HomeMy WebLinkAboutContract 1824AMENDMENT NO. 3
TO BE ATTACHED TO AND MADE PART OF GROUP POLICY NO.' 000010033889
ISSUED TO: City of Columbia Heights
It is agreed that the above policy be replaced with the attached Policy, which is revised and dated
October 1, 2004.
The effective date of this amendment is October 1, 2004; but only with respect to disabilities incurred
on or after that date. Nothing contained in this amendment shall change any of the terms and conditions
of this Policy; except as stated above.
Accepted by the Group Policyholder this
Jefferson Pilot Financial Insurance Company
day of
Title
Officer of the Company
GL1100 AMEND.
JEFFERSON PILOT
FINANCIAL
Jefferson Pilot Financial Insurance Company
8801 Indian Hills Drive, Omaha NE 68114-4066
(800) 423-2765 A Stock Company
In Consideration of the application for this Policy made by
City of Columbia Heights
(herein called the Policyholder)
and the payment of all premiums when due, Jefferson Pilot Financial Insurance Company
agrees to make the payments provided in this Policy to the person or persons entitled to them.
Policy No. 000010033889 Policy Effective Date: February 1, 2001
Monthly Premium: .35 % of Total Covered Payroll per Month
Policy Anniversaries will be annually beginning on: February 1, 2005
The first premium is due on this Policy's Effective Date, and subsequent premiums are due on
March 1, 2001, and on the same day of each month thereafter.
This Policy is delivered in the state of Minnesota and subject to the laws of that jurisdiction.
Jefferson Pilot Financial Insurance Company has executed this Policy at its Home Office in
Omaha, Nebraska this 27th day of October, 2004.
Chief Executive Officer Secretary
GROUP LONG TERM DISABILITY INSURANCE POLICY
GL3001-LTD-1
Policy Face Page
10/01/04
TABLE OF CONTENTS
Schedule of Benefits .............................................................................. 3
Definitions .......................................................................................... 4
General Provisions ................................................................................ 9
Claims Procedures ................................................................................ 11
Eligibility ........................................................................................... 14
Effective Dates .................................................................................... 14
Individual Termination ........................................................................... 16
Policy Termination ................................................................................ 16
Premiums and Premium Rates .................................................................. 18
Total Disability Monthly Benefit ............................................................... 19
Partial Disability Monthly Benefit ............................................................. 20
Other Income Benefits ............................................................................ 22
Recurrent Disability .............................................................................. 23
Exclusions .......................................................................................... 24
Specified Injuries or Sicknesses Limitation ................................................... 25
Voluntary Vocational Rehabilitation Benefit Provision .................................... 26
Reasonable Accommodation Benefit ........................................................... 27
Prior Insurance Credit Upon Transfer of Insurance Carriers ............................. 28
Family Income Benefit ........................................................................... 29
Cost-of-Living Adjustment ...................................................................... 30
Notice ............................................................................................... 31
GL3001-LTD-2
2 1 o/o 1/04
City of Columbia Heights
000010033889
SCHEDULE OF BENEFITS
ELIGIBLE CLASS means:
Class 1
All Full-Time Police Officers represented by LELS, Sergeants
represented by the Teamsters, Clerical and Technical employees
represented by AFSCME, and Public Works employees represented by
IUOE, excluding employees not covered by LELS, the Teamsters,
AFSCME and IUOE.
LONG-TERM DISABILITY BENEFITS
MINIMUM HOURS PER WEEK: 40
BENEFIT PERCENTAGE: 60 %
MAXIMUM MONTHLY BENEFIT: $6,000
MINIMUM MONTHLY BENEFIT: $100
Long-Term Disability Benefits for PRE-EXISTING CONDITIONS will be subject to the Pre-Existing
Condition Exclusion on the Exclusion page.
ELIMINATION PERIOD: 180 days of Disability due to the same or a related Sickness or Injury, which
must be accumulated within a 360 day period.
MAXIMUM BENEFIT PERIOD (For Sickness or Injury): The Insured Employee's Social Security Normal
Retirement Age, or the Maximum Benefit Period shown below (whichever is later).
A~ge at Disability
Maximum Benefit Period
Less than Age 60 To Age 65
60 60 months
61 48 months
62 42 months
63 36 months
64 30 months
65 24 months
66 21 months
67 18 months
68 15 months
69 and Over 12 months
OWN OCCUPATION PERIOD means a period beginning at the end of the Elimination Period and ending 24
months later for Insured Employees.
WAITING PERIOD: None (For date insurance begins, refer to "Effective Dates" section)
CONTRIBUTIONS:
Insured employees are not required to contribute to the coSt of the Long-Term
Disability coverage.
