1988 Employer Benefit Plan

THE 1988 EMPLOYER BENEFIT PLAN
BENEFIT PLAN
FOR
UMWA REPRESENTED EMPLOYEES
OF
[ Name of Employer ]
Effective as of February 1, 1988
TABLE OF CONTENTS
INTRODUCTION
ARTICLE I DEFINITIONS……………………………………………… 1
ARTICLE II ELIGIBILITY…………………………………………….. 1
A. Active Employees…………………………………………….. 1
B. Pensioners………………………………………………….. 2
C. Disabled Employees…………………………………………… 3
D. Eligible Dependents………………………………………….. 4
E. Surviving Spouse and Dependents of Deceased Employees or Pensioners.. 4
ARTICLE III BENEFITS……………………………………………… 5
A. Health Benefits…………………………………………….. 6
(1) Inpatient Hospital Benefits………………………………. 6
(a) Semi-private room……………………………………… 6
(b) Intensive Care Unit – Coronary Care Unit…………………. 6
(c) Private Room………………………………………….. 7
(d) Renal Dialysis………………………………………… 7
(e) Mental Illness………………………………………… 7
(f) Alcoholism and Drug Abuse………………………………. 7
(g) Oral Surgical/Dental Procedures…………………………. 7
(h) Maternity Benefits…………………………………….. 8
(i) General………………………………………………. 8
(2) Outpatient Hospital Benefits……………………………… 8
(a) Emergency Medical and Accident Cases…………………….. 8
(b) Surgical Cases………………………………………… 8
(c) Laboratory Tests and X-rays…………………………….. 8
(d) Chemotherapy and Radiation Therapy………………………. 8
(e) Physiotherapy…………………………………………. 8
(f) Renal Dialysis………………………………………… 9
(3) Physicians’ Services and Other Primary Care…………………. 9
(a) Surgical Benefits………………………………………. 9
(b) Assistant Surgeons……………………………………… 9
(c) Obstetrical Delivery Service…………………………….. 9
(d) Anesthesia Services…………………………………….. 9
(e) Oral Surgery…………………………………………… 9
(f) Surgical Services Limitations…………………………… 10
(g) Inhospital Physicians’ Visits…………………………… 10
(h) Home, Clinic, and Office Visits…………………………. 10
(i) Emergency Treatment……………………………………. 10
(j) Laboratory Tests and X-rays…………………………….. 10
(k) Radiation and Chemotherapy Benefits……………………… 11
(l) Medical Consultation…………………………………… 11
(m) Specialist Care……………………………………….. 11
(n) Primary Care – Podiatrists’ Services…………………….. 11
(o) Primary Medical Care – Miscellaneous…………………….. 11
(p) Services Not Covered…………………………………… 12
(4) Prescription Drugs………………………………………. 13
(a) Benefits Provided……………………………………… 13
(b) Benefits Excluded……………………………………… 13
TABLE OF CONTENTS Cont.
(5) Skilled Nursing Care and Extended Care Units……………….. 14
(a) Skilled Nursing Care Facility…………………………… 14
(b) Extended Care Units……………………………………. 14
(6) Home Health Services & Equipment………………………….. 15
(a) General Provisions…………………………………….. 15
(b) Physical and Speech Therapy…………………………….. 15
(c) Skilled Nursing……………………………………….. 15
(d) Medical Equipment……………………………………… 15
(e) Oxygen……………………………………………….. 16
(f) Coal Miners Respiratory Disease Program………………….. 16
(7) Other Benefits………………………………………….. 16
(a) Orthopedic and Prosthetic Devices……………………….. 16
(b) Physical Therapy………………………………………. 17
(c) Speech Therapy………………………………………… 17
(d) Hearing Aids………………………………………….. 17
(e) Ambulance and Other Transportation………………………. 18
(f) Outpatient Mental Health, Alcoholism and Drug Addiction……. 18
(8) Co-Payments…………………………………………….. 18
(9) Vision Care Program……………………………………… 20
(a) Benefits……………………………………………… 20
(c) Exclusions……………………………………………. 20
(10) General Provisions………………………………………. 21
(a) HMO Election………………………………………….. 21
(b) Administration………………………………………… 21
(c) Services Rendered Outside the United States………………. 21
(d) Medicare……………………………………………… 21
(e) Subrogation…………………………………………… 22
(f) Non-Duplication……………………………………….. 22
(g) Explanation of Benefits (EOB), Cost Containment and Hold
Harmless………………………………………………. 23
(11) General Exclusions………………………………………. 25
B. Life and Accidental Death and Dismemberment Insurance…………… 26
(1) Active Employees………………………………………… 26
(2) Pensioners……………………………………………… 27
C. Death Benefits……………………………………………… 27
(1) Deaths Prior to December 6, 1977………………………….. 27
(2) Deaths after December 5, 1977 and Prior to March 27, 1978……. 27
D. General Provisions………………………………………….. 28
(1) Continuation of Coverage…………………………………. 28
(a) Layoff……………………………………………….. 28
(b) Disability……………………………………………. 28
(c) Leave of Absence………………………………………. 28
(d) Maximum Continuation of Coverage………………………… 29
(e) Quit or Discharge……………………………………… 29
(f) Other Employment………………………………………. 29
(g) Article III (j) – Wage Agreement………………………… 29
(h) COBRA Continuation Coverage…………………………….. 29
(2) Advanced Insurance Premiums………………………………. 30
(3) Conversion Privilege…………………………………….. 30
(a) Life Insurance………………………………………… 30
(b) Health Benefits……………………………………….. 30
INTRODUCTION
This Benefit Plan for United Mine Workers of America Represented Employees
of (Name of Employer) (“the Plan”) has been established pursuant to the
provisions of Article XX of the National Bituminous Coal Wage Agreement of
1988.
The Plan provides health and vision care for Employees and Pensioners and
their eligible Dependents, life insurance and accidental death and
dismemberment insurance for Employees and life insurance for Pensioners.
These benefits are provided by (Name of Employer) through insurance
carriers or professional contract administrators.
Each eligible Employee and Pensioner will receive an identification card.
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ARTICLE I DEFINITIONS
The following terms shall have the meanings herein set forth:
(1) “Employer” means (Insert Employer’s Name) .
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of
1988, as amended from time to time and any successor agreement.
(3) “Plan Administrator” shall be the Employer, a subsidiary of the
Employer, an affiliated company of the Employer or an employee of the
Employer,as designated by the Employer.
(4) “Employee” shall mean a person working in a classified job for the
Employer, eligible to receive benefits hereunder.
(5) “Pensioner” shall mean any person who is receiving a pension, other
than (i) a deferred vested pension based on less than 20 years of credited
service, or (ii) a pension based in whole or in part on years of service
credited under the terms of Article II G of the 1974 Pension Plan, or any
corresponding paragraph of any successor thereto, under the 1974 Pension Plan
(or any successor thereto), whose last classified signatory employment was
with the Employer, subject to the provisions of Article II B of this Plan.
(6) “Beneficiary” shall mean any person who is eligible pursuant to the
Plan to receive health benefits as set forth in Article III hereof.
(7) “Dependent” shall mean any person described in Section D of Article II
hereof.
(8) “Attains the age” shall mean on or after 12:01 A.M. of the anniversary
date of one’s birth.
(9) “Signatory Service” shall have the meaning assigned to such term in
the United Mine Workers of America 1974 Pension Plan (the “1974 Pension Plan”)
or any successor thereto.
(10) “Trustee” or “Trustees” shall mean the Trustees of the United Mine
Workers of America Health and Retirement Funds.
