> n:Rl\IINA TING TIlE PLAN
If the Plan is lenninated, the rights of the Plan Participants are limited (0 expenses incurred before
tenninatilln,
The Emplllyer intends to maintain this Plan indefinitely; however, it reserves the right, at any time, to
amend, bUlpcn<l or tenninate lhe Plan in whole or in part. This includes amending the benefits under the
Plallor Ihe Tmst agrccment (if any), Any such amendment or termination shall be adopted by fOnTIal
wrillcn a(lion of the M:magml\ Partner, who is authorized to act on behalf of the Employer.
CEItTAIN EIIIPLOYEE rwarrs UNDER ERISA
I'lanPaltkip:t1I1S illlhh 1'\;11I ale entitlClj to ccrtain rights and protections under the Employee Retirement
Imlllllc Senility Ad .,1 1'17,1 (ElHSA) ERISA specifies that all Plan Participants shall be entitled to:
013
:, ..., ";''''''''', ..:...~,::'" ,'-', " .' .'. ': ", ,:..: '. " '" ' , ' '.. '" ,., ...", ,.", :. : '
ll) l:.xanUI1C. WlU'UU~ .........0..' M_
copies of all documents filed by the Plan with the U.S. Department at Laour, sue" oC>
detailed annual reports and Plan descriptions,
(2) Obtain copies of all Plan documents and other Plan information upon written request to
the Plan Administrator. The Plan Administrator may make a reasonable charge for the
copies .
(3) File suit in a federal court, if any materials requested are not received within 30 days of
the Plan patticipant's request, unless the materials were not sent because of matters
beyond the control of the Plan Administrator, The court may require the Plan
Administrator to pay up to $100 for each day's delay until the materials are received.
In addition to creating rights for Plan participants, ERISA imposes obligations upon the individuals who
are responsible for the operation of the Plan. The individuals who operate the Plan, called "fiduciaries"
of the Plan, have a duty to do so prudently and in the interest of the Plan participants and their
beneficiaries. No one, including the Employer or any other person, may fire a Plan Participant or
otherwise discriminate against a Plan Participant in any way to prevent the Plan Participant from
obtaining benefits under the Plan or from exercising his or her rights under ERISA.
If a Plan Participant's claim for a benefit is denied, in whole or in part, the Plan participant must receive
a written explanation of the reason for the denial. The Plan Participant has the right to have the Plan
review and reconsider the claim. Under ERISA there are steps that the Plan Participant can take to
enforce the above rights. For instance, if the Plan Participant requests materials from the Plan and does
not receive them within 30 days, that person may file suit in federal court. In such a ease, the court may
require the Plan Administrator to provide the materials and to pay the Plan participant up to $100 a day
until he Of she receives the materials, unless the materials were not sent because of reasons beyond the
control of the Plan Administrator, If the Plan Participant has a claim for benefits which is denied or
ignored, in whole or in part, that participant may file suit in state or federal court.
If it should happen that the Plan fiduciaries misuse the Plan's money, or if a Plan Participant is
discriminated against for asserting his or her rights, he or she may seek assistance from the U.S,
Deparrment of Labor, or may file suit in a federal court. The court will decide who should pay court
costs and legal fees. If the Plan Participant is successful, the court may order the person sued to pay theSe
costs and fees, If the Plan participant loses, the court may order him or her to pay these costs and fees,
for example, if it finds the claim or suit to be frivolous.
If the Plan Participant has any questions about the Plan, he or she should contact the Plan Administrator
If the Plan Participant has any questions about this statement or his or her rights under ERISA, that Pial
Participant should contact the nearest area office of the U .S, Labor-Management Services Administration
Department of Labor.
44