The Local 170 Health and Welfare Fund provides a bundled plan of benefits consisting of medical benefits, dental benefits, life insurance benefits, accidental death and dismemberment insurance benefits, short-term disability income benefits, prescription drug benefits, spousal burial benefits, dependent life benefits, vision benefits and certain wellness benefits. The Fund files a form 5500 each year, as required by ERISA, and identifies itself as one plan. Participating Employers are required to make contributions on behalf of their Employees as a condition of plan coverage.
The Plan Administrator establishes a minimum rate of contribution for each tier of benefits and the Union and the participating Employers engage in contract negotiations including the cost and benefit of participating in the Fund. Each company has the opportunity to negotiate the tier of benefits, as described hereafter. All benefits are bargained and paid for as one package. Once negotiated, the Employees individually select which medical care provider network they desire to utilize, Blue Cross Blue Shield or Fallon Health. The medical networks are very similar in size; the standard of care is equally comprehensive and employees are provided with excellent medical and prescription drug benefits in both plans. All participants and dependents are offered dental benefits as administered by Blue Cross Blue Shield MA, and vision benefits administered by Davis Vision.
Further, each active Employee is automatically provided welfare benefits. It is, and has been the intention of the Plan Administrator, that the health and welfare benefits of the Plan encompass and constitute one benefit plan for ERISA purposes. The plan has one name, the Teamsters Local 170 Health and Welfare Plan.
- Life Insurance Benefit – ACTIVE EMPLOYEES ONLY
The Fund has procured group life insurance coverage from the Hartford Life and Accident Insurance Company (the “Hartford”), which provides fifty thousand dollars ($50,000) in coverage for active full time employees and twenty-five thousand dollars ($25,000) for active part time employees. The coverage applies only to active employees. Retired Employees and Dependents are not provided the life insurance benefit. Active employees are automatically enrolled in this plan when they meet eligibility requirements. Payment will only be made by the Hartford if all terms and conditions of the policy have been satisfied. Consequently, the terms, conditions and exclusions of the life insurance policy shall in all respects govern the payment of benefits. A copy of the life insurance benefit plan can be found in Attachments #10 and #11.
Filing a Life Insurance Claim
To file a life insurance claim:
- A family member must call Teamsters Local 170 Health and Welfare Fund and ask for the appropriate claim form
- Teamsters Local 170 Health and Welfare Fund will send the claim form to the designated beneficiary
- The beneficiary completes and returns the form to the Teamsters Local 170 Health and Welfare Fund
- A certified copy of the death certificate must be provided
- See attachments #10 and #11 which describe the Plans Claims and Appeals procedures for filing claims and appeals for life insurance benefits
Facility of Payment
If, at the time of death, there is no designated Beneficiary with respect to all or any part of the Life Insurance Benefit, or if the designated Beneficiary does not survive the Participant, the Life Insurance Benefit (or any portion thereof) for which there is no designated Beneficiary will be paid in the following order of priority to the Participant’s:
- Executor/Administrator; or
- Spouse; or
- Child or Children (in equal shares); or
- Mother and or Father (in equal shares)
A Participant may designate or change the name of his Beneficiary by filing a written, signed and witnessed request in a form satisfactory to the Fund Office. No change of Beneficiary will take effect until received by the Fund. When the change has been received, however, regardless of whether the Participant is then living or not, it will take effect as of the date of execution of the written request but without prejudice to the Fund on account of any payment made or any action taken or permitted by the Fund or its life insurance carrier before receipt of the request. Consent of the Beneficiary will not be required to change the Beneficiary.
No payment shall be made for any loss which is excluded by the Hartford Benefit Plan found in the Attachments #10 and #11 to this document.
Converting Teamsters Local 170 Health and Welfare Fund Life Insurance to an Individual Policy
If your Teamsters Local 170 Health and Welfare Fund Life insurance ends for any reason, you can “convert” from Teamsters Local 170 Health and Welfare Fund to an individual policy. You will need to pay the premiums for this continued coverage.
To convert, you will not need to show evidence of insurability. However, you must apply for the conversion by completing a notice of Conversion Right Form within 31 days after your active Teamsters Local 170 Health and Welfare Fund coverage ends or within 15 days after the Fund signs the form, whichever is later. No request for conversion will be accepted if these forms are not received by The Hartford more than 91 days after your coverage with the Fund ends.
In addition, if you should die anytime during the 31-day conversion period the Hartford will pay to your designated beneficiary the full amount of insurance you would have been entitled to convert.
The conversion rights provided to you are subject to the terms and conditions set forth in attachments #10 and #11 of this Summary Plan Description.
- Accelerated Death Benefit Option-Active Employees Only- ACTIVE EMPLOYEES ONLY
Teamsters Local 170 Health and Welfare Fund offers a special life insurance option that applies if you are under age 60 and certified by a doctor as being terminally ill and your illness is caused by a condition that is reasonably expected to result in a drastically limited life span of 12 months or less.
