DISCLAIMER: Information on this website is not a guarantee of the type or amount of any benefits. Your rights to eligibility and to benefits can only be determined by the provisions of the Plan Documents, which are subject to revision by the Boards of Trustees.
Health & Welfare Plan
Total Views: 13935
Part II: Summary Plan Description & FAQ's
Before we get down to the specifics of the Plan, we would advise you to read the definitions contained in Section l of the Plan Document. If you refer to these definitions as you are reading this booklet, it will help to make the Plan easier to understand.
We have attempted to write this Summary Plan Description in language that is simple. Yet, any employee benefit plan, by its very nature, has unique terms. Please look carefully at the definitions including, but not limited to “Participant”, “Covered Family Member”, “Covered Child”, “Employee”, “Hospital”, “Physician”, “Primary Care Physician”, “Incurred”, “Preferred Provider Organization (PPO)” and “Period of Confinement or Disability”. This will enable you to become more familiar with the Plan. When the word "Participant" is used in the Summary Plan Description it shall apply to Employee and Dependent Participants, unless otherwise noted.If you have any questions, please do not hesitate to contact the Fund Office. The official text of the Plan is set forth at Part III of this Site. Always bear in mind that the written terms of the entire Plan govern, no matter what anyone else tells you. The Plan may be amended from time to time by the Trustees. Such amendments will be posted to the Plan's web site (www.itpebenefits.org) and will be distributed to each participant as a supplement to the published booklet.
You should also bear in mind that the Trustees of the Fund, or such representatives as they designate, have full authority in their absolute discretion to determine the nature and amount of benefits to be provided by the Plan, eligibility to participate in the Plan and eligibility to receive benefits from the Plan, together with all questions, policies and procedures relating to those subjects. All decisions and determinations of the Trustees or their designees are final and binding on all Participants and other interested parties.
Close All | Open All
The benefits provided for you under the Plan include:
Death Benefits
Accidental Death and Dismemberment Benefits
Survivor Income
Sickness and Accident Benefits
Medical Care
Dental Care
Vision Care
Scholarship Program
Prescription Drug Coverage Read More ...
Preferred Provider Organization (PPO) Network
The Trustees of the Fund have engaged Anthem Blue Cross Blue Shield (Anthem) as the Claims Administrator and as the Preferred Provider Organization (PPO) for the Fund. Read More ...
The Trustees of the Fund have engaged Anthem Blue Cross Blue Shield (Anthem) as the Claims Administrator and as the Preferred Provider Organization (PPO) for the Fund. Read More ...
The Plan does not provide coverage for the following items: Read More ...
If you are disabled and no contributions are being made on your behalf, Medical, Vision, Dental Care and Prescription Drug Benefits for you and your Covered Family Members will be continued for a period of two months from the date of your last contribution period. To continue Medical, Vision, Dental Care and Prescription Drug Benefits for you or your Covered Family Members following said two month period, application must be made for Continuation of Coverage ("COBRA") as described in this Booklet, unless you are eligible for leave under the Federal Family and Medical Leave Act. If you do not choose to elect Continuation of Coverage, all benefits for you and your Covered Family Members will cease at the end of two months following your last day of work. However, the Fund will continue to pay for covered expenses up to the maximum amount of benefits payable for the disability that prevented your return to work for up to 26 weeks following the first day of your disability.
Back to FAQ's Read More ...
Back to FAQ's Read More ...
Should you and/or your Covered Family Members lose eligibility for the medical care, vision care, dental care or prescription drug benefits provided by the Plan, you may be entitled to elect continuation coverage in accordance with federal law. If your employer normally employs twenty or more people, and your employment is terminated for any reason other than gross misconduct you have certain rights under certain conditions to continue your coverage under a federal law known as the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
Read More ...
The Fund shall pay prescription drug benefits for a Participant in accordance with the amounts and terms set forth in your Schedule of Benefits, provided that the prescription drugs are obtained pursuant to a prescription issued by a Physician.
Read More ...
In order to be eligible for benefits under the ITPE Health and Welfare Fund, you must first fill out an enrollment and beneficiary card and send it to the Fund office directly or through your Shop Steward, Union Representative or Employer.
Read More ...
The Fund provides benefits for loss of life, limbs, or the entire and irrecoverable loss of sight, which occurs directly from bodily injuries caused solely through accidental means when the loss occurs within ninety (90) days after the accident.
Read More ...
The Fund provides benefits for certain dental procedures incurred by you or your Covered Family Member.
Read More ...
You have certain rights regarding your health information that is maintained by the Fund. Those rights are as follows:
Read More ...
A vision care benefit is provided for you or your Covered Family Member for an eye examination and toward the purchase of single vision, bifocal or higher vision lenses.
Read More ...
What Kind of Scholarships are Awarded?
The Trustees of the Fund administer a scholarship program known as the ITPE John F. Conley– Happy I. Franklin Scholarship Program. Each year this program awards five 4-year scholarships for study at a college or university in amounts up to $15,000.00 per year. Read More ...The Following Procedures Will be Followed for Claims for Medical Benefits Only:
Effective July 1, 2012, all claims for medical benefits and appeals from denials of such claims shall be handled exclusively by the Claims Administrator (Anthem). It shall be the responsibility of the Participant to give Read More ...