ARTICLE II ELIGIBILITY
The persons eligible to receive the health benefits pursuant to Article III
are as follows:
A. Active Employees
Benefits under Article III shall be provided to any Employee who:
(1) is actively at work1
for the Employer on the effective date of the
Wage Agreement; or
(2) is on layoff or disabled from the Employer and had continuing
eligibility as of the effective date of the Wage Agreement for coverage under
the 1984 Employer’s Benefit Plan (“prior Plan”) as a laid-off or disabled
employee. Coverage for such laid-off or disabled Employees shall not continue
beyond the date when they would no longer have been eligible for such coverage
under the provisions of the prior Plan.

1
Actively at work includes an Employee of the Employer who was actively at
work on January 31, 1988, and who returns to active work with the
Employer two weeks after the effective date of the Wage Agreement.
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(3) Except as provided in paragraph (2) above, any Employee of the
Employer who is not actively at work1
for the Employer on the effective date
of the Wage Agreement will not be eligible for coverage under the Plan until
he returns to active employment with the Employer.
Any Employee of the Employer who as of January 31, 1988, was eligible for
benefits under the prior Plan who is not scheduled to work within two weeks
after the effective date of the Wage Agreement because of lack of work, such
an Employee will, for purposes of this Plan, be considered eligible for
coverage under this Plan as of the effective date of the Wage Agreement but as
an Employee on layoff as of such date.
(4) A new Employee will be eligible for health benefits from the first day
worked with the Employer.
B. Pensioners
Health benefits and life insurance under Article III hereof shall be
provided to Pensioners as follows:
(1) Any Pensioner who is not again employed in classified signatory
employment subsequent to
(a) such Pensioner’s initial date of retirement under the 1974 Pension
Plan, and
(b) February 1, 1988, shall be eligible for coverage as a Pensioner
under, and subject to all other provisions of this Plan. Notwithstanding (i)
and (ii) of the definition of Pensioner in Article I(5) of this Plan, any such
Pensioner who was eligible for benefits under the 1974 Benefit Plan as a
Pensioner on December 5, 1977, shall be eligible for such benefits, subject to
all other provisions of this Plan.
(2) Any person who
(a) has been covered as a Pensioner under this Plan, and
(b) is again employed in classified signatory employment after February
1, 1988, with an Employer signatory to the Wage Agreement, other than the
Employer, shall have coverage under the Plan suspended during such period of
employment. If such person is credited with at least three or more years of
service under the 1974 Pension Plan after February 1, 1988, while so employed
with the same Employer, coverage shall be terminated under this Plan.
(3) Any person who
(a) has been receiving a pension under the 1974 Pension Plan,
(b) has not been previously covered as a Pensioner under this Plan, and
(c) is employed in a classified job by the Employer after February
1,1988, shall, upon subsequent retirement, be covered as a Pensioner under
this Plan only if such person is credited with at least three or more years of
service under the 1974 Pension Plan subsequent to the most recent date of
employment in a classified job with the Employer.
(4) Health benefits shall not be provided during any month in which the
Pensioner is regularly employed at an earnings rate equivalent to at least
$500 per month.
C. Disabled Employees
In addition to disabled Pensioners who are receiving pension benefits and
are therefore entitled to receive health benefits under paragraph B of this
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Article II, health benefits under Article III shall also be provided to any
Employee who:
(1)(a) Has completed 20 years of credited service, including the required
number of years of signatory service pursuant to Article IV C(6) of the 1974
Pension Plan or any corresponding paragraph of any successor thereto, and
(b) has not attained age 55, and
(c) became disabled after December 6, 1974 while in classified
employment with the Employer, and
(d) is eligible for Social Security Disability Insurance Benefits under
Title II of the Social Security Act or its successor;
(2) Becomes totally disabled due to a compensable disability within four
years of the date the Employee would be eligible to receive a pension under
the 1974 Pension Plan or any successor thereto, as long as the Employee
continues to be so disabled during the period for which Workers’ Compensation
payments (Workers’ Compensation does not include Federal Black Lung Benefits)
are applicable; or
(3) Is receiving or would, upon proper application, be eligible to receive
Sickness and Accident Benefits pursuant to the Wage Agreement.
Life and accidental death and dismemberment insurance shall also be
provided to Employees described in (3) above.
D. Eligible Dependents
Health benefits under Article III shall be provided to the following
members of the family of any Employee, Pensioner, or disabled Employee
receiving health benefits pursuant to paragraphs A, B, or C of this Article
II:
(1) A spouse who is living with or being supported by an eligible Employee
or Pensioner;
(2) Unmarried dependent children of an eligible Employee or Pensioner who
have not attained age 22;
(3) A parent of an eligible Employee, Pensioner or spouse, if the parent
has been dependent upon and living in the same household (residence) with the
eligible Employee or Pensioner for a continuous period of at least one year;
(4) Unmarried dependent grandchildren of an eligible Employee, Pensioner
or spouse who have not attained age 22 and are living in the same household
(residence) with such Employee or Pensioner;
(5) Dependent children (of any age), of an eligible Employee, Pensioner or
spouse, who are mentally retarded or who become disabled prior to attaining
age 22 and such disability is continuous and are either living in the same
household with such Employee or Pensioner or are confined to an institution
for care or treatment. Health benefits for such children will continue as
long as a surviving parent is eligible for health benefits.
For purposes of this paragraph D, a person shall be considered dependent
upon an eligible Employee, Pensioner or spouse if such Employee, Pensioner or
spouse provides on a regular basis over one-half of the support to such
person.
E. Surviving Spouse and Dependents of Deceased Employees or Pensioners
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Health benefits under Article III shall be provided to (i) any unmarried
surviving spouse (who was living with or being supported by the Employee or
Pensioner immediately prior to the Employee or Pensioner’s death) and (ii)
such spouse’s unmarried surviving dependent’s children as defined in subparagraphs (2) and (5) of paragraph D of an Employee or Pensioner who died:
(1) As a result of a mine accident occurring on or after the effective
date of the Plan while the Employee was working in a classified job for the
Employer;
(2) Under conditions which qualify such spouse for a Surviving Spouse
benefit under the 1974 Pension Plan or any successor thereto;
(3) At a time when such Employee or Pensioner is entitled to receive
health benefits pursuant to paragraph A, B, or C of this Article II, provided
that (i) if such Employee or Pensioner died prior to the effective date of the
Wage Agreement and the spouse is not eligible for a Surviving Spouse’s
benefit, then only for the period that the spouse is eligible to receive death
benefits in installment payments pursuant to paragraph C of Article III, or
(ii) if such Employee or Pensioner died on or after the effective date of the
Wage Agreement and the spouse is not eligible for a Surviving Spouse’s benefit
and life insurance benefits or death benefits are payable in a lump sum, then
only for 60 months following the month of the death of such Employee or only
for 22 months following the month of the death of such Pensioner. If life
insurance benefits are not payable, health benefits shall be provided only to
the end of the month in which the Employee or Pensioner died.
Any children who have not attained age 22 shall not be entitled to receive
health benefits under this paragraph E if they are employed and living outside
the household (residence) of the surviving spouse or the immediate family of
the deceased Employee or Pensioner.
Health benefits shall continue for a surviving spouse until remarriage of
such spouse, but if such spouse is entitled to such benefits under paragraph
(3) above, such health benefits will continue not longer than for the period
specified in paragraph (3) above. Health benefits shall not be provided
during any month in which such surviving spouse is regularly employed at an
earnings rate equivalent to at least $500 a month.
At the death of an Employee described in paragraph (1) above, health
benefits will be continued for the unmarried children until they attain age
22, even if there is no surviving spouse or if the surviving spouse dies
before they attain age 22; provided, however, health benefits shall not be
provided for any child during any month in which such child is regularly
employed at an earnings rate equivalent to at least $500 per month, unless
such child is a full-time student.
