EIGHT: Life and Dismemberment Insurance and WA&S (Level
If you die while you're covered under this Plan, your beneficiary
is eligible for a benefit of $50,000.
- Your eligible dependents are covered for a $20,000
Life Insurance benefit, payable to you, as the member.
- When you're no longer eligible for Life Insurance coverage
through this Plan, you may convert your insurance to an
individual contract by submitting a written application
within 31 days of your termination.
- If you have a terminal illness, you may be eligible
to receive up to 75% of your life insurance benefit prior
to your death.
- If you become disabled, you will not forfeit your Life
Insurance benefit. Your benefit can be extended during
Accelerated Payment of Life Insurance Benefit
If while covered under this Plan for Life Insurance you become terminally
ill; or your spouse becomes terminally ill; you may request that
Aetna pay an Accelerated Death Benefit.
“A terminal illness as defined by Aetna means: suffers from an incurable,
progressive, and medically recognized disease or condition; and to a reasonable
medical probability and based on a generally accepted prognostic protocol,
will not survive more than the 24 months.”
You may elect to have up to 75% of your benefit payable to you under
the Accelerated Payment Option. The total amount of your Life Insurance
benefit that would have been payable upon your death will be reduced.
For more information, contact the Fund Office at (401) 467-3323.
What is Totally Disabled?
You are "totally disabled" when you
are not working at any job for wage or profit, and you are
unable to work in any job that is reasonably suited to you by
your education, training or experience.
Extended Life Insurance Benefits During Total Disability
If you become totally disabled while you are covered by this Plan,
and you are less than age 60 when your disability starts, and you
have been Totally Disabled for at least nine months, your Life Insurance
benefit may be extended for successive one-year periods.
You are permanently and totally disabled only if a disease or injury
stops you from working at:
- your own job; or
- any other job for pay or profit; and
- it must continue to stop you from working at any reasonable job.
You must meet all of the following to be eligible:
- Your Life Insurance must be be in force when you become permanent
and totally disabled
- You must be under age 60 at the time you are first permanently
and totally disabled.
- Your permanent and total disability must have lasted for at least
9 consecutive months without interruption.
Aetna must receive your written notice of claim
for this extension at its Home Office within 15 months from the date
you cease active work. If your written notice is not received
by Aetna within 15 months, you will not be eligible for this benefit
This extended insurance will be the amount you were insured for on
the date your disability began.
This extension period will end on the first to occur of:
- Your total disability ends;
- You fail to provide the required proof of your total disability
to Aetna; and
- The date you are well enough to work in any job that is reasonably
suited to you by your education, training or experience.
- The date you start to work in any job for pay or profit.
After insurance has been extended continuously
for 2 years. Aetna
will not request an exam or proof more often than once in a 15 month
NOTE: If you retire early before age 60 with a disability you
can elect to extend your Life Insurance Benefit, OR you can elect $5,000
Retiree Life Insurance if you are eligible. You cannot have both. If
you apply for the extended Life Insurance Benefit and you do not get
it, you may be able to get Retiree Life Insurance, if you qualify.
See Section 10: Retiree Benefits for more information.
Converting Your Life Insurance
You may convert all or part of your insurance to an individual life
insurance contract if you are no longer eligible for life insurance
under this Plan because:
- Your employment ends or you are transferred out of a covered class;
- Because of age or retirement
You must apply for the individual contract and pay the first premium
within 31 days after you cease to be insured for the Employee Term
The individual contract must conform to the following:
- The contract amount must not exceed the amount of your Employee
Term Life Insurance coverage you had under this Plan when your insurance
- Your premium must be based on Aetna's rate as it applies to the
form and amount, and to your class of risk and age at the time.
- The effective date is the end of the 31-day period during which
you may apply for the individual contract.
Life Insurance for Your Dependents
If your eligible dependent dies while covered by this Plan, you (as
the member) are eligible to receive a life insurance benefit of $20,000.