COST-OF-LIVING PERCENTAGE: 3 %; maximum of 10 Cost-of-Living Adjustments
This Schedule of Benefits is amended effective October 1, 2004, supercedes any prior Schedule of Benefits
issued and applies to disabilities commencing on or after such date.
GL3001-LTD-SB
3 10/01/04
City of Columbia Heights
000010033889
SCHEDULE OF BENEFITS
ELIGIBLE CLASS means: Class 2 All Full-Time Public Managers
LONG-TERM DISABILITY BENEFITS
MINIMUM HOURS PER WEEK: 40
BENEFIT PERCENTAGE: 60%
MAXIMUM MONTHLY BENEFIT: $6,000
MINIMUM MONTHLY BENEFIT: $100
Long-Term Disability Benefits for PRE-EXISTING CONDITIONS will be subject to the Pre-Existing
Condition Exclusion on the Exclusion page.
ELIMINATION PERIOD: 90 days of Disability due to the same or a related Sickness or Injury, which must
be accumulated within a 180 day period.
MAXIMUM BENEFIT PERIOD (For Sickness or Injury): The Insured Employee's Social Security Normal
Retirement Age, or the Maximum Benefit Period shown below (whichever is later).
Age at Disability Maximum Benefit Period
Less than Age 60 To Age 65
60 60 months
61 48 months
62 42 months
63 36 months
64 30 months
65 24 months
66 21 months
67 18 months
68 15 months
69 and Over 12 months
OWN OCCUPATION PERIOD means a period beginning at the end of the Elimination Period and ending 24
months later for Insured Employees.
WAITING PERIOD: None (For date insurance begins, refer to "Effective Dates" section)
CONTRIBUTIONS: Insured employees are not required to contribute to the cost of the Long-Term
Disability coverage.
COST-OF-LIVING PERCENTAGE: 3 %; maximum of 10 Cost-of-Living Adjustments
GL3001-LTD-SB
3-2 10/o 1/o4
DEFINITIONS
As used throughout this Policy, the following terms shall have the meanings indicated below. Other parts of
this Policy contain definitions specific to those provisions.
ACTIVE WORK or ACTIVELY-AT-WORK means an Employee's full-time performance of all main
duties of such Employee's occupation at:
1. the Employer's usual place of business; or
2. any other business location to which the Employer requires the Employee to travel.
Unless Disabled on the prior wotkday or on the day of absence, an Employee will be considered Actively at
Work on the following days:
1. a Saturday, Sunday or holiday which is not a scheduled workday;
2. a paid vacation day or other scheduled or unscheduled non-workday; or
3. an excused or emergency leave of absence (except a medical leave) of 30 days or less.
ANNUAL SALARY means the Insured Employee's Basic Monthly Earnings or Predisability Income
multiplied by 12.
BASIC MONTHLY EARNINGS or PREDISABILITY INCOME means the Insured Employee's average
monthly base salary or hourly pay from the Employer before taxes on the determination date. The
determination date is the last day worked just prior to the date the Disability begins.
It also includes:
1. commissions averaged over the 12 months just prior to the determination date or over the
actual period of employment with the Employer just prior to that date, if shorter.
It does not include bonuses, overtime pay, or any other extra compensation. It does not include income fi'om
a source 'other than the Employer. It will not exceed the amount shown in the Employer's financial records,
the amount for which premium has been paid, or the maximum covered earnings permitted by this Policy;
whichever is less.
COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraska corporation, whose Home
Office address is 8801 Indian Hills Drive, Omaha, Nebraska 68114-4066.
GL3001-LTD-3 98
4 10/01/04
DEFINITIONS
(continued)
DAY or DATE means the period of time which begins at 12:01 a.m. and ends at 12:00 midnight, standard
time, at the Policyholder's place of business. When used with regard to effective dates, it means 12:01 a.m.
When used with regard to termination dates, it means 12:00 midnight.
DISABLED or DISABILITY means Totally Disabled and/or Partially Disabled.
DISABILITY BENEFIT when used with the term Retirement Plan, means a benefit which:
1. is payable under a Retirement Plan due to disability as defined in that plan; and
2. does not reduce the benefits which would have been paid as Retirement Benefits at the
normal retirement age under the plan if the disability had not occurred.
If the payment of the benefit does cause such a reduction, the benefit will be deemed a Retirement Benefit as
defined in this Policy.
ELIGIBILITY WAITING PERIOD means the period of time that:
1. begins with an Employee's most recent date of employment with the Employer; and
2. ends on the day prior to the day such Employee is eligible for coverage under this Policy.
ELIMINATION PERIOD means the number of days of Disability during which no benefit is payable.
Elimination Period is shown in the Schedule of Benefits. It applies as follows.