If at the death of an Employee or pensioner described in paragraph (3)
above, there is no surviving spouse, or if the surviving spouse dies during
any period in which health benefits are being continued, such health benefits
will be continued for the unmarried children during the period in which such
spouse would have been eligible for health benefits but in no event beyond
their attaining age 22; provided, however, health benefits shall not be
provided for any child during any month in which such child is regularly
employed at an earnings rate equivalent to at least $500 per month, unless
such child is a full-time student.
The unmarried, dependent children of a Surviving Spouse eligible under (2)
above shall be eligible for health benefits until they attain age 22, so long
as the Surviving Spouse is eligible for benefits; provided, however, health
benefits shall not be provided during any month in which such child is
regularly employed at an earnings rate equivalent to at least $500 per month,
unless such child is a full-time student.
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ARTICLE III BENEFITS
Covered services shall be limited to those services which are reasonable
and necessary for the diagnosis or treatment of an illness or injury and which
are given at the appropriate level of care, or are otherwise provided for in
the Plan. The fact that a procedure or level of care is prescribed by a
physician does not mean that it is medically reasonable or necessary or that
it is covered under this Plan. In determining questions of reasonableness and
necessity, due consideration will be given to the customary practices of
physicians in the community where the service is provided. Services which are
not reasonable and necessary shall include, but are not limited to the
following: procedures which are of unproven value or of questionable current
usefulness; procedures which tend to be redundant when performed in
combination with other procedures; diagnostic procedures which are unlikely to
provide a physician with additional information when they are used repeatedly;
procedures which are not ordered by a physician or which are not documented in
timely fashion in the patient’s medical records; procedures which can be
performed with equal efficiency at a lower level of care. Covered services
that are medically necessary will continue to be provided, and accordingly
this paragraph shall not be construed to detract from plan coverage or
eligibility as described in this Article III.
A. Health Benefits
(1) Inpatient Hospital Benefits
(a) Semi-private room
When a Beneficiary is admitted by a licensed physician (hereinafter
“physician”) for treatment as an inpatient to an Accredited Hospital
(hereinafter “hospital”), benefits will be provided for semi-private room
accommodations (including special diets and general nursing care) and all
medically necessary services provided by the hospital as set out below for the
diagnosis and treatment of the Beneficiary’s condition.
Medically necessary services provided in a hospital include the
following:
Operating, recovery, and other treatment rooms
Laboratory tests and x-rays
Diagnostic or therapy items and services
Drugs and medications (including take-home drugs which are limited
to a 30-day supply)
Radiation therapy
Chemotherapy
Physical therapy
Anesthesia services
Oxygen and its administration
Intravenous injections and solutions
Administration of blood and blood plasma
Blood, if it cannot be replaced by or on behalf of the Beneficiary
(b) Intensive Care Unit – Coronary Care Unit
Benefits will also be provided for treatment rendered in an Intensive
Care or Coronary Care Unit of the hospital, if such treatment is certified as
medically necessary by the attending physician.
(c) Private Room
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For confinement in a private room, benefits will be provided for the
hospital’s most common charge for semi-private room accommodations and the
Beneficiary shall be responsible for any excess over such charge except that
private room rates will be paid when (i) the Beneficiary’s condition requires
him to be isolated for his own health or that of others, or (ii) the hospital
has semi-private or less expensive accommodations but they are occupied and
the Beneficiary’s condition requires immediate hospitalization. Semi-private
room rates, not private room rates, will be paid beyond the date a semiprivate room first becomes available and the Beneficiary’s condition permits
transfer to those accommodations.
(d) Renal Dialysis
Benefits will be provided for renal dialysis provided that the renal
dialysis therapy is administered in accordance with Federal Medicare
regulations as in effect from time to time.
(e) Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary
who is confined for mental illness in a hospital by a licensed psychiatrist.
When medically necessary, hospitalization may be extended for a maximum of 30
additional days for confinements for an acute (short-term) mental illness, per
episode of acute illness. (More than 90 days of confinement for mental
illness over a two-year period, (dating from the first day of hospital
confinement, even if the first day of confinement occurred during a prior Wage
Agreement) is deemed for purposes of this Plan to be a chronic (long-term)
mental problem for which the Plan will not provide inpatient hospital
benefits.
(f) Alcoholism and Drug Abuse
Benefits are provided for a Beneficiary who requires emergency
detoxification hospital care for the treatment of alcoholism or emergency
treatment for drug abuse. Such treatment is limited to 7 calendar days per
inpatient hospital admission.
If treatment of a medical or mental condition is necessary following
detoxification or emergency treatment for drug abuse, benefits may be provided
under other provisions of this Plan and are subject to any requirements or
limitations in such provisions.
See paragraph (7)(f) for information concerning other services related
to treatment of alcoholism and drug abuse.
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital
for the oral surgical procedures described in paragraph (3)(e) provided
hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for
dental procedures only if hospitalization is necessary due to a pre-existing
medical condition and prior approval is received from the Plan Administrator.
(h) Maternity Benefits
Benefits are provided for a female Beneficiary who is confined in a
hospital for pregnancy. Such benefits will also be available for services
pertaining to termination of pregnancy but only if medically necessary and is
so certified to and such services are performed by licensed gynecologist or
surgeon.
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(i) General
Accredited Hospital is a hospital which is operated primarily for the
purpose of rendering inpatient therapy for the several classifications of
medical and surgical cases and which is approved by the Joint Commission on
Accreditation of Hospitals or which has been approved by the Trustees of the
United Mine Workers of America 1950 Benefit Plan and Trust.
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical
treatment or medical treatment of an injury as the result of an accident,
provided such emergency medical treatment is rendered within 48 hours
following the onset of acute medical symptoms or the occurrence of the
accident.
(b) Surgical Cases
Benefits are provided for a Beneficiary who receives surgical treatment
in the outpatient department of a hospital.
(c) Laboratory Tests and X-rays
Benefits are provided for laboratory tests and x-ray services performed
in the outpatient department of a hospital which provides such services and
when they have been ordered by a physician for diagnosis or treatment of a
definite condition, illness or injury.
(d) Chemotherapy and Radiation Therapy
Benefits are provided for chemotherapy treatments of a malignant disease
or radiation treatments performed in the outpatient department of a hospital.
(e) Physiotherapy
Benefits are provided for physiotherapy treatments performed in the
outpatient department of a hospital. Such therapy must be prescribed and
supervised by a physician.
(f) Renal Dialysis
Benefits are provided for outpatient renal dialysis treatments rendered
in accordance with Federal Medicare regulations as in effect from time to
time.
(3) Physicians’ Services and Other Primary Care
(a) Surgical Benefits
Benefits are provided for surgical services essential to a Beneficiary’s
care consisting of operative and cutting procedure (including the usual and
necessary post-operative care) for treatment of illnesses, injuries, fractures
or dislocations, which are performed either in or out of a hospital by a
physician.
When surgical services consist of necessary major surgery (primary) and
the physician performs surgery additional to the primary surgery (incidental
surgery), benefits payment for the incidental surgery will be provided but at
a rate 50% lower than the physician’s normal charge had he performed only the
incidental surgery.
Page 8
(b) Assistant Surgeons
If the Beneficiary is an inpatient in a hospital, benefits will also be
provided for the services of a physician who actively assists the operating
physician in the performance of such surgical services when the condition of
the Beneficiary and type of surgical service require such assistance.
(c) Obstetrical Delivery Service
Benefits are provided for a female Beneficiary for obstetrical delivery
services (including pre- and post-natal care) performed by a physician.
Benefits will also be provided if such delivery is performed by a midwife
certified by the American College of Nurse Midwifery and licensed where such
licensure is required.
Such benefits will also be provided for termination of pregnancy but
only if medically necessary and is so certified to and such services are
performed by a licensed gynecologist or surgeon.
(d) Anesthesia Services
Benefits are provided for the administration of anesthetics provided
either in or out of the hospital in surgical or obstetrical cases, when
administered and billed by a physician, other than the operating surgeon or
his assistant, who is not an employee of, nor compensated by, a hospital,
laboratory or other institution.