To help with some of the emotional and financial burdens that can occur at such a time, you are eligible to receive up to 80% of your total $50,000 for full time employees or 80% of your total $25,000 for part time employees while living. This option may only be exercised once. There are no restrictions on how to use the money you receive.
The accelerated death benefit is provided to you is subject to the terms and conditions set forth in attachments #10 and #11 of this Summary Plan Description
- Life Insurance Benefits if You’re Disabled – Waiver of Premium
Waiver of Premium is a provision which allows you to continue your life insurance coverage without paying premium while you are disabled and qualify for waiver of premium.
Disabled, means you are prevented by injury of sickness from doing any work for which you are, or could become qualified by: 1) education, 2) training or 3) experience. In addition, you would be considered disabled if you have been diagnosed with a life expectancy of 12 months or less.
The waiver of premium benefit is provided to you is subject to the terms and conditions set forth in attachments #10 and #11 of this Summary Plan Description.
- Accidental Death and Dismemberment Benefit- ACTIVE EMPLOYEES ONLY
The Teamster Local 170 Health and Welfare Fund Accidental Death and Dismemberment (AD&D) Insurance Benefit provides the active employee with additional life and accident insurance protection. AD&D coverage is provided for the active employee only. Retired Employees and Dependents are not eligible for this benefit.
The Fund has procured group Accidental Death and Dismemberment coverage from the Hartford. The Hartford shall pay those benefits in accordance with the terms and conditions of the Hartford policy. If an active employee suffers certain kinds of serious injury as a result of an accident, the Hartford pays the AD&D benefit to the active employee. If an active employee dies as a result of an accident, the AD&D insurance pays a benefit to the beneficiary designated by the active employee. The Plan provides this AD&D benefit in addition to the normal life insurance.
AD&D Basic Benefits
If you sustain an injury that results in any of the following losses within 365 days of the date of accident, you will be paid the amount of the principal sum, which is $50,000.00 for full time active employees or $25,000.00 for Part time employees, or a portion of the principal sum, as shown opposite the loss.
Loss Benefit Loss of Life Principle Sum Loss of Both Hands Principle Sum Loss of Both Feet Principle Sum Loss of Sight of Both Eyes Principle Sum Loss of One Hand and One Foot Principle Sum Loss of One Hand and Sight of One Eye Principle Sum Loss of One Foot and Sight of One Eye Principle Sum Loss of Speech and Hearing (both ears) One-half Principal Sum Loss of Sight of One Eye One-half Principal Sum Loss of Thumb and Index Finger of either Hand One-quarter Principal Sum Quadriplegia (movement of both upper and lower limbs) Principal Sum Triplegia (movement of three limbs) Three-quarters Principal Sum Paraplegia (movement of both lower limbs) Three-quarters Principal Sum Hemiplegia (movement of the upper and lower limbs of one side of the body) One-half Principal Sum Uniplegia (movement of one limb) One-fourth Principal Sum Loss of a hand or a foot One-half Principal Sum
The Plan has certain technical definitions of the particular losses, limbs, or faculties identified above. If you need specific information on any of the occurrences described above contact the Fund office (see attachments #10 and #11 of this Summary Plan Description). It is important to note that the maximum AD&D benefit for any one accident is $50,000.00 for active full time employees and $25,000.00 for active part time employees.
The terms, conditions and exclusions of the accidental death and dismemberment insurance policy shall in all respects govern the payment of benefits. A copy of the Accidental Death and Dismemberment Benefit Plan can be found in Attachment #10 and #11.
No payment shall be made or any loss which is excluded by the AD&D benefit plan found in the Attachments #10 & #11 of this document.
There is coverage for additional benefits, including a repatriation benefit, seatbelt coverage and an education benefit. These benefits are subject to the terms and conditions of the plan which can be found in the Attachments #10 & #11 to this document.
- Short Term Disability Income Benefit- ACTIVE EMPLOYEES ONLY
If while eligible for benefits, an active Employee becomes totally disabled and therefore is unable to perform the duties of his occupation or employment because of a non-occupational injury or illness, the Fund shall pay Short Term Disability Income Benefits to the Employee. A participant will be considered totally disabled when as a result of a non-occupational injury or illness, he is unable to perform duties of his occupation, as documented by a treating physician’s orders. Such payments will be made for the period that begins as described in Section labeled “Commencement” below, and ends as described in Section labeled “Termination”. Pregnancy, child birth and related medical conditions are considered an eligible disability for weekly disability benefits for the duration that it is deemed medically necessary.
The period for which Short-Term Disability Income Benefits are payable shall begin as follows:
In the case of an Injury or Illness, on the eighth (8th) day that the Employee becomes totally disabled. Documentation of the treatment by a Physician must be submitted to the Fund Office.
The period for which Short Term Disability Income Benefits are payable shall end on the earlier of:
- The last day that the Employee is disabled as described above;
- The day the Employee has exhausted the maximum of twenty-six (26) weeks of benefits in a fifteen (15) month period;
- The date the Employee retires, regardless as to whether the member receives a pension; or
- The day the Fund does not timely (14 days from the date the same is due) receive the supplemental form required from the disabled Employee’s physician.
