Employee Coverage

Eligible Employees

To be eligible for employee coverage under this plan, an employee must be an active full-time employee. And he must belong to a class of employees covered by this plan.

"Full-time" means an employee regularly works at least the number of hours in the normal work week set by his employer (but not less than 30 hours per week), at his employer's place of business.

Other Conditions

• If the employee must pay part of the cost of employee coverage we won't insure him until he enrolls in the plan and agrees to make the required payments. If he does this: (a) more than 31 days after he first becomes eligible; or (b) after he previously had coverage which ended because he failed to make a required payment we also ask for proof that he's insurable. And he won't be covered by this plan until we approve that proof in writing.
  

• Part of the employee's insurance under this plan may be subject to proof that he's insurable. He won't be covered by that part of this plan until he gives the proof to us and we approve it in writing. Other parts of this booklet explain if and when we require such proof.
  

• If an employee's active full-time service ends before he meets any proof of insurability requirements that apply to him he'll still have to meet those requirements if he's later reemployed.
  

• If an employee initially waived major medical coverage under this plan because he was covered under another group plan and he now elects to enroll in the major medical coverage under this plan the proof of insurability requirements will not apply to him provided his coverage under the other plan ends due to one of the following events: (a) termination of his spouse's employment; (b) loss of eligibility under his spouse's plan; (c) divorce; (d) death of his spouse; or (e) termination of the other plan.
  

When Employee Coverage Starts

Employee benefits that don't require proof that the employee is insurable are scheduled to start on the effective date shown on the sticker attached to the inside front cover of this booklet.

Employee benefits that require such proof won't start until the employee sends us the proof and we approve it in writing. Once we've approved it, the benefits are scheduled to start on the effective date shown in the endorsement section of the employee's application. A copy of the approved application is furnished to the employee.

But the employee must be actively at work on a full-time basis on the scheduled effective date or dates. And he must have met all of the applicable conditions explained above. If the employee is not actively at work on any date part of his insurance is scheduled to start, we'll postpone that part of his coverage until the date he returns to active full-time work.

Sometimes, the effective date shown on the sticker or in the endorsement is not a regularly scheduled work day. But coverage will still start on that date if the employee was actively at work on a full-time basis on his last regularly scheduled work day.

When Employee Coverage Ends

Employee coverage under this plan ends on the date an employee's active full-time service ends for any reason. Such reasons include disability, death, retirement, layoff, leave of absence and the end of employment.

It also ends on the date the employee stops being a member of a class of employees eligible for insurance under this plan, or when this plan ends for all employees. And it ends when this plan is changed so that benefits for the class of employees to which an employee belongs end.

If the employee is required to pay part of the cost of this plan and he fails to do so, his coverage ends. It ends on the last day of the period for which the employee made the required payments, unless coverage ends earlier for other reasons.

Read this booklet carefully if employee coverage ends. An employee may have the right to continue certain group benefits for a limited time. And he may have the right to replace certain group benefits with converted policies.

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Dependent Coverage

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Eligible Dependents for Dependent Health Benefits

Your eligible dependents are: your legal spouse; your unmarried dependent children who are under age 20 ; and your unmarried dependent children, from age 20 until their 26th birthday, who are enrolled as full-time students at accredited schools.

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Eligible Dependents for Dependent Life Benefits

Your eligible dependents are: your legal spouse and your unmarried dependent children who are 14 or more days old, until their 23rd birthday, and your unmarried dependent children, from age 23 until their 25th birthday, who are enrolled as full-time students at accredited schools.

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Adopted Children and Step-Children

Your "unmarried dependent children" include your legally adopted children and, if they depend on you for most of their support and maintenance , your step-children. We treat a child as legally adopted from the time the child is placed in your home for the purpose of adoption. We treat such a child this way whether or not a final adoption order is ever issued.

The "Pre-Existing Conditions" provision of the major medical portion of this plan, if any, does not apply to an adopted child, if the child: (a) is adopted or placed for adoption prior to his or her 18th birthday; and (b) becomes covered by this plan within 30 days of such placement.

We exclude any dependent who is insured by this plan as an employee. And we exclude any dependent who is on active duty in any armed force.

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Handicapped Children

You may have an unmarried child with a mental or physical handicap, or developmental disability, who can't support himself. Subject to all of the terms of this section and the plan, such a child may stay eligible for dependent health benefits past this plan's age limit.

The child will stay eligible as long as he stays unmarried and unable to support himself, if: (a) his conditions started before he reached this plan's age limit; (b) he became insured by this plan before he reached the age limit, and stayed continuously insured until he reached such limit; and (c) he depends on you for most of his support and maintenance.

But, for the child to stay eligible, you must send us written proof that the child is handicapped and depends on you for most of his support and maintenance. You have 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, we can't ask for this proof more than once a year.

The child's coverage ends when yours does.

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Proof of Insurability

We require proof that a dependent is insurable, if you: (a) enroll a dependent and agree to make the required payments after the end of the enrollment period; (b) in the case of a newly acquired dependent, other than the first newborn child, have other eligible dependents who you have not elected to enroll; or (c) in the case of a newly acquired dependent, have other eligible dependents whose coverage previously ended because you failed to make the required contributions, or otherwise chose to end such coverage.

A dependent is not insured by any part of this plan that requires such proof until you give us this proof, and we approve it in writing.