(e) Oral Surgery
Benefits are not provided for dental services. However, benefits are
provided for the following limited oral surgical procedures if performed by a
dental surgeon or general surgeon:
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular Joint Dysfunction, only when medically necessary
and related to an oral orthopedic problem.
Biopsy of the oral cavity
Dental services required as a direct result of an accident
(f) Surgical Services Limitations
Benefits are not provided for certain surgical services without prior
approval of the Plan Administrator. Such surgical procedures include, but are
not limited to, the following:
Plastic surgery, including mammoplasty
Reduction mammoplasty
Intestinal bypass for obesity
Gastric bypass for obesity
Cerebellar implants
Dorsal stimulator implants
Prosthesis for cleft palate if not covered by crippled children
services
Organ transplants
(g) Inhospital Physicians’ Visits
If a Beneficiary is confined as an inpatient in a hospital because of an
illness or injury, benefits are provided for inhospital visits by the
physician in charge of the case. Such benefits will also be provided
Page 9
concurrently with benefits for surgical, obstetrical and radiation therapy
services when the Beneficiary has a separate and complicated condition, the
treatment of which requires skills not possessed by the physician who is
rendering the surgical, obstetrical or radiation therapy services.
(h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in
a clinic (including the outpatient department of a hospital) or in the
physician’s office for the treatment of illnesses or injuries, if provided by
a physician.
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary
who receives outpatient emergency medical treatment or treatment of an injury
as the result of an accident, provided such emergency medical treatment is
rendered within 48 hours following the onset of acute medical symptoms or the
occurrence of the accident.
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a
licensed laboratory when ordered by a physician for diagnosis or treatment of
a definite condition, illness or injury.
Such benefits will not cover laboratory tests and x-rays ordered in
connection with a routine physical examination, unless the examination is
considered medically necessary by a physician.
(k) Radiation and Chemotherapy Benefits
Benefits are provided for treatment by x-ray, radium external radiation
or radioactive isotope (including the cost of materials unless supplied by a
hospital), provided in or out of a hospital, when performed and billed by a
physician.
When a Beneficiary’s condition requires radiation therapy services in
conjunction with medical, surgical or obstetrical services, benefits will be
provided for such radiation therapy in addition to the payment for such other
types of covered services if the physician performing the radiation therapy
services is not the same physician who performs the medical, surgical or
obstetrical services.
Benefits are provided for treatment of malignant diseases by
chemotherapy provided in or out of the hospital when prescribed and billed by
a physician.
(l) Medical Consultation
Benefits are provided for services rendered, at the request of the
attending physician in charge of the case, by a physician who is qualified in
a medical specialty necessary in connection with medical treatment required by
a Beneficiary.
(m) Specialist Care
Benefits will be provided for treatment prescribed or administered by a
specialist if the treatment is for illness or injury which falls within the
specialist’s area of medical competence.
(n) Primary Care – Podiatrists’ Services
Benefits are provided for minor surgery rendered by a qualified licensed
Page 10
podiatrist. Routine care of the feet such as trimming of nails, the treatment
of corns, bunions (except capsular or bone surgery therefor) and calluses is
excluded.
Covered minor surgery includes surgery for ingrown nails and surgery in
connection with the treatment of flat feet, fallen arches, weak feet, chronic
foot strain or symptomatic complaints of the feet.
Benefits for major surgical procedures rendered by a licensed podiatrist
are not provided, except if such surgery is rendered in a hospital.
(o) Primary Medical Care – Miscellaneous
1. Benefits are provided for care of newborn babies and routine medical
care of children prior to attaining age 6.
2. Benefits are provided for immunizations, allergy desensitization
injections, pap smears, screening for hypertension and diabetes, and
examinations for cancer, blindness, deafness, and other screening and
diagnostic procedures when medically necessary.
3. Benefits are provided for physical examinations when certified as
medically necessary by a physician. Medically necessary will mean that a
Beneficiary (i) has an existing medical condition under treatment by a
physician, (ii) has attained age 55, (iii) is undergoing an annual or semiannual routine examination by a gynecologist, or (iv) is undergoing a routine
examination prescribed by a specialist as part of such specialist’s care of a
medical condition.
4. Benefits are provided for “physician extender” care or medical
treatment administered by nurse practitioners, physician’s assistants or other
certified or licensed health personnel when such service is rendered under the
supervision of a physician.
5. Benefits are provided for a nominal fee covering instruction in
preparation for natural childbirth, if rendered by a hospital or clinic.
6. Benefits are provided for family planning counseling when rendered
by a physician or by other appropriately trained and supervised health care
professionals.
7. Benefits are provided covering artificial insemination if the
service is provided by a licensed gynecologist.
8. Benefits are provided for sterilization procedures if such
procedures are performed by a physician.
9. Birth control services and medications are not covered under the
Plan, except that benefits are provided for physician services rendered in
connection with the prescription of oral contraceptives, the fitting of a
diaphragm or the insertion or removal of an IUD.
(p) Services Not Covered
1. Services rendered by a chiropractor or naturopathic services.
2. Acupuncture therapy.
3. Home obstetrical delivery.
4. Telephone conversations with a physician in lieu of an office
visit.
5. Charges for writing a prescription.
Page 11
6. Medications dispensed by other than a licensed pharmacist.
7. Charges for medical summaries and medical invoice preparation.
8. Services of any practitioner who is not legally licensed to
practice medicine, surgery, or counseling except as specifically provided
herein.
9. Cosmetic surgery, unless pertaining to surgical scars or to
correct results of an accidental injury or birth defects.
10. Physical examinations, except as specifically provided
herein.
11. Removal of tonsils or adenoids, unless medically necessary.
(4) Prescription Drugs
(a) Benefits Provided
Benefits are provided for insulin and prescription drugs (only those
drugs which by Federal or State law require a prescription) dispensed by a
licensed pharmacist and prescribed by a (i) physician for treatment or control
of an illness or nonoccupational accident or (ii) licensed dentist for
treatment following the performance of those oral surgical services set forth
in (3)(e). The initial amount dispensed shall not exceed a 30 day supply.
Any original prescription may be refilled for up to six months as directed by
the attending physician. The first such refill may be for an amount up to,
but no more than, a 60 day supply. The second such refill may be for an
amount up to, but no more than, a 90 day supply. Benefits for refills beyond
the initial six months require a new prescription by the attending physician.
Reasonable charges for prescription drugs or insulin are covered
benefits. Reasonable charges will consist of the lessor of:
(1) The amount actually billed per prescription or refill,
(2) The average wholesale price plus 25%, to be not less than
$2.50 above nor more than $10.00 above the average wholesale price per
prescription or refill, or
(3) For a pharmacist participating in a Trustee-established
prescription drug program, the current price paid by the Funds and
available to the Employer in a piggybacked program.
The Plan Administrator may determine average wholesale price from either
the American Druggist Blue Book, the Drugtopics Redbook, or the Medi-Span
Prescription Pricing Guide.
(b) Benefits Excluded
Benefits shall not be provided under paragraph (4)(a) for the following:
1. Medications dispensed in a hospital (including take-home drugs),
skilled nursing facility or physician’s office. (See Article III A (1)(a) and
(5)(a) for benefits provided for drugs and medications during inpatient
confinement in a hospital or skilled nursing facility.)