1. The Elimination Period:
(a) begins on the first day of Disability; and
(b) is satisfied when the required number of days is accumulated within a period
which does not exceed two times the Elimination Period.
During a period of Disability, the Insured Employee may return to full-time work, at
his or her own or any other occupation, for an accumulated number of days not to
exceed the Elimination Period.
2. Only days of Disability due to the same or a related Sickd~ess or Injury will count towards the
Elimination Period. Days on which the Insured Employee returns to full-time work will not
count towards the Elimination Period.
The
EMPLOYEE means a person:
1. whose employment with the Employer is:
(a) on a regular full-time basis;
(b) the person's principal occupation; and
(c) for regular wage or salary;
2. who is regularly scheduled to work at such occupation at least the minimum number of hours
shown in the Schedule of Benefits; and
3. who is a member of an Eligible Class which is eligible for coverage under this Policy;
4. who is not a temporary or seasonal employee; and
5. who is a citizen of the United States or legally works in the United States.
EMPLOYER means the Policyholder and includes any division, subsidiary or affiliated company named in
the Application.
EVIDENCE OF INSURABILITY means a statement of proof of an Employee's medical history. The
Company uses this to determine his or her acceptance for insurance, or for an increased amount of insurance.
Such proof will be provided at the Employee's own expense.
GL3001-LTD-3A 98
Residual Partial
10/01/04
DEFINITIONS
(continued)
FAMILY OR MEDICAL LEAVE means a leave of absence which is approved in writing by the Employer;
and which is subject to:
1. the federal Family and Medical Leave Act of 1993, and any amendments to it; or
2. any similar state law requiring the Employer to grant family or medical leaves.
INSURED EMPLOYEE means an Employee for whom Policy coverage is in effect.
INJURY means bodily injury which is caused by and results directly from an accident, independently of all
other causes. For purposes of determining benefits under this Policy, a Disability will be considered due to
an Injury only if:
1. the Disability begins within 90 days after the Injury; or
2. the Injury occurred while the Employee was insured under this Policy.
The term "Injury" shall not include any:
1. condition to which a physical or mental sickness, the natural progression of a sickness, or the
treatment of a sickness is a substantial contributing factor (based upon the preponderance of
medical evidence);
2. condition caused solely by emotional stress or mental trauma;
3. repetitive trauma condition which results from repetitious, physically traumatic activities that
occur over time;
4. pregnancy; except for complications which result from a covered Injury;
5. condition caused by infection; except pyogenic bacterial infection of a covered Injury; or
6. condition caused by medical or surgical treatment; except when the treatment is needed
solely because of a covered Injury.
GL3001-LTD-4 98
6 10/01/04
DEFINITIONS
(continued)
MAIN DUTIES or MATERIAL AND SUBSTANTIAL DUTIES means those job duties which:
1. are normally required to perform the Insured Person's regular occupation; and
2. cannot reasonably be modified or omitted.
It includes those main duties as performed in the national workforce; not as performed for a certain firm or at
a certain work site.
MEDICALLY APPROPRIATE TREATMENT means diagnostic services, consultation, care or services
which are consistent with the symptoms or diagnosis causing the Insured Employee's Disability. Such
treatment must be rendered:
1. by a Physician whose license and any specialty are consistent with the disabling condition;
and
2. according to generally accepted, professionally recognized standards of medical practice.
MONTHLY BENEFIT means the mount payable monthly by the Company to the Insured Employee who is
Totally or Partially Disabled.
OWN OCCUPATION PERIOD means a period as shown in the Schedule of Benefits.
PARTIALLY DISABLED or PARTIAL DISABILITY shall be as defined in the Partial Disability Monthly
Benefit sections.
PARTIAL DISABILITY EMPLOYMENT means the Insured Employee is working at his or her own or
any other occupation; but because of a Partial Disability:
1. the Insured Employee's hours or production is reduced;
2. one or more main duties of the job are reassigned; or
3. the Insured Employee is working in a lower-paid occupation.
His or her current earnings must be at least 20 % of Predisability Income, and may not exceed the percentage
specified in the Partial Disability Benefit section.
PHYSICIAN means:
1. a legally qualified medical doctor who is licensed to practice medicine, to prescribe and
administer drugs, or to perform surgery; or
2. any other duly licensed medical practitioner who is deemed by state law to be the same as a
legally qualified medical doctor.
The medical doctor or other medical practitioner must be acting within the scope of his or her license; and
must be qualified to provide medically appropriate treatment for the Insured Employee's disabling condition.
Physician does not include the Insured Employee or a relative of the Insured Employee receiving treatment.
(Relatives include the Insured Employee's spouse, siblings, parents, children and grandparents; and his or her
spouse's relatives of like degree.)
