The following terms have special meanings when used in this Summary Plan Description.
Collective Bargaining Agreement
means the labor agreement in force and effect between a sprinkler fitter
Local Union and the National Fire Sprinkler Association or an employer
together with any modifications, supplements or amendments.
Co-payment
means the percentage of covered Usual and Customary charges
which you are responsible to pay after the Deductible has been met
each calendar year. For example, if the Plan will pay 80% of the
Usual and Customary charges for Covered Expenses under the
Comprehensive Medical Coverage, you are responsible for 20% of
the Usual and Customary charges for such Covered Expenses. You
are also responsible for payment of any balance that exceeds the
Usual and Customary charge.
Convalescent Facility
means an institution that is licensed to keep patients regularly
overnight. The facility must provide supervision by a legally qualified
physician or a registered professional nurse, 24-hour skilled
nursing care by licensed nursing personnel under the direction of a
full-time registered professional nurse, and training in self-care for
the essential activities of daily living. The institution must also
maintain a complete medical record on each patient and have a utilization
review plan for all of its patients. An institution is not a
Convalescent Facility if it is used principally for the care of mental
retardation or any other form of mental disorder. Institutions such as
clinics, or places for rest, educational care, care of the aged, Custodial
Care, care of drug addicts or alcoholics do not qualify as
Convalescent Facilities. To qualify for coverage, confinement in a
Convalescent Facility must occur within 14 days after a minimum
threeday hospital Confinement for the same illness.
Covered Expense
means a charge to the extent it is within the Usual and Customary
amount that is allowable under the Plan for a service or supply that
is Medically Necessary for diagnosis, treatment, mitigation or cure of
an Illness or Injury to a structure or function of the mind or body.
No amount in excess of the actual charge for a service or supply will
be considered a covered expense.
Custodial Care
means services and supplies, including room and board and other
institutional services, which are provided whether or not you are disabled,
primarily to assist you in the activities of daily living. Such
services and supplies are Custodial Care without regard to the practitioner
or provider by whom or by which they are prescribed, recommended
or performed. Room and board and skilled nursing services,
when provided in a Hospital or other institution for which coverage
is specifically provided, are not Custodial Care when such services
must be combined with other necessary therapeutic services and
supplies in accordance with generally accepted medical standards to
establish a program of medical treatment which can reasonably be
expected to contribute substantially to the improvement of the individual’s
medical condition and is not merely the maintenance or stabilization
of such individual’s medical condition.
Deductible
means the total out-of-pocket Covered Expenses that you must pay
each year before a benefit is payable from the Plan. Any expenses
applied against the Deductible for dental expenses in the last three
months of a calendar year will also be applied against the Deductible
for the next calendar year.
Disability and Disabled
mean the inability to perform the duties of your occupation because
of a medically determinable physical or mental impairment, as certified
by your Physician, and the inability to receive substantial compensation
for any employment. For a dependent, Disability means
the inability to perform, due to a medically determinable physical or
mental impairment, the functions and activities of a person of like
age and sex who is in good health.
Hospital
means an institution that is accredited as a Hospital by the Joint
Commission on Accreditation of Health Care Organizations or any
similar hospital in a foreign country. A licensed facility that is set up,
equipped, and operated under the direction of a Physician solely as a
birthing center for prenatal care, delivery, and immediate postpartum
care is a “Hospital.” The term “Hospital” does not include rest
or nursing homes, convalescent homes or institutions, sanatoriums
or similar institutions that primarily operate training schools for
patients or primarily provide Custodial or institutional care. To be
considered a Hospital for purposes of this Plan, a Hospital must regularly
keep patients overnight; have full diagnostic, surgical and therapeutic
facilities under the supervision of a staff of legally qualified
physicians; and regularly provide 24-hour nursing service by registered
graduate nurses.
Medically Necessary
means services or supplies that are: furnished or prescribed by a
Physician or other licensed provider to identify or treat a diagnosed
or reasonably suspected illness or injury; consistent with the diagnosis
and treatment of the patient’s condition; in accordance with standards
of good medical practice; required for reasons other than the
convenience of the patient, Physician, or other licensed provider; and
the most appropriate level of service or supply that can be provided
safely for the patient. When the term “Medically Necessary” is used
to describe inpatient care in a Hospital, it means that your medical
symptoms and condition are such that the service or supply cannot
be provided safely on an outpatient basis. The fact that services or
supplies are furnished or prescribed by a Physician or other licensed
provider does not necessarily mean that the services and supplies are
“Medically Necessary.”
Out-of-Pocket Expenses
means an individual’s Deductible plus an amount in a calendar year
as shown on the Schedule of Benefits. Once an individual has paid
his or her Out-of-Pocket Expenses for the year, covered benefits other
than mental and nervous expenses will be paid at 100% for that person
in that calendar year. Out-of-Pocket expenses apply to each person
covered under the Plan and there is no family maximum limit.
Outpatient Facility
means a clinic or other establishment that provides surgery, diagnosis,
and treatment on an outpatient basis. The facility must have an
attending medical staff consisting of at least one Physician and anesthesiologist
(or a nurse anesthetist under the supervision of a
Physician). Convalescent homes, nursing homes, homes for the needy,
homes for nursing and domiciliary care, infirmaries or orphanages,
sanatoriums, maternity homes for pre-natal or post-natal care, mental
health facilities, or other homes or institutions primarily providing
Custodial Care are not Outpatient Facilities. Outpatient Facilities
include alternative care facilities such as Emergicenters or 24-hour
clinics. The following are not Outpatient Facilities: Convalescent
homes, nursing homes, homes for the needy, homes for nursing and
domiciliary care, infirmaries or orphanages, sanatoriums, maternity
homes for pre-natal or post-natal care, mental health facilities, or
other homes or institutions primarily providing Custodial Care.
Other facilities, not otherwise covered by the Plan, may be approved
in advance by the Fund if they fall within standard medical practice
and treatment is recommended by a Physician.
Physician
means a person who is licensed to practice medicine or to perform
surgery or, if specifically approved by the Trustees, a licensed practitioner
performing services that would be payable under the Plan if
performed by a Physician. The term “Physician” includes a doctor of
medicine, osteopathy, dental surgery, or podiatry. Physician charges
also include the services of a qualified professional chiropractor,
physiotherapist, nursemidwife, and nurse anesthetist.
Total Disability and Totally Disabled
means your complete inability to engage in substantial, gainful activity
because of a medically determinable physical or mental impairment
that is expected to last permanently or indefinitely. Proof of
your eligibility for a Social Security Disability Award is proof of Total
Disability (see Definitions, page 95). For a dependent, Total
Disability means the complete inability to perform the functions and
activities of a person of like sex and age who is in good health, due to
a medically determinable physical or mental impairment that is
expected to last indefinitely or permanently.
Usual and Customary (UC)
means a level of charges that does not exceed the prevailing level
generally charged by providers in the “locality” for like or comparable
services or supplies. The term “locality” means a geographical
area that includes a cross-section of persons or entities regularly furnishing
the type of treatment, services, or supplies for which the
charge is made. In determining whether charges are Usual and
Customary, consideration is given to the condition being treated and
to any medical complications or unusual circumstances that may
require additional time, skill, or experience. Benefits are payable
according to the plan’s UC scale as determined and changed from
time to time by the Board of Trustees. Where appropriate, the UC
charge is based upon the scale promulgated by the Health Insurance
Association of America (HIAA); however, other industry sources are
used if the HIAA scale is not available. In any event, Covered
Expenses under this plan must not exceed the actual amount charged
for a service or supply, up to the Usual and Customary level, except
where medical service is rendered on an emergency basis.
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