2. Birth control prescriptions.
3. Prescriptions dispensed by other than a licensed pharmacist.
4. Any medication not specifically provided for in (a) above.
Page 12
(5) Skilled Nursing Care and Extended Care Units
(a) Skilled Nursing Care Facility
Upon determination by the attending physician that confinement in a
licensed skilled nursing facility2
is medically necessary, to the extent that
benefits are not available from Medicare or other State or Federal programs,
benefits will be provided for:
1. skilled nursing care provided by or under the supervision of a
registered nurse;
2. room and board;
3. physical, occupational, inhalation and speech therapy, either
provided or arranged for by the facility;
4. medical social services;
5. drugs, immunizations, supplies, appliances, and equipment
ordinarily furnished by the facility for the care and treatment of inpatients;
6. medical services, including services provided by interns or
residents in an approved, hospital-run training program, as well as other
diagnostic and therapeutic services provided by the hospital; and
7. other health services usually provided by skilled nursing care
facilities.
The Plan will not pay for services in a nursing care facility:
1. that is not licensed or approved in accordance with state laws or
regulations;
2. unless the service is provided by or under the direct supervision
of licensed nursing personnel and under the general direction of a physician
in order to achieve the medically desired results.
Exclusions:
Telephone, T.V., radio, visitor’s meals, private room or private
nursing (unless necessary to preserve life), custodial care, services not
usually provided in a skilled nursing facility.
(b) Extended Care Units
Benefits are provided for up to two weeks of specialized medical
services and daily treatments by licensed personnel in extended care units.
When medically necessary, benefits may be provided for a longer period of
time, subject to approval from the Plan Administrator.
The Plan will not pay for services in an extended care unit unless, in
the case of a Medicare patient, such extended care has prior approval of
Medicare.
Exclusions:
1. Services, drugs or other items which are not covered for hospital
inpatients;

2
Skilled nursing care facility is limited to a skilled nursing care
facility which is licensed and approved by Federal Medicare.
Page 13
2. Custodial care.
(6) Home Health Services & Equipment
(a) General Provisions
Benefits are provided for home health services, including nursing visits
by registered nurses and home health aides, and various kinds of
rehabilitation therapy, subject to the following conditions and approval of
the Plan Administrator.
1. The Beneficiary must be under the care of a physician.
2. The Beneficiary’s medical condition must require skilled nursing
care, physical therapy, or speech therapy at least once in a 60-day period.
3. The physician must initiate a treatment plan and specify a
diagnosis, the Beneficiary’s functional limitations and the type and frequency
of skilled services to be rendered.
4. The Beneficiary must be confined to his home. The services must be
provided by a certified home health agency.
(b) Physical and Speech Therapy
Benefits are provided for physical and speech therapy services at home
when prescribed by a physician to restore functions lost or reduced by illness
or injury. Such services must be performed by qualified personnel. When the
Beneficiary has reached his or her restoration potential, the services
required to maintain this level do not constitute covered care.
(c) Skilled Nursing
Benefits are provided for skilled nursing care rendered by a registered
nurse as a home health service when a Beneficiary’s condition has not
stabilized and a physician concludes that the Beneficiary must be carefully
evaluated and observed by a registered nurse. The Plan Administrator may
request an evaluation visit to the Beneficiary’s home.
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of
medical equipment suitable for home use when determined to be medically
necessary by a physician.
(e) Oxygen
Benefits are provided for oxygen supplied to a Beneficiary subject to
the following conditions when ordered by the attending physician:
1. The patient is referred to a designated pulmonary consultant for
testing.
2. Such consultant’s report is submitted to the Plan Administrator
with the order for oxygen.
Benefits are also provided for services of inhalation therapists in the
home with the attending physician’s order.
(f) Coal Miners Respiratory Disease Program
Benefits are provided for services or treatments administered by
personnel employed by the Coal Miners Respiratory Disease Program to a
Page 14
Beneficiary in such Beneficiary’s home when ordered or requested by a
physician, except where such benefits are available under a governmental
program and such Beneficiary is eligible, or upon application would be
eligible, under such programs.
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed
by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or
external body parts, other than dental.
These include artificial eyes, noses, hands (or hooks), feet, arms,
legs, and ostomy bags and supplies.
2. Prosthesis following breast removal.
3. Leg, arm, back, and neck braces.
4. Trusses.
5. Stump stockings and harnesses when these devices are essential for
the effective use of an artificial limb. An examination and recommendations
by an orthopedic physician is required.
Note: Benefits are provided for repairs and adjustments for braces,
trusses, stump stockings and harnesses as well as replacement of any of those
devices which have been worn out and can no longer be repaired. Benefits will
be provided for replacements for usable appliances and artificial limbs if
they are needed because of a change in the Beneficiary’s condition. Benefits
will also be provided to cover repair and adjustment cost for appliances and
artificial limbs.
If replacement of a prosthesis is required, the Beneficiary should in
all cases be reevaluated by an orthopedic physician.
6. Surgical stocking (up to two pairs per prescription with no
refills) when prescribed by a physician for surgical or medical conditions.
The Plan will not pay Beneficiary’s for support hose, garter belts, etc.
7. Orthopedic shoes when specifically prescribed by a physician or
licensed podiatrist for a Beneficiary according to orthopedist specifications,
including orthopedic shoes attached to a brace that have to be modified to
accommodate the brace. Benefits will not be provided for stock orthopedic
shoes.
8. Orthopedic corrections added to ordinary shoes by a physician or
licensed podiatrist. Benefits are provided for only the correction to the
shoe.
(b) Physical Therapy
Benefits are provided for physical therapy in a hospital, skilled
nursing facility, treatment center, or in the Beneficiary’s home. Such
therapy must be prescribed and supervised by a physician and administered by a
licensed therapist. The physical therapy treatment must be justified on the
basis of diagnosis, medical recommendation and attainment of maximum
restoration.
Page 15
(c) Speech Therapy
Benefits are provided for speech therapy rendered by a qualified
licensed speech therapist if the Beneficiary is a stroke patient or has had
conditions including ruptured aneurysm, brain tumors or autism and needs
special instruction to restore technique of sound and to phonate, and needs
direction in letter and word exercises in order to express basic needs.
Benefits are also provided for speech therapy for child Beneficiaries with a
speech impediment from a qualified speech therapist provided that the child
cannot receive speech therapy through the public schools.
(d) Hearing Aids
Benefits are provided for hearing aids recommended by a licensed
otologist or otolaryngologist and a certified clinical audiologist. Such
hearing aids must be purchased from a participating vendor. Benefits for
necessary repairs and maintenance, except the replacement of batteries, will
be provided after the expiration of the warranty period. Benefits will be
provided for replacement hearing aids only if a new aid is needed because of a
change in the Beneficiary’s condition, or if the aid no longer functions
properly. Benefits will not be provided for any fees for incorporating
hearing aids into eyeglasses.
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a
hospital, clinic, medical center, physician’s office, or skilled nursing care
facility, when considered medically necessary by a physician.
With prior approval from the Plan Administrator benefits will also be
provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s
home and the Beneficiary must be taken to an out-of-area medical center.
2. If the Beneficiary requires frequent transportation between the
Beneficiary’s home and a hospital or clinic for such types of treatment as
radiation or physical therapy or other special treatment which would otherwise
require hospitalization, benefits will be provided for such transportation
only when the Beneficiary cannot receive the needed care without such
transportation.
3. If the Beneficiary requires an escort during transportation, the
attending physician must submit satisfactory evidence as to why the
Beneficiary needs an escort.
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for:
Psychotherapy, psychological testing, counseling, group therapy and
alcoholism or drug rehabilitation programs where free care sources are not
available and when determined to be medically required by a physician.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental
deficiencies.
Page 16
3. School related behavioral problems.
4. Services by private teachers.
5. Alcoholism and drug rehabilitation if an advance determination has
not been made by the rehabilitation team that the Beneficiary is a good
candidate for rehabilitation.
6. Alcoholism and drug rehabilitation programs not approved by
Medicare.