Effective July 1, 2012, all claims for medical benefits and appeals from denials of such claims shall be handled exclusively by the Claims Administrator (Anthem). It shall be the responsibility of the Participant to give Read More ...
General Rule
If an individual is entitled to benefits or services for which benefits are payable under the ITPE Health and Welfare Plan, and is also covered under any other plan, the benefit provided by the ITPE Health and Welfare Plan will be coordinated so that the combination of such benefit payments does not exceed the maximum benefit payable by the Plan which has the primary coverage for the claim in question. Read More ...
If an individual is entitled to benefits or services for which benefits are payable under the ITPE Health and Welfare Plan, and is also covered under any other plan, the benefit provided by the ITPE Health and Welfare Plan will be coordinated so that the combination of such benefit payments does not exceed the maximum benefit payable by the Plan which has the primary coverage for the claim in question. Read More ...
In the event of the death of a covered family member from any cause while you are eligible for benefits, you will receive the benefit listed in your Schedule of Benefits.
Read More ...
This depends on the type of benefit involved.
Read More ...
All Medical and Dental benefits payable by the Fund shall be deemed assigned by the affected Participant to the Health Care or Dental Provider in question.
Read More ...
When Are Death Benefits Paid?
Death Benefits are payable in the event of your death from any cause at any time or place while you are eligible for benefits. Payment will be made in a lump sum to the beneficiary designated by you. Read More ...
Death Benefits are payable in the event of your death from any cause at any time or place while you are eligible for benefits. Payment will be made in a lump sum to the beneficiary designated by you. Read More ...
The Federal Family and Medical Leave Act ("FMLA") provides that eligible employees are entitled up to twelve (12) weeks of unpaid leave for the following circumstances:
Read More ...
It shall be the responsibility of the Participant to give proper notice of any other coverage he or she may have when filing a claim
Read More ...
All claims for benefits provided by the Plan must be submitted within one (1) year from the date the claim is "incurred". Read More ...
Birth Control benefits
Read More ...
On October 21, 1998, Congress enacted the Women's Health and Cancer Rights Act of 1998. Under this law, group health plans that provide coverage for mastectomies must also cover reconstructive surgery and prostheses for mastectomy patients.
Read More ...
For the purpose of computing medical benefits, maternity is treated as any other illness for female employees or covered family member wives. Read More ...
The Fund pays eligible Employees a weekly benefit while they are disabled and prevented from working provided that they are under the care of a legally qualified physician and their disability results from a non-job related accident, sickness or disease for which benefits are not payable under any workmen's compensation law or any law or policy of insurance providing for the payment of motor vehicle "No-Fault" or First-Party Benefits.
Read More ...
If you or your Covered Family Member makes claim for benefits from the Fund under circumstances where the injury or illness for which such benefits are claimed gives rise to a claim or lawsuit against a third party, payments of benefits by the Fund shall be made on the condition and with the understanding that the Fund will be reimbursed for payment of such benefits out of any recovery made in your third-party claim. The full details of the Plan's Rules on Subrogation can be found at Section 22 of the Plan.
Back to FAQ's Read More ...
Back to FAQ's Read More ...
Who Qualifies for Health and Welfare Benefits?
Health and welfare benefits are provided by the ITPE Health and Welfare Fund for active Employees who have eligibility and also for their Covered Family Members. Employees and Covered Family Members who are eligible for benefits from the Fund are known as “Participants”. The amount of your benefits is based on the average number of hours you actually work per week and the hourly rate your employer contributes on your behalf.
Read More ...
Some Employees may be employed by two or more ITPE Employers at the same time, and attain eligibility for benefits from the Plan by virtue of their employment with each such Employer.
Read More ...
The Plan has adopted policies and procedures designed to protect your personal information from unauthorized use or disclosure.
Read More ...
Under this law, group health plans may not restrict benefits for any hospital length of stay in connection with child birth for the mother or newborn child to less than forty-eight (48) hours following a normal vaginal delivery, or less than ninety-six (96) hours following a Caesarian Section.
Read More ...
An application for any benefits described in this Summary Plan Description, other than Medical benefits, must be made in writing on an official Plan claim form.
Read More ...
When both a Covered Child and one or more parents are ITPE Employees eligible for benefits under the Plan, all benefit claims for such Covered Child shall be paid by first exhausting the benefits available to such Covered Child as an Employee and then applying the benefits available as a Covered Child of an Employee.
In no event shall the combination of such benefit payments exceed the maximum combined benefit payable under the Plan for the claim in question.
Back to FAQ's Read More ...
In no event shall the combination of such benefit payments exceed the maximum combined benefit payable under the Plan for the claim in question.
Back to FAQ's Read More ...
In addition to the death benefits previously described, the Fund will pay a survivor death benefit in monthly installments to your beneficiary in the event of your death from any cause at any time or place while you are eligible for benefits.
Read More ...
The Plan provides benefits for maternity care at a freestanding facility that:
Read More ...