You will need to submit a certified death certificate to the Fund
Office. If your spouse dies, you will also need to submit your marriage
You may cover your:
- Wife or husband; and
- Unmarried children who are 14 days or older but under 19 years
- Any other unmarried child who is under age 25 as long as he or
she is a full-time student in a post-secondary educational institution
as defined in Section 2 of this Summary Plan Description.
- Note: Proof of a student’s full-time
enrollment in a post-secondary educational institution is required
Your children include:
- Your biological children
- Your adopted children
- Your stepchildren
- Your foster child
The following dependents are not eligible
- Those in full-time active military service.
- Children less than 14 days of age
Handicapped Dependent Children
Life Insurance and Accidental Death and Personal Loss Coverage for
your fully handicapped dependent child may be continued past the
maximum age for a dependent child. However, such coverage may
not be continued if the child has been issued a personal life conversion
Your child is fully handicapped if:
- he or she is not able to earn his or her own living because of
a mental retardation or a physical handicap which started prior to
the date he or she reaches the maximum age for dependent children;
- he or she depends chiefly on you for support and maintenance
Proof that your child is fully handicapped must be submitted to Aetna
no later than 31 days after the date your child reaches the maximum
Coverage will end on the first to occur of:
- Cessation of the handicap
- Failure to give proof that the handicap continues
- Failure to have any required exam
- Termination of Dependent Coverage as to your child for any reason
other than reaching the maximum age.
Aetna will have the right to require proof of the continuation of
the handicap. Aetna also has the right to examine your child as often
as needed while the handicap continues.
An exam will not be required more often than once a year after 2 years
from the date your child reached the maximum age.
Vested Death Benefit
(Frozen as of December 31, 1990)
The Vested Death Benefit is frozen as of December 31, 1990. If you
qualified for this benefit as of December 31, 1990, you may be entitled
to a benefit of $500 or more to use to pay for eligible medical expenses
What You Need To Do:
- Contact the Fund Office for a claim form if you have eligible expenses.
- Submit your claim and receipts to the Fund Office to use the money
in your account to pay for your eligible expenses.
- In the event of your death, your beneficiary should notify the
Fund Office and provide a certified death certificate to receive
the balance remaining in your account.
Your Vested Death Benefit
You are only eligible for the Vested Death Benefit if you met the eligibility
requirements before benefits stopped accruing on December 31, 1990.
The Vested Death Benefit a sum of money (based on your years of service)
that is put into an account for you. You may use this money one month
after your benefits terminate to pay for certain eligible medical
expenses. The remainder will be paid to your designated beneficiary
upon your death.
In order to be eligible for the Vested Death Benefit you must:
- Have qualified for this benefit as of December 31, 1990;
- No longer be working in Covered Employment;
- No longer be eligible for the life insurance benefit provided by
- Be at least age 55;
- Have been eligible for benefits under the Fund for at least five
years before December 31, 1990.
- Apply for this benefit within one year from the date the group
life insurance benefit terminates.
If you meet these requirements, you will be credited with $100 in
addition to the $500 minimum for every year over the five years you
were eligible for benefits from the Fund, up to a maximum of $1,500.
This money is kept in an account for you to use when you retire. You
may withdraw up to 100% of the money in your account to pay for hospital,
surgical, eye care, medical expenses, dental expenses or premiums that
are not paid by Medicare. You do not have to be eligible for Medicare
to use this money.
How to Receive Reimbursement
Submit a claim form and evidence of the expenses you incur to the Fund
Office. Any amount you withdraw from your account will be deducted
from the Vested Death Benefit that will be paid to your beneficiary
when you die.
If you leave covered employment and are awarded your Vested Death Benefit,
but then return to covered employment, your Vested Death Benefit will
be suspended until you retire again.
Accidental Death and Dismemberment Benefits
Your Accidental Death and Dismemberment (AD&D) coverage for Level
I benefits only pays benefits for the accidental loss of your life,
sight, hand or foot. The injury causing the loss must occur while you
are covered under this Plan.
