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Group Long Term Disability ERISA Terms and Conditions

Long Term Disability Terms and Conditions

Administrative Information: The following information, along with the information contained in the Certificate of Insurance, comprises the Summary Plan Description under the Employee Retirement Income Security Act of 1974 (“ERISA”), as amended, for the benefits described in the Certificate of Insurance. This Plan is insured by New York Life Insurance Company under a Group Contract No. G-29344-0 issued to GEBA.

Important Information concerning your Plan is outlined below:

Name of Plan: GEBA Group Benefits Plan (“Plan”). All benefit programs that GEBA sponsors for its membership, including this group long-term disability program, constitute one employee welfare benefit plan within the meaning of ERISA, the federal law that governs this Plan.

Plan Participants: The Plan provides benefits for all members who have been approved for coverage.

Plan Sponsor: Government Employees’ Benefit Association, Inc., P.O. Box 206, Annapolis Junction, MD 20701, (301) 688-7912.

Employer ID Number: EIN #52: 6051763 Plan Number: 501

Plan Administrator: The Plan is administered and maintained by GEBA, at the address listed above (see “Plan Sponsor”). Benefits are provided by the New York Life Insurance Company under a Group Contract No. G-29344-0 issued to GEBA.

Type of Administration: The Plan is administered by the Plan Administrator (GEBA), at the address listed above (see “Plan Sponsor”). The duty of the Plan Administrator is to see that the provisions of the Plan, including this program, are carried out for the benefit of the persons entitled to participate without discrimination among participants.

Amendment or Termination of Plan: This program and any other program under the Plan and the Plan itself may be amended or terminated at any time by GEBA. If the Plan is terminated, GEBA may use Plan assets to pay benefits outstanding as of the later of the date the termination is adopted or is effective, and Corporation (GEBA) expenses. Any remaining assets will be allocated by a Board of Directors’ resolution that conforms with applicable law and does not adversely affect the Code Section 501(c) (9) qualified status held by GEBA. If the Plan is merged with another plan or Plan assets are transferred to another plan, Plan assets will be allocated according to the merger or acquisition agreement’s terms.

Agent for Service of Legal Process: National Registered Agents, Inc., 1090 Vermont Ave. N.W., Washington, D.C. 20005. Legal Process may also be served on GEBA’s Chief Executive Officer, at the address listed above (see “Plan Sponsor”). For disputes arising under the insurance contract, service of legal process may be made upon New York Life Insurance Company at one of its local offices or upon the Supervisory Official of the Insurance Department in the State in which you reside.

Plan Year: All financial records of the Plan are kept on a fiscal year of January 1 through December 31.

Cost of Benefits and Plan Funding: Premiums for this program are paid by you, the Plan Participants. Benefits under this program are funded by a New York Life Group Contract G-20344-0 issued to GEBA.

Details of the Plan: Consult your Group Insurance certificate for information about the Plan regarding eligibility for participation, description of benefits, and disqualification, ineligibility or denial, loss, forfeiture, or suspension of benefits.

Claims Procedures

Procedures for Presenting Claims for Benefit: Claim forms needed to file for benefits under the group insurance program can be obtained from the Government Employees’ Benefit Association, Inc. (GEBA) staff who will also be ready to answer questions about the insurance benefits and to assist you or your beneficiary in filing claims. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully.

Usually, the completed claim form should be returned to GEBA who will certify that you are insured under the Plan and will then forward the claim form to New York Life Insurance Company.

When the claim has been processed, you or your beneficiary will be notified of the benefits paid. If any benefits have been denied, you or your beneficiary will receive a written explanation.

Requesting a Review of Claims Denied in Whole or in Part (“Adverse Benefit Determination”): In the event a claim has been denied in whole or in part, you or your beneficiary may request a review of the adverse benefit determination by New York Life Insurance Company.

This request for review must be sent to Group Insurance Claims Review at the address of the New York Life Insurance Company office which processed the claim, within 60 days after you or your beneficiary received notice of denial of the claim. When requesting a review, please state the reason you or your beneficiary believe the claim was improperly denied and submit any questions or comments deemed appropriate.

New York Life Insurance will reevaluate the information and you will be informed of the decision in writing in a timely manner.

The New York Life Insurance Company as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious.

ERISA Claims and Appeals Effective April 1, 2018

The regulations governing ERISA disability claims and appeals have been amended. The amended regulations apply to disability claims filed on or after April 1, 2018. These new rights and procedures include:

  • Any cancellation or discontinuance of your disability coverage that has a retroactive effect will be treated as an adverse benefit determination, except in the case of failure to timely pay required premiums or contributions toward the cost of coverage.
  • If you live in a county with a significant population of non-English speaking persons, the Plan will provide, in the non-English language(s), a statement of how to access oral and written language services in those languages.
  • For any adverse benefit determination, you will be provided with an explanation of the basis for disagreeing or not following the views of: (1) health care professionals who have treated you or vocational professionals who have evaluated you; (2) the advice of medical or vocational professionals obtained on behalf of the Plan; and (3) any disability determination made by the Social Security Administration regarding you and presented to the Plan by you.
  • For any adverse benefit determination, you will be given either the specific internal rules, guidelines, protocols, standards or other similar criteria of the Plan relied upon in making that decision, or a statement that such rules, etc. do not exist.
  • Prior to a final decision being made on an appeal, you will have the opportunity to review and respond to any new or additional rationale or evidence considered, relied upon, or generated by the Plan in connection with your claim.
  • If an adverse benefit determination is upheld on appeal, you will be given notice of any applicable contractual limitations period that applies to your right to bring legal proceedings and the calendar date on which that period expires.
  • Should the Plan fail to establish or follow ERISA required disability claims procedures, you may be entitled to pursue legal remedies under section 502(a) of ERISA without exhausting your administrative remedies, as more completely set forth in section 503 of ERISA.
  • If your claim is denied based on medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the disability coverage to your medical circumstances or a statement that such an explanation will be provided free of charge upon request.
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.

Your Rights Under ERISA
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”), as amended. ERISA provides that all Plan Participants shall be entitled to:

Receive Information About Your Plan and Benefits

  1. Examine, without charge, at the GEBA Office, all Plan documents and copies of all documents filed by the Plan with the U.S. Department of Labor, such as the latest annual reports (form 5500 Series) and Plan descriptions. This examination may take place between the hours of 10 a.m. and 3 p.m. Monday through Friday, except holidays.
  2. Obtain copies of these Plan documents (including insurance contracts and the Series 5500 report) upon written request to the Board of Directors of GEBA who may make a reasonable charge for the copies.
  3. Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including an employer, your benefit association, or any other entity may discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a benefit is denied in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to this decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in federal district court. In such case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits that are denied or ignored in whole or in part, you may file suit in a state or federal court. If the Plan Fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal court. The court will decide who should pay court costs and fees. If you lose, the court may order you to pay these costs and fees. For example, you may have to pay these fees if the court finds your claim to have been frivolous.

Assistance with Your Questions

If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Updated: November 2018

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