When both husband and wife are ITPE Employees eligible for benefits under the Plan, all benefits payable to such husband and wife shall be paid by first exhausting the benefits available to such spouse as an Employee, and then applying the benefits available as a result of such spouse's status as a dependent.
In no event shall the combination of such benefit payments exceed the maximum benefit payable under the Plan for the claim in question or the actual amount of charges for the claim in question.
Benefits for Covered children of such a husband and wife shall be paid by first exhausting the benefits available by virtue of the employment of whichever spouse has been employed longest, or, if employment time is equal, by virtue of the earliest birth date in the calendar year and then applying the benefits available as a result of the employment of the other spouse.
In no event shall the combination of such benefit payments exceed the maximum combined benefit payable under the Plan for the claim in question.
Back to FAQ's Read More ...
In no event shall the combination of such benefit payments exceed the maximum benefit payable under the Plan for the claim in question or the actual amount of charges for the claim in question.
Benefits for Covered children of such a husband and wife shall be paid by first exhausting the benefits available by virtue of the employment of whichever spouse has been employed longest, or, if employment time is equal, by virtue of the earliest birth date in the calendar year and then applying the benefits available as a result of the employment of the other spouse.
In no event shall the combination of such benefit payments exceed the maximum combined benefit payable under the Plan for the claim in question.
Back to FAQ's Read More ...
The Fund collects information about you to help us provide Plan benefits to you and your Covered Family Members, and to fulfill legal and regulatory requirements. The Board of Trustees considers all information about you in possession of the Plan to be personal information, even if you cease to be a Plan participant. The personal information we collect may include, among other things:
Read More ...
How To Name Or Change A Beneficiary.
To name a beneficiary, simply complete the enrollment and beneficiary card furnished to you by your union representative, Fund representative or employer. The card must then be sent to the Fund office. Read More ...
To name a beneficiary, simply complete the enrollment and beneficiary card furnished to you by your union representative, Fund representative or employer. The card must then be sent to the Fund office. Read More ...
Your eligibility for benefits terminates on the date when you leave the employment of an Employer covered by the Fund or if the Board of Trustees terminates the Fund, whichever happens first. The Board of Trustees may change or eliminate benefits under the Fund and may terminate the entire Fund or any portion of it. The Board of Trustees may terminate the Fund when there is no longer a collective bargaining agreement in force between the Employers and the Union requiring any Employer contributions to the Trust Fund. At any other time, the Fund may be terminated by a unanimous vote of all Trustees, with consent of the Employers and the Union.
Coverage of an eligible child terminates automatically when the child attains 26 years of age. If you request coverage after January 1, 2011 for an eligible child under the age of 26, there will be a 30 day waiting period from the date of your request before such child is enrolled for benefits. If an eligible child becomes totally and permanently disabled prior to attaining the age of 26, the Employee parent of such child must notify the Fund Office of such disability within 60 days of the onset of same. Coverage of a disabled child over 26 ceases if the child is found to be no longer totally or permanently disabled. Coverage of the spouse of an Employee terminates automatically as of the date of divorce or death. Coverage for all family members terminates automatically as of the date of death of the Employee. Any stepchildren who are not enrolled for health coverage from the Fund as of the close of business on December 31, 2010, are not eligible for such coverage.
In the event your Employer is two months delinquent in remitting contributions on your behalf to the Fund, your eligibility for benefits incurred after such two month period shall be suspended until such time as the employer is no longer delinquent for two months. During such a period of suspension, the Fund shall hold such claims in abeyance pending payment of the contributions. Once your employer is no longer delinquent for two months, such claims will be promptly processed by the Fund.
Back to FAQ's Read More ...
Coverage of an eligible child terminates automatically when the child attains 26 years of age. If you request coverage after January 1, 2011 for an eligible child under the age of 26, there will be a 30 day waiting period from the date of your request before such child is enrolled for benefits. If an eligible child becomes totally and permanently disabled prior to attaining the age of 26, the Employee parent of such child must notify the Fund Office of such disability within 60 days of the onset of same. Coverage of a disabled child over 26 ceases if the child is found to be no longer totally or permanently disabled. Coverage of the spouse of an Employee terminates automatically as of the date of divorce or death. Coverage for all family members terminates automatically as of the date of death of the Employee. Any stepchildren who are not enrolled for health coverage from the Fund as of the close of business on December 31, 2010, are not eligible for such coverage.
In the event your Employer is two months delinquent in remitting contributions on your behalf to the Fund, your eligibility for benefits incurred after such two month period shall be suspended until such time as the employer is no longer delinquent for two months. During such a period of suspension, the Fund shall hold such claims in abeyance pending payment of the contributions. Once your employer is no longer delinquent for two months, such claims will be promptly processed by the Fund.
Back to FAQ's Read More ...
As a participant in the ITPE Health & Welfare Fund you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).
Read More ...
All claims for Death Benefits, Covered Family Member's Death Benefits, Survivor Monthly Death Benefits and Non-Occupational Accidental Death Benefits and Dismemberment Benefits must be submitted to the Plan Office within three (3) years from the date of the death or Read More ...