(8) Co-Payments
Certain benefits provided in this Plan shall be subject to the copayments set forth below and such co-payments shall be the responsibility of
the Beneficiary. The Plan Administrator shall implement such procedures as
deemed appropriate to achieve the intent of these co-payments. Beneficiaries
and providers shall provide such information as the Plan Administrator may
require to effectively administer these co-payments, or such Beneficiaries or
providers shall not be eligible for benefits or payments under this Plan. Any
overpayments made to a provider who overcharges the Plan in lieu of collecting
the applicable co-payment from a participant or Beneficiary shall be repaid to
the Plan Administrator by such provider.
For the purpose of this paragraph (8), the working group shall be deemed
to be Beneficiaries who are described in Article II A and C(3) and their
eligible dependents. The non-working group shall be deemed to be those
Beneficiaries who are described in Article II B, C(2) and E and their eligible
dependent Co-payments for covered Health Benefits are established as follows:
Benefit Co-Payment
(a) Physician services as an Working Group — $7.50 per visit
out patient as set forth in up to a maximum of $150 per 12-month
section A(2) and physician visits period3
per family.
in connection with the benefits
set forth in section A(3), paragraph Nonworking Group — $5 per visit
(c) but only for pre- and post- up to a maximum of $100 per 12-month
natal visits if the physician period3
per family.
charges separately for such visits
in addition to the charge for
delivery, and paragraphs (g)
through (m), paragraph (n) except
inpatient surgery, paragraph (o)
and section A(7) paragraph (f).
(b) Prescription drugs and $5 per prescription or refill up
insulin, as set forth in section to $50 maximum per 12-month period3
A(4) and take-home drugs following per family. Note: For purposes of
hospital confinement as set this co-payment provision, a prescripforth in section (A)(1)(a). tion or refill shall be deemed to be
each 30 days (or fraction thereof)
supply.
If an employee is covered under an employer Plan (established pursuant to
the NBCWA of 1978) by more than one signatory employer during a 12-month
period3
, the total co-payments made by the employee during such period shall
be counted toward the 12-month3
maximum.

3
The 12-month periods shall begin on the following dates: March 27, 1988;
March 27, 1989; March 27, 1990; March 27, 1991 and March 27, 1992.
Page 17
(9) Vision Care Program
Actual Charge Up To
(a) Benefits Maximum Amount Frequency Limits
Vision Examination $20 Once every 24 months
Per Lens (Maximum = 2) Once every 24 months
– Single Vision 10
– Bifocal 15
– Trifocal 20
– Lenticular 25
– Contact 15
Frames 14 Once every 24 months
Note: The 24 month period shall be measured from the date the examination
is performed or from the date the lenses or frames are ordered, respectively,
even if the last examination occurred during a prior Wage Agreement.
(b) Lenses will not be covered unless the new prescription differs from
the most recent one by an axis change of 20 degrees or .50 diopter sphere or
cylinder change and the lenses must improve visual acuity by at least one line
on the standard chart.
(c) Exclusions include:
1. sunglasses (other than Tints #1 or #2);
2. extra charges for photosensitive or anti-reflective lenses;
3. drugs or medication (other than for vision examination), medical or
surgical treatment of eyes;
4. special procedures, such as orthoptics, vision training, subnormal
vision aids, aniseikonic lenses and tonography;
5. experimental services or supplies;
6. replacement of lost or broken lenses and/or frames unless replacement
is eligible under the frequency and prescription limitations;
7. services or supplies not prescribed as necessary by a licensed
physician, optometrist or optician;
8. services or supplies for which the insured person is entitled to
benefits under any other provision of the Plan or as prescribed under a mine
safety glass program;
9. any services which are covered by any workers compensation laws or
employer’s liability laws, or services which the Employer is required by law
to furnish in whole or in part;
Page 18
10. services or supplies which are obtained from any governmental agency
without cost by compliance with laws or regulations enacted by any federal,
state, municipal or other governmental body;
11. charges for services or supplies for which no charge is made that the
Beneficiary is legally obligated to pay or for which no charge would be made
in the absence of vision care coverage.
(d) The exclusions in (c) above shall not be read to limit or exclude
coverage that may be contained elsewhere in the Plan.
(10) General Provisions
(a) HMO Election
Any Beneficiary as described in Article II, Sections A, B, C and E may
elect coverage by a certified health maintenance organization (HMO) in lieu of
the health benefits provided under this Plan, in accordance with Federal or
State laws governing HMO’s; provided, however, that all Beneficiaries in a
family shall be governed by an HMO election.
If the monthly charge made by the HMO exceeds the monthly cost of this Plan
to the Employer, the excess charge shall be paid by the Beneficiary.
(b) Administration
The Plan Administrator is authorized to promulgate rules and regulations to
implement and administer the Plan, and such rules and regulations shall be
binding upon all persons dealing with the Beneficiaries claiming benefits
under this Plan. The Trustees of the UMWA Health and Retirement Funds will
resolve any disputes, including excessive fee disputes, to assure consistent
application of the Plan provisions which are identical to the benefit
provisions of the 1950 Benefit Plan and Trust.
The Plan Administrator shall give written notice to each employee of the
termination of extended coverage under the Benefit Plan. Such notice shall
explain the conversion privileges of the Benefit Plan and the enrollment
procedures to be followed. Failure to provide such notice shall not extend
coverage beyond the period otherwise provided in the Benefit Plan.
(c) Services Rendered Outside the United States
Benefits are provided for health care rendered outside the United States
on the same basis as if such care had been rendered in the United States.
(d) Medicare
1. For Pensioners, and surviving spouses, the benefits provided under
the Plan will not be paid to a Beneficiary otherwise eligible if such
Beneficiary is eligible for Hospital Insurance coverage (Part A) of Medicare
where a premium is not required and/or Medical Insurance coverage (Part B) of
Medicare unless such Beneficiary is enrolled for each part of Medicare for
which such Beneficiary is eligible. Any such Beneficiary who is enrolled in a
Medicare program shall receive the benefits provided under the Plan only to
the extent such benefits are not provided for under Medicare.
2. For Employees age 65 or older the benefits provided under the Plan
will be paid to a Beneficiary unless the company is furnished written notice
of electing coverage under Medicare rather than coverage under the Plan.
Alternatively, the participant may elect to enroll for Medicare as secondary
payor.
The Plan Administrator shall give written notification of the obligation
to enroll with respect to 1. above and of the options to enroll with respect
Page 19
to 2. above. For active Employees such notice shall be given prior to their
65th birthdays, but subsequent to their 64th birthdays. Said notice shall
explain the limited annual enrollment period and the effect of failing to
enroll if retirement should occur prior to the next enrollment period.
Failure to provide such notification shall not remove any obligation to
enroll.
(e) Subrogation
The Plan does not assume primary responsibility for covered medical
expenses which another party is obligated to pay or which another insurance
policy or other medical plan covers. Where there is a dispute between the
carriers, the Plan shall, subject to provisions 1. and 2. immediately below,
pay for such covered expenses but only as a convenience to the Beneficiary
eligible for benefits under the Plan and only upon receipt of an appropriate
indemnification or subrogation agreement; but the primary and ultimate
responsibility for payment shall remain with the other party or carrier.
Obligations to pay benefits on behalf of any Beneficiary shall be conditioned:
1. upon such Beneficiary taking all steps necessary or desirable to
recover the costs thereof from any third party who may be obligated therefore,
and;
2. upon such Beneficiary executing such documents as are reasonably
required by the Plan Administrator, including, but not limited to, an
assignment of rights to receive such third party payments, in order to protect
and perfect the Plan’s right to reimbursement from any such third party.
(f) Non-Duplication
The health benefits provided under this Plan are subject to a nonduplication provision as follows:
1. Benefits will be reduced by benefits provided under any other group
plan, including a plan of another Employer signatory to the Wage Agreement, if
the other plan:
(i) does not include a coordination of benefits or non-duplication
provision, or

(ii) includes a coordination of benefits or non-duplication
provision and is the primary plan as compared to this Plan;
2. In determining whether this Plan or another group plan is primary,
the following criteria will be applied:
(i) The Plan covering the patient other than as a dependent will be
the primary plan.