What You Need To Do:
- If you suffer a loss, contact the Fund Office for a claim form.
- Ask your physician to provide a statement (proof of loss) describing
- Send the physician's statement along with the completed claim form
within 365 days after the date of loss to:
Teamsters Local 251
Health Services and Insurance Plan
1201 Elmwood Avenue
Providence, RI 02907-3799
Your AD&D Benefit
You are eligible for AD&D benefits if:
- You sustain an accidental bodily injury while you're covered by
- The loss results directly from that injury and from no other cause;
- You suffer the loss within 365 days after the accident.
The following Accidental Death and Dismemberment Benefits are payable
to covered participants under this Plan:
Type of Loss
Sight of Both Eyes
Third Degree Burns covering
75% or more of the body
Third Degree Burns covering
50% to 74% or more of the body
Sight of One Eye
Thumb and Index finger
of same hand
Speech and hearing
Speech or hearing in
Loss of sight means total and permanent loss of sight. Loss of hand
or foot means loss by severance at or above the wrist or ankle. The
maximum benefit for all losses you sustain from one
accident is $50,000 and $20,000 for your eligible dependents.
Payment of Benefits
The Accidental Death benefit is payable to your beneficiary.
The Accidental Dismemberment benefit is payable to you.
What's Not Covered
A loss is not covered if it is a result of:
- A bodily or mental infirmity;
- A disease, ptomaine, or bacterial infection;*
- Medical or surgical treatment;*
- Suicide or attempted suicide (while sane or insane);
- An intentionally self-inflicted injury;
- A war or any act of war (declared or not declared);
- Voluntary inhalation of poisonous gases;
- Commission of or attempt to commit a criminal act;
- Use of alcohol, intoxicants, or drugs, except as prescribed by
a physician. An accident in which the blood alcohol level of the
operator of a motor vehicle meets or exceeds the level at which intoxication
would be presumed under the law of the state where the accident occurred
shall be deemed to be caused by the use of alcohol;
- Intended or accidental contact with nuclear or atomic energy by
explosion and/or release;
- Air or space travel. This does not apply if a person is a passenger,
with no duties at all, on an aircraft being used only to carry passengers
(with or without cargo);
- These do not apply if the loss is caused by:
An infection which results directly from the injury.
Surgery needed because of the injury.
The injury must not be one which is excluded by the terms of this
Passenger Restraint and Airbag Benefit
If a covered loss of life occurs solely and as a direct result of an
accident involving a motor vehicle while the person;
- is an occupant of the motor vehicle; and
- at the time of the accident is properly using a passenger restraint;
- if the driver has, at the time of the accident
a valid driver’s
Passenger Restraint Benefit Maximum for you and each covered dependent
Airbag Benefit Maximum for you and each covered dependent is $5,000.
No Airbag Benefit will be payable unless a Passenger Restraint Benefit
Educational Benefit for Dependent Child and Spouse
If you or your covered dependent spouse suffer a loss of life solely
and as a direct result of an accident an Education Benefit is payable
on behalf of each Dependent Child.
Education Benefit Maximum for each dependent child is 5% of your
Principal Sum not to exceed $5,000 per year per child for up to 4
spouse’s benefit is 5% of your Principal Sum not to exceed $5,000
per year for up to 4 years.
Child Care Benefit
The Child Care Benefit is paid at 3% of the member's or spouses principal
to a Maximum of $2,000 per child per year. The benefit is payable
for a maximum of 4 years from the date of death.
Repatriations of Remains Benefit
$5,000 is payable if repatriation occurs outside of 200 miles from
the principal residence.
If, while insured, a person suffers a bodily injury caused by an accident
and if, within 30 days after the accident, he or she becomes comatose
solely and as a direct result of the accident, Aetna will pay a monthly
benefit provided the person is continually comatose for at least 30
Proof that the person is comatose must be submitted to Aetna no later
than 60 days after the date he or she become comatose.