No payment shall be made:
- For any employment related illness or injury; or
- For any period during which the Employee is not undergoing regular treatment by a Physician for a disability; or
- For any period during which the Employee works for wages or profit; or
- To or for anyone who contributed to his or her injury by: a) operating a motor vehicle while under the influence of alcohol, marijuana, or any narcotic drug, or b) while committing a felony or seeking to avoid arrest by a police officer; or c) with the specific intent of causing injury to himself or others.
Full time active Employees will be paid 75% of their gross weekly wage to a maximum of three hundred fifty dollars ($350) or four hundred fifty dollars ($450) per week. The maximum weekly benefit is determined by the tier of benefits of the disabled Employees Collective Bargaining Agreement. Full time tier 1 Employees are paid a short-term disability benefit equal to 75% of the gross weekly wage up to four hundred fifty dollars ($450) per week. Otherwise, the disabled Employee will be provided 75% of his gross weekly wage up to three hundred fifty dollars ($350) per week. The 75% benefit is to be calculated based upon the disabled Employees average thirteen (13) week gross pay immediately prior to the covered incident.
Part time Employees will be provided a short-term disability benefit equal to 75% of their gross weekly wage to a maximum of two hundred dollars ($200) per week. The 75% benefit is to be calculated based upon the disabled Employees average thirteen (13) week gross pay immediately prior to the covered incident.
Continuation of Benefits If You Become Disabled
For the first four (4) weeks of disability, your Employer (if set forth in the applicable Collective Bargaining Agreement) is required to contribute to the Fund at a rate of 32 hours per week, for a full-time employee and 16 hours per week for a part- time employee. After the first four (4) weeks of disability, the Fund Office will credit full-time employees 30 hours per week and part-time employees 17 hours per week.
Active Employee Benefit
Only active Employees are eligible to receive Short Term Disability Income Benefit.
Timeliness of Claims
Disability claims must be submitted to the Fund Office within sixty (60) days of the date of disability. Claims submitted after sixty (60) days will not be paid.
Disability Resulting from Motor Vehicle or Motorcycle Accident
If you have a disability claim related to a motor vehicle or motorcycle accident, you, or someone acting on your behalf, must notify the Fund as soon as possible. The Fund’s coverage varies with a number of factors. If you are involved in a motor vehicle accident covered by a no-fault insurance carrier, initial the no-fault insurance will be liable for weekly disability benefits up to the first $8,000 of expenses related to the accident, as required by law. The Fund will also be liable for weekly disability benefits up to the maximum of 26 weeks, including the weeks paid by the auto insurance carrier. For example; if the no-fault carrier pays 12 weeks of disability payments the Fund may pay additional 14 weeks of disability payments for a maximum benefit of 26 weeks. In order to collect disability benefits you must provide a copy of the Police Report and/or a copy of your accident report. No disability benefits will be paid without this information. You must also provide a completed form and a completed and signed Subrogation, Assignment of Rights Reimbursement Agreement.
- Spousal Burial Benefit- ACTIVE EMPLOYEES ONLY
The Fund presently self -insures and provides a Spousal Burial Benefit of Three Thousand Dollars ($3,000). The Fund shall pay this benefit if:
- The active Employee as defined in this Summary Plan Description must be actively employed by an Employer at the time of his Spouse’s death;
- The active Employee must be legally married at the time of his Spouse’s death;
- The active Employee or his representative must provide a death certificate of his Spouse to the Fund Office.
Upon receipt of a certified death certificate, the Fund shall pay the active Employee the sum of Three Thousand Dollars ($3,000).
Only active Employees are eligible to receive the Spousal Burial Benefit.
- Dependent Child's Life Benefit-ACTIVE EMPLOYEES ONLY
The Fund presently self-insures and provides a Dependent Child’s Life Benefit of Three Thousand Dollars ($3,000). The Fund shall pay this benefit if:
- The active Employee as defined in this Summary Plan Description must be actively employed by an Employer at the time of his Dependent Child’s death;
- The active Employee or his representative must provide a death certificate of his Dependent Child to the Fund Office
Upon receipt of a certified death certificate, the Fund shall pay the active Employee the sum of Three Thousand Dollars ($3,000).
Only active Employees are eligible to receive the dependent Child Life benefit.
- Wellness Programs
The Fund may provide wellness benefits or programs (a Welfare Benefit) subject to the provisions of the Patient Protection and Affordable Care Act, the Genetic Information Nondiscrimination Act, ERISA, the Internal Revenue Code and HIPAA. By way of example these programs may be subject to reasonable design limitations; voluntary participation; limits on incentives; and information subject to confidentiality requirements. Presently, the Plan provides certain wellness benefits programs in conjunction with Fallon Health and or Blue Cross Blue Shield MA, who administer the programs. The Fund shall pay for the cost and expense of any Wellness Program/Benefit provided to the Participants and their dependents. In addition, the Fund shall pay the rewards and or incentives established by such a program to the Participants and their dependents, subject to any limitations or requirements set forth in the particular Wellness Program.