Plan Facts

Facts about this plan

 

The Employee Retirement Income Security Act of 1974 (ERISA) requires that Teamsters Local 170 Health and Welfare Fund furnish you with certain information regarding this plan, which is a benefit option provided to you as a member of Teamsters Local 170 Health and Welfare Fund If you have questions regarding any aspect of the plan, you should contact the Plan Administrator named below who will help you understand fully your rights and obligations.

1. Name of plan:
Teamsters Local 170 Health and Welfare Benefit Plan

2. Name and address of plan sponsor:
Teamsters Local 170 Health and Welfare Fund
Board of Trustees
P.O. Box 1046
Worcester, MA 01613
1-508-791-3416

3. Federal Identification Number:
04-2219623

4. Plan number:
501

5. Type of plan:
The plan is a self-funded health and welfare plan that provides health benefits for eligible Teamsters Local 170 members and their dependents.

6. Type of administration:
The Plan Administrator is responsible for administering the plan. Certain administrative functions in connection with the plan, including claims processing, utilization review and the provision of a network of providers are to be performed by Fallon Health & Life Assurance Company, Inc. (FHLAC), as agreed to by Teamsters Local 170 Health and Welfare Fund and FHLAC.

Fallon Health & Life Assurance Company, Inc.
10 Chestnut St.
Worcester, MA 01608
1-508-799-2100

7. Name and address of Plan Administrator:
Teamsters Local 170 Health and Welfare Fund
P.O. Box 1046
Worcester, MA 01613
1-508-791-3416

8. Person(s) eligible:
All persons who meet the eligibility requirements as defined in this Member Handbook of the Teamsters Local 170 Health and Welfare Benefit Plan.

9. Plan benefits:
The plan provides group health benefits. Your Member Handbook contains a detailed description of benefits. If you lose or misplace your Member Handbook, you may obtain a new copy, without charge, from the Plan Administrator.

For the member welfare benefit plan(s) described herein: Teamsters Local 170 Health and Welfare Fund reserves the right to modify, suspend or terminate the plan or any benefit option or service therein, including the plan of benefits offered by the plan as described in this Member Handbook, for benefits payable there under, in whole or in part at any time and from time to time for any reason by written notification.

In some situations, federal law may provide a right to continue benefits beyond the date upon which they otherwise would have terminated. Please refer to the COBRA section contained herein, which describes a federal law under which you and/or your dependents may have a right to continue coverage beyond the date it otherwise would terminate. See the Plan Administrator if you have any questions regarding this law or if you have any questions regarding other arrangements if any, may be made to continue your coverage beyond the date your employment terminates or you cease to be eligible.

10. Funding of the plan:
Collective Bargaining Agreement(s): The plan is (partially) maintained as a result of a Collective Bargaining Agreement (CBA) between Teamsters Local 170 and participating employers, with various dates and as subsequently amended. You may obtain a copy of the applicable CBA upon written request to the Plan Administrator. A reasonable charge will be made for copies of the agreement. You may also examine the applicable CBA, without charge, during regular business hours at the Fund Office.

Upon request, the Fund Office will provide you with information as to whether a particular employer is contributing to the Plan on behalf of participants working under a Collective Bargaining Agreement.

11. Effective date:
The plan, as described in this Member Handbook, became effective January 1, 2012.

12. Agent for service of legal process:
The Plan Administrator at the above address.

13. Plan records:
The financial records of the plan are maintained on the basis of a plan year beginning on January 1 and ending on the following December 31.