(ii) Where both plans cover the patient as a dependent child, the
plan covering the patient as a dependent child of a male will be the primary
plan.
(iii) Where the determination cannot be made in accordance with (i)
or (ii) above, the plan which has covered the patient the longer period of
time will be the primary plan.
(iv) In the event a Pensioner or surviving spouse is covered under
another group plan by reason of his or her employment, the other group plan
shall be the primary plan for such Pensioner or surviving spouse and their
eligible dependents.
3. As used herein, “group plan” means (i) any plan covering the
Page 20
individuals as members of a group and providing hospital or medical care
benefits or services through group insurance or a group prepayment
arrangement, or (ii) any plan covering individuals as employees of an employer
and providing such benefits or services, whether on an insured, prepayment or
uninsured basis.
4. If it is determined that benefits under this Plan should have been
reduced because of benefits provided under another group plan, the Plan
Administrator shall have the right to recover any payment already made which
is in excess of the Plan’s liability. Similarly, whenever benefits which are
payable under the Plan have been provided under another group plan, the Plan
Administrator may make reimbursements directly to the insurance company or
other organization providing benefits under the other plan.
5. For the purpose of this provision the Plan Administrator may,
without consent or notice to any Beneficiary, release to or obtain from any
insurance company or other organization or person any information which may be
necessary regarding coverage, expense and benefits.
6. Any Beneficiary claiming benefits under this Plan must furnish the
Plan Administrator such information as may be necessary for the purpose of
administering this provision.
(g) Explanation of Benefits (EOB), Cost Containment and Hold Harmless
1. Each Beneficiary shall receive an explanation of billing and payment
rendered on behalf of such Beneficiary. Should full payment for a service be
denied because of a charge that has been determined by the Plan Administrator
to be in excess of the reasonable and customary charge, a copy of such EOB
shall be forwarded to the UMWA (International Headquarters, Attention:
Benefits Department).
2. (i) Regarding health care cost containment, designed to control health
care costs and to improve the quality of care without any reduction of plan
coverage or benefits, the Trustees of the UMWA Health and Retirement Funds are
authorized to establish programs of optional in-patient hospital pre-admission
and length of stay review, optional second surgical opinions, and case
management and quality care programs, and are to establish industry-wide
reasonable and customary schedules for reimbursement of medical services at
the 85th percentile (except when actual charges are less), and other cost
containment programs that result in no loss or reduction of benefits to
participants. The Trustees are authorized to take steps to contain
prescription drug costs, including but not limited to, paying only the current
average wholesale price, encouraging the use of generic drugs instead of brand
name drugs where medically appropriate, and encouraging the use of mail order
drug programs when advantageous.
(ii) The Trustees shall make available to the Plan Administrator any
special cost containment arrangements that they make with outside vendors
and/or providers. Further, the Plan Administrator may “piggyback” the cost
containment programs adopted by the Trustees.
(iii) Disputes shall continue to be resolved in accordance with Article
XX (e)(6) of the Wage Agreement.
(iv) It is expressly understood that nothing contained in this Section
shall diminish or alter any rights currently held by the Employer in the
Administration of this Plan.
(v) Consistent with Article XX (12) of the 1984 and 1988 Wage
Agreements, this section in no way authorizes or implies a reduction of
benefits or additional costs for covered services provided or relieves the
Page 21
Employer of any obligation set forth in Article XX of the Wage Agreement.
(vi) The Employer shall adopt the industry-wide reasonable and
customary schedules for reimbursement of medical services at the 85th
percentile (except when actual charges are less) as established pursuant to
subsection (i) above.
3. The Employer and the UMWA agree that the excessive charges and
escalating health costs are a joint problem requiring a mutual effort for
solution. In any case in which a provider attempts to collect excessive
charges or charges for services not medically necessary, as defined in the
Plan, from a Beneficiary, the Plan Administrator or his agent shall, with the
written consent of the Beneficiary, attempt to resolve the matter, either by
negotiating a resolution or defending any legal action commenced by the
provider. Whether the Plan Administrator or his agent negotiates a resolution
of a matter or defends a legal action on a Beneficiary’s behalf, the
Beneficiary shall not be responsible for any legal fees, settlements,
judgements or other expenses in connection with the case, but may be liable
for any services of the provider which are not provided for under the Plan.
The Plan Administrator or his agent shall have sole control over the conduct
of the defense, including the determination of whether the claim should be
settled or an adverse determination should be appealed.
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the
Plan, benefits are also not provided for the following:
1. Cases covered by worker’s compensation laws or employer’s liability
acts or services for which an employer is required by law to furnish in whole
or in part.
2. Services rendered
(i) prior to the effective date of a Beneficiary’s eligibility under the
Plan;
(ii) subsequent to the period after which a Beneficiary is no longer
eligible for benefits under the Plan; or
(iii) in a non-accredited hospital, other than for emergency services as
set forth in A(2)(a) and (3)(i).
3. Services furnished by any governmental agency, including benefits
provided under Medicaid, Federal Medicare and Federal and State Black Lung
Legislation for which a beneficiary is eligible or upon proper application
would be eligible.
4. Services furnished by tax-supported or voluntary agencies.
5. Immunizations provided by local health agencies.
6. Evaluation procedures such as pulmonary function tests, in
connection with applications for black lung benefits, or required by Federal
or State Black Lung Legislation.
7. Private duty nursing. If necessary to preserve life and certified
as medically necessary by the attending physician and an Intensive Care Unit
is unavailable, benefits are provided for private duty nursing services for up
to 72 hours per inpatient hospital admission. In no event will payment be
made for private duty nursing during a period of confinement in the Intensive
Care Unit of a hospital.
8. Custodial care, convalescent or rest cures.
Page 22
9. Personal services such as barber services, guest meals and cots,
telephone or rental of radio or television and personal comfort items not
necessary to the treatment of an illness or injury.
10. Charges for private room confinement, except as specifically
described in the Plan.
11. Services for which a Beneficiary is not required to make payment.
12. Excessive charges.
13. Charges related to sex transformation.
14. Charges for reversal of sterilization procedures.
15. Charges in connection with a general physical examination, other
than as specified in this Plan.
16. Inpatient confinements solely for diagnostic evaluations which can
be provided on an outpatient basis.
17. Charges for medical services for inpatient or outpatient treatment
for mental retardation and other mental deficiencies.
18. Finance charges in connection with a medical bill.
19. Dental services.
20. Birth control devices and medications.
21. Abortion, except as specifically described in the Plan.
22. Eyeglasses or lenses, except when medically required because of
surgically caused refractive errors or as otherwise provided in section A(9).
23. Exercise equipment.
24. Charges for treatment with new technological medical devices and
therapy which are experimental in nature.
25. Charges for treatment of obesity, except pathological, morbid forms
of severe obesity (200% or more of desirable weight) when prior approval is
obtained from the Plan Administrator.
26. Charges for an autopsy or post-mortem surgery.
27. Any types of services, supplies or treatments not specifically
provided by the Plan.
B. Life and Accidental Death and Dismemberment Insurance
(1) Active Employees
Life and accidental death and dismemberment insurance will be provided
for Employees, as described in Article II, Sections A and C(3), in accordance
with the following schedule:
(a) Upon the death of an Employee due to other than violent, external and
accidental means, life insurance in the amount of $35,000 will be paid to the
Employee’s named beneficiary.
(b) Subject to (d) below, upon the death of an Employee due solely to
violent, external and accidental means as the result of an injury occurring
Page 23
while insured and on or after February 1, 1988, Life insurance in the amount
of $70,000 will be paid to the Employee’s named beneficiary.