The monthly benefit is the Coma Benefit Percentage less any benefit
amount paid or payable under this benefit section for any loss the
covered person suffers as a direct result of a bodily injury caused
by the same accident. The monthly benefit of 5% of the Principal
Sum is payable for 11 months. The full Principal Sum less any
benefit amount paid or payable under this benefit section because of
the same accident will be payable after the covered person has been
continually comatose for 12 months.
No more than the full Principal Sum is payable for all losses resulting
from the same accident.
The monthly benefit is payable for as long as the coma continues, until
the earliest occur of:
- failure to have any required exam;
- failure to give proof that the coma continues
- the date the full Principal Sum is paid under this benefit section;
- the date the covered person is no longer comatose, by death, recovery,
or any other change of condition, as certified by a physician; or
- termination of the group policy
Aetna will have the right to require proof of the continuation of
the coma. Aetna will not request an exam more than twice in a 12 month
The information contained in this section is a summary of your life
insurance benefits.The Certificate of Coverage issued by Aetna is the
governing document that contains a complete description of benefits,
exclusions, limitations and conditions of coverage. To request
the Certificate of Coverage contact Teamsters Local 251 Health Services
and Insurance Plan.
Local 251 Health Services and
and Sickness Benefits
If you become temporarily disabled as a result of a non-work
related injury or illness and cannot work, you may be eligible for
a Weekly Accident and Sickness Benefit of up to $500 per week and a
credit of 25 hours per week towards benefits for up to 26 weeks. A
W-2 will be issued for any money received from this benefit. In order
to qualify for benefits, you must be an active employee at the time
of your injury. For example, if you are out on a worker’s compensation
injury at the time of your injury, you are not eligible for weekly
accident and sickness benefits.
What You Need To Do
- You are eligible for weekly accident and sickness benefits only
once every 24 months. This means that you may file only one claim
for benefits during a 24 month period. For example, if you file a
claim on July 1, 2010, and benefits are awarded for that claim, you
may not file another claim for benefits until on or after July 1,
2012. The Trustees may, in their sole discretion, permit you to file
another claim within the 24 month period if your injury is severe
and requires hospitalization.
- If you become disabled, you must call the Fund Office for the proper
paperwork which includes:
- an Accident and Sickness Claim Form,
- an Attending Physician's Report (APR),
- the Authorization to Release Information and Reimbursement Agreement,
- Form W-4S (tax form),
- Authorization for Release of Protected Health information, and
- a self-addressed envelope.
- Fill out the Accident and Sickness Claim form;
- Ask your attending physician(s) to complete a statement of evidence
of your disability (APR). A faxed copy will not be acceptable.
- Read and complete the Authorization to Release Information
form; on the back of the form be sure to choose the box that best
describes your situation (you must have this form notarized).
and sign form W-4S:
- If you want Federal and Rhode Island income tax
withheld, the minimum Federal amount to be withheld is $20 and
all withholding must be in whole dollars, no cents.
- If you do not want Federal and Rhode Island
income taxes withheld from the benefit payments indicate "NONE" in
the amount to be withheld box.
- Mail all of the completed information to the Fund Office in the
- The Fund Office will mail your employer a "13-Week Form" to
determine your gross weekly pay during the 13 weeks immediately before
your covered incident. Your benefit will be 75% of the average or
$500, whichever is less.
- If requested by the Fund, you must undergo a physical examination
by the Fund's independent doctor at any time while you are seeking
or receiving benefits. Your failure to submit to an examination may
affect your continued eligibility for benefits.
Note: All of this information must be completed and returned
to the Fund Office no later than 45 days from date of the
covered incident. If a completed claim
form is not filed within that period, you will have no rights to
benefits under this Section. (The Trustees
may, in their sole discretion, permit you to file documents after
the deadline for good cause shown. Good cause will be determined
by the Trustees in their sole discretion.)