If the dependent coverage ends for any reason, including failure to make the required payments, your dependents won't be covered by this plan again until you give us new proof that they're insurable and we approve that proof in writing.

However, if you initially waived major medical and dental coverage for your spouse or eligible dependent children under this plan because they were covered under another group plan, and you now elect to enroll them in the major medical and dental coverage under this plan, (i) the proof of insurability requirements will not apply to your spouse or eligible dependent children with regard to major medical coverage; and (ii) the penalty for late entrance provision will not apply to. Then with regard to dental coverage, provided their coverage under the other plan ends due to one of the following events: (a) termination of your spouse's employment; (b) loss of eligibility under your spouse's plan; (c) divorce; (d) death of your spouse; or (e) termination of the other plan.

But, you must enroll your spouse or eligible dependent children in the major medical and dental coverage under this plan within 30 days of the date that any of the events described above occur.

In addition, the proof of insurability requirements for major medical coverage and the Penalty for Late Entrance provisions for dental coverage will not apply to your spouse or eligible dependent children if: (a) you are under legal obligation to provide major medical and dental coverage due to a court-order; and (b) you enroll your spouse or eligible dependent children in the major medical and dental coverage under this plan within 30 days of the issuance of the court-order.

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When Dependent Coverage Starts

In order for your dependent coverage to begin you must already be insured for employee coverage, or enroll for employee and dependent coverage at the same time. Subject to the "Exception" stated below and to all of the terms of this plan, the date your dependent coverage starts depends on when you elect to enroll your initial dependents and agree to make any required payments.

If you do this on or before your eligibility date, the dependent's coverage is scheduled to start on the later of your eligibility date and the date you become insured for employee coverage.

If you do this within the enrollment period, the coverage is scheduled to start on the later of the date you sign the enrollment form; and the date you become insured for employee coverage.

If you do this after the enrollment period ends, your dependent coverage is subject to proof of insurability and won't start until we approve that proof in writing, except as explained in the "Proof of Insurability" provision.

Once you have dependent coverage for your initial dependents, you must notify us when you acquire any new dependents and agree to make any additional payments required for their coverage.

A newly acquired dependent will be covered for those dependent benefits not subject to proof of insurability from the later of the date you notify us and agree to make any additional payments, and the date the newly acquired dependent is first eligible.

If proof of insurability is required for dependent benefits as explained above, those benefits are scheduled to start, subject to the "Exception" stated below, on the effective date shown in the "Endorsement" section of your application, provided that you send us the proof we require and we approve that proof in writing. A copy of the approved application is furnished to you.

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Exception

If a dependent, other than a newborn child, is confined to a hospital or other health care facility; or is home-confined; or is unable to carry out the normal activities of someone of like age and sex on the date his dependent health benefits would otherwise start, we will postpone the effective date of such benefits until the day after his discharge from such facility; until home confinement ends; or until he resumes the normal activities of someone of like age and sex.

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Newborn Children

We cover an employee's newborn child for dependent health benefits, from the moment of his birth, if the employee is already insured for dependent coverage when the child is born. If the employee does not have dependent coverage when the child is born, we cover the newborn child, for dependent health benefits, for the first 31 days from the moment of his birth. To continue the child's dependent health benefits past the first 31 days, the employee must notify us in writing within 31 days of the child's birth.

We also cover a dependent child's newborn child for dependent health benefits if that child is a dependent of the employee for federal income tax purposes. Coverage is from the moment of birth until the earlier of: (a) the date the parent of the newborn child is no longer insured under this plan; (b) the date the employee is no longer insured under this plan; or (c) the date the newborn child is no longer a dependent of the employee for federal income tax purposes.

The benefits we pay are described under the Major Medical portion of this plan.

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When Dependent Coverage Ends

Dependent coverage ends for all of your dependents when your employee coverage ends. But if you die while insured, we'll automatically continue dependent health benefits for those of your dependents who are insured when you die. We'll do this for six months at no cost, provided: (a) the group plan remains in force; (b) the dependents remain eligible dependents; and (c) in the case of a spouse, the spouse does not remarry.

If a surviving dependent elects to continue his dependent health benefits under this plan's "Federal Continuation Rights" provision, or under any other continuation provision of this plan, if any, this free continuation period will be provided as the first six months of such continuation. Premiums required to be paid by, or on behalf of a surviving dependent will be waived for the first six months of continuation, subject to restrictions (a), (b) and (c) above. After the first six months of continuation, the remainder of the continuation period, if any, will be subject to the premium requirements, and all of the terms of the "Federal Continuation Rights" or other continuation provisions.

Dependent coverage also ends for all of your dependents when you stop being a member of a class of employees eligible for such coverage. And it ends when this plan ends, or when dependent coverage is dropped from this plan for all employees or for an employee's class.

If you are required to pay part of the cost of dependent coverage, and you fail to do so, your dependent coverage ends. It ends on the last day of the period for which you made the required payments, unless coverage ends earlier for other reasons.

An individual dependent's coverage ends when he stops being an eligible dependent This happens to a child at 12:01 a.m. on the date the child attains this plan's age limit, when he marries, or when a step-child is no longer dependent on the employee for support and maintenance. It happens to a spouse when a marriage ends in legal divorce or annulment.

Read this plan carefully if dependent coverage ends for any reason. Dependents may have the right to continue certain group benefits for a limited time. And they may have the right to replace certain group benefits with converted policies.

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