(c) If an Employee shall lose two or more members due to violent, external
and accidental means as the result of an injury occurring while insured and on
or after February 1, 1988, such Employee shall receive a $35,000 dismemberment
benefit. If an Employee shall lose one member due solely to violent, external
and accidental means as the result of an injury occurring while insured and on
or after February 1, 1988, such Employee shall receive a $17,500 dismemberment
benefit. A member for the purpose of the above is (i) a hand at or above the
wrist, (ii) a foot at or above the ankle or (iii) total loss of vision of one
eye.
(d) Accidental death or dismemberment benefits are not payable if caused
in whole or in part by disease, bodily or mental infirmity, ptomaine or
bacterial infection, hernia, suicide, intentional self-inflicted injury,
insurrection, or acts of war or is caused by or results from committing a
felony.
(2) Pensioners
Upon the death of a Pensioner, as described in Article II, section B, life
insurance shall be paid in a lump sum to the Pensioner’s named beneficiary in
the following amounts:
(a) If such Pensioner had Dependents at the time of death, for the period
beginning February 1, 1988 and ending January 31, 1990, $3,000, and for the
period beginning February 1, 1990 and ending at the expiration of the 1988
Wage Agreement, $3,500; or
(b) If such Pensioner did not have Dependents at the time of death, $2,500
during the period beginning February 1, 1988 and ending January 31, 1990,
and for the period beginning February 1, 1990 and ending at the expiration
of the 1988 Wage Agreement, $3,000.
C. Death Benefits
(1) Deaths Prior to December 6, 1977
Death benefit payments shall be continued in those cases which were in pay
status as of December 5, 1977, under the 1974 Benefit Plan, for deceased
Employees and Pensioners, whose last classified employment was with the
Employer, in the same manner and the same amounts, as previously provided for
in the 1974 Benefit Plan.
(2) Deaths after December 5, 1977 and Prior to March 27, 1978
Death benefit payments shall be made for deaths occurring between and
including December 6, 1977, and immediately prior to March 27, 1978, for
Employees and Pensioners whose last classified employment was with the
Employer, and who were participants in the 1974 Benefit Plan as of December 5,
1977, in the same manner and in the same amounts, as previously provided for
in the 1974 Benefit Plan.
D. General Provisions
(1) Continuation of Coverage
(a) Layoff
If an Employee ceases work because of layoff, continuation of health, life
and accidental death and dismemberment insurance coverage is as follows:
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Number of Hours Worked for
the Employer in the 24
Consecutive Calendar Month
Period Immediately Prior to Period of Coverage
the Employee’s Date Continuation from the
Last Worked Date Last Worked
2,000 or more hours Balance of month plus
12 months
500 or more but less than Balance of month plus
2,000 hours 6 months
Less than 500 hours 30 days
(b) Disability
Except as otherwise provided in Article II, Section C, if an Employee
ceases work because of disability, the Employee will be eligible to continue
health, life and accidental death and dismemberment insurance coverage while
disabled for the greater of (i) the period of eligibility for Sickness and
Accident benefits, or (ii) the period set forth in the schedule in (a) above.
(c) Leave of Absence
1. During any period for which an employee is granted an approved leave
of absence for the purpose of accepting temporary employment with the United
Mine Workers of America (UMWA) such Employee shall be eligible to continue
health, life and accidental death and dismemberment insurance coverage for a
period not to exceed 120 calendar days within any 12-month period.
2. During any period for which an Employee is granted an approved leave
of absence for any other reason, such Employee’s eligibility for health, life
and accidental death and dismemberment insurance shall be terminated as of the
day last worked and shall not be reinstated until the Employee returns to
active work except as provided in paragraph 3. below.
3. If an Employee who is on approved leave of absence is placed on layoff status, or would have been placed on lay-off status had the Employee been
actively at work, health, life and accidental death and dismemberment coverage
shall be reinstated as of the effective date of the lay-off. Such coverage
shall continue for a period determined pursuant to the provisions of paragraph
(a) above using the commencement date of the leave of absence in place of the
date last worked for the purpose of determining the number of hours worked.
In no event shall coverage under this paragraph continue beyond the balance of
the month plus 12 months from the effective date of the lay-off. An Employee
who returns to work after having been on leave of absence shall not have the
period for which such Employee was on leave of absence included in the 24-
calendar-month period as used in paragraph (a) for determining eligibility for
continuation of coverage.
(d) Maximum Continuation of Coverage
In no event shall any combination of the provisions of (a), (b), (c),
(e) or (g) above result in continuation of coverage beyond the balance of the
month plus 12 months from the date last worked.
(e) Quit or Discharge
If an Employee quits (for any reason) or is discharged, health, life and
accidental death and dismemberment insurance coverage will terminate as of the
date last worked. An Employee who ceases to work and will be found to be
eligible for health benefits as a retiree on the first of the month subsequent
Page 25
to the date on which he last worked shall be eligible for benefits without
interruption as provided by the Plan from the date he last worked.
(f) Other Employment
Notwithstanding the forgoing, in the event an Employee accepts
employment during a period of continued coverage under paragraph (a) health,
life and accidental death and dismemberment insurance coverage will terminate
as of the date of such employment. If, however, such employment subsequently
terminates prior to the Employee’s coverage under paragraph (a) otherwise
terminates, such Employee’s life, health and accidental death and
dismemberment insurance coverage will be reinstated following the later of (i)
termination of such employment or (ii) any continued health coverage resulting
therefrom, and will continue to the date such coverage under paragraph (a)
would have otherwise terminated. It is the obligation of the Employee to
notify the Employer within 10 days by certified mail of both acceptance and
termination of such employment; failure to provide such notice will result in
permanent termination of coverage. Nothing in this paragraph shall extend
coverage beyond the date determined pursuant to paragraph (a).
(g) Article III (j) – Wage Agreement
An Employee terminated under the provisions of Article III (j) of the
Wage Agreement shall not be treated as a quit or discharge for purposes of
continuation of coverage. Such an Employee shall be entitled to continuation
of coverage on the same basis as provided in paragraph (b) above; provided,
however, hours worked and the period of continuation of coverage shall be
determined as of the date last worked.
(h) COBRA Continuation Coverage
Notwithstanding the forgoing, this Plan shall comply with the health
care continuation coverage provisions of Sections 601-608 of ERISA and Section
162(i) and (k) of the Internal Revenue Code, effective the first day of the
plan year beginning on or after January 31, 1988. The Plan Administrator
shall include appropriate language explaining the Employee’s, Beneficiary’s
and Pensioner’s rights under COBRA in the next Summary Plan description
booklet distributed.
(2) Advanced Insurance Premiums
In the event of an economic strike at the expiration of the 1988 Bituminous
Coal Wage Agreement, the Employer shall advance the premiums for its health,
vision care, and life and accidental death and dismemberment insurance
coverage for the first 30 days of such strike, Such advanced premiums shall
be repaid to the Employer by such Employees through a check-off deduction upon
their return to work. Should a strike continue beyond 30 days, the Union or
such Employees may elect to pay premiums themselves.
(3) Conversion Privilege
(a) Life Insurance
Upon application to the insurance carrier within 31 days after life
insurance coverage terminates, the Employee may, subject to applicable state
insurance laws, arrange to continue life insurance protection under an
individual policy, for an amount not greater than $35,000 without evidence of
insurability. Such individual policy may be on any one of the forms of policy
then customarily issued by the insurance company, other than a policy of term
insurance or one which provides disability benefits in the event of accidental
death, and will be issued at the rate applicable to the Employee’s age and
class of risk at the time.
(b) Health Benefits
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When health coverage terminates, a Beneficiary may, upon application,
convert, without medical examination, to a policy issued by the insurance
carrier provided such application is made to the insurance carrier within 31
days after the date coverage terminates. The type of policy, coverage and
premiums therefor are subject to the terms and conditions set by the insurance
carrier.
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File:EBP-88.PAG