To qualify for Weekly Accident and Sickness Benefits, you must:
- Be covered for Level I medical benefits;
- Work at least one hour of covered employment after the effective
date of your Level I coverage;
- Be unable to perform work for at least 8 days due to an illness,
non-work related injury or accident;
- Not be receiving a pension. As of the date of your retirement,
you are no longer eligible for this benefit;
- Not be collecting unemployment benefits or workers compensation
- At any time you request the WA&S forms,
you may be required to see the Fund's doctor;
- Submit all of the completed forms to the Fund Office within forty-five
days of the date of the covered incident;
- Return to work one day before you can be entitled to a claim on
Weekly accident and sickness benefits claim.
- There is a maximum benefit of 26 weeks in a twenty four month period.
The “date of the covered incident” is
the first date on which you are unable to perform work due to an
illness, non-work related injury or accident.
|You will need to apply for TDI, and submit your approval
or denial to the Fund Office before any benefits will be paid.
You can apply for TDI by calling (401)
How Benefits Are Paid
The Weekly Accident and Sickness Benefit is designed to help you maintain
your health coverage. It may provide income as a supplement to Temporary
disability insurance (TDI) or supplement any short-term disability
income you may receive from another source, such as TDI. The maximum
weekly disability income you can receive from both sources combined
is $500 or 75% of your weekly earnings, whichever is less. The 75%
is calculated based on your average 13 week gross pay immediately
before your covered incident.
For example, Jason earns $800 per week. Through TDI, he receives a weekly
short-term disability benefit of $250. If he applies for a disability benefit
through this Plan, the maximum weekly benefit he could receive is $250 so that
the total benefit he receives from both sources is $500 per week.
|Maximum Weekly Benefit
If you do not have other disability income, the Fund's
benefit provides up to $500 per week or 75% of your weekly earnings,
whichever is less, and contribution credit of 25 hours per week
for up to 26 weeks.
However, Brian earns $600 per week. Through TDI he also receives
a weekly short-term disability benefit of $250. If he applies for
a disability benefit through this Plan, the maximum amount he could
receive is $450 per week, because $450 is 75% of his regular weekly
earnings. Through this Plan he would be eligible to receive a weekly
benefit of $200
The Fund will pay weekly accident and sickness benefits for mental
injury claims only in the following situations: If
you become disabled as a result of a mental injury caused or accompanied
by identifiable physical trauma or from a mental injury caused by emotional
stress resulting from a situation of substantially greater dimensions
than the day-to-day emotional strain and tension which employees typically
encounter on a daily basis without serious mental injury, you may be
eligible for benefits. In addition, the Fund will provide weekly
accident and sickness benefits where the mental injury results in hospitalization.
For the purposes of this section, mental injury means an observable
and substantial impairment in your ability to function within the normal
range of performance and behavior.
The Fund's Trustees have final, discretionary authority to determine
whether a mental injury may result in eligibility for weekly accident
and sickness benefits.
Receiving Your Benefit
Your weekly benefit payments will begin on the eighth day of your disability
and may continue as long as you are disabled, up to 26 weeks. You will
receive a benefit for the first seven days of your disability after
you have been out on disability for a full 30 days.
You will receive 25 hours per week credit toward your ongoing eligibility
requirements, after your employer has met their obligation, for a maximum
of 26 weeks. No pension contributions will be made on your
behalf for Weekly Accident and Sickness benefits.
If you retire, your Weekly Accident and Sickness benefits end as of
your retirement date.
Notify the Fund Office
- You recover from your disability;
- You return to work;
- There is a change in the amount of benefits
you receive from other sources.
- You retire
Please notify the Fund Office as soon you apply for your Pension.
Disabilities that result from a work-related illness or injury are
not covered. In addition, any period of disability that exists at
the same time as a work-related illness or injury is not covered.
If you have applied and been denied by Workers' Compensation, upon
proof of your denial, you may apply for this benefit subject to the
If you receive any payment from a third party relating to your disability
claim, you will be required to reimburse the Fund Office for any and
all of the Weekly Accident and Sickness benefit that you received based
on the reimbursement agreement.