POLICY means this Group Long Term Disability Insurance Policy issued by the Company to the
Policyholder.
POLICYHOLDER means the person, individual, firm, trust or other organization as shown on the Face
Page of this Policy.
PREDISABILITY INCOME - See Basic Monthly Earnings.
GL3001-LTD-5 98
7 10/01/04
DEFINITIONS
(continued)
REGULAR CARE OF A PHYSICIAN or REGULAR ATTENDANCE OF A PHYSICIAN means the
Insured Employee:
1. personally visits a Physician, as often as medically required according to standard medical
practice to effectively manage and treat his or her disabling condition; and
2. receives medically appropriate treatment, by a Physician whose license and any specialty are
consistent with the disabling condition.
REGULAR OCCUPATION or OWN OCCUPATION means the occupation, trade or profession:
1. in which the Insured Employee was employed with the Employer prior to Disability; and
2. which was his or her primary source of earned income prior to Disability.
It includes any work in the same occupation for pay or profit; whether such work is with the Employer, with
some other firm or on a self-employed basis. It includes the main duties of that occupation as performed in
the national workforce; not as performed for a certain firm or at a certain work site.
RETIREMENT BENEFIT when used with the term Retirement Plan, means a benefit which:
1. is payable under a Retirement Plan either in a lump sum or in the form of periodic payments;
2. does not represent contributions made by an Employee (payments which represent Employee
contributions are deemed to be received over the Employee's expected remaining life
regardless of when such payments are actually received); and
3. is payable upon:
(a) early or normal retirement; or
(b) disability, if the payment does reduce the benefit which would have been paid at
the normal retirement age under the plan, if disability had not occurred.
RETIREMENT PLAN means a defined benefit or defined contribution plan which provides Retirement
Benefits to Employees and which is not funded wholly by Employee contributions. The term shall not
include any 401(k), profit-sharing or thrift plan; informal salary continuance plan; individual retirement
account (IRA); tax sheltered annuity (TSA); stock ownership plan; or a non-qualified plan of deferred
compensation. An Employer's Retirement Plan is deemed to include any Retirement Plan:
1. which is part of any federal, state, county, municipal or association retirement system; and
2. for which the Employee is eligible as a result of employment with the Employer.
SICK LEAVE or ANY SALARY CONTINUANCE PLAN means a plan which:
1. is established and maintained by the Employer for the benefit of Insured Employees; and
2. continues payment of all or part of an Insured Employee's Predisability Income for a
specified period after he or she becomes Disabled.
It does not include compensation the Employer pays an Insured Employee for work actually performed
during a Disability.
SICKNESS means illness, pregnancy or disease.
TOTAL COVERED PAYROLL means the total amount of Basic Monthly Earnings for all Employees
insured under this Policy.
TOTAL DISABILITY or TOTALLY DISABLED shall be defined in the Total Disability Monthly Benefit
section.
GL3001-LTD-6 98
8 10/01/04
GENERAL PROVISIONS
ENTIRE CONTRACT. The entire contract between the parties shall consist of:
1. this Policy and the Application (a copy of which is attached);
2. the Employer's Participation Agreement, if any; and
3. the Insured Employee's enrollment forms, if any.
In the absence of fraud, all statements made by the Policyholder and by Insured Employees are
representations and not warranties. No statement made by an Insured Employee will be used to contest the
coverage provided by this Policy; unless a copy of the statement has been furnished to such Insured
Employee.
AUTHORITY TO MAKE OR AMEND CONTRACT. Only a Company Officer located in the Company's
Home Office has the authority to:
1. determine the insurability of a group or any individual within a group;
2. make a contract in the Company's name;
3. amend or waive any provision of this Policy; or
4. extend the time for payment of any premium.
No change in this Policy will be valid; unless it is made in writing and signed by such a Company Officer.
TIME LIMIT ON CERTAIN DEFENSES. After this Policy has been in effect for two years from its date of
issue, no statement of the Policyholder shall be used to void this Policy. After an Insured Employee's
insurance has been in effect for two years, no statement by that Employee on a written application for
insurance shall be used to reduce or deny his or her claim.
RESCISSION. The Company may not rescind any insurance for an Insured Employee without such
Employee's written consent, except:
1. where such Employee commits fraud or misrepresentation with respect to eligibility or any
other material fact. (However, the rescission must not be based upon the failure of the
Employee to meet the eligibility requirements, if the Policyholder requested that the
Company include the Employee under the coverage); or
2. where the rescission is solely due to the lack of advance notification of the Employee's
termination of employment.
A material misrepresentation is an incomplete or untrue statement that caused the Company to issue coverage
which it would have disapproved, had it known the truth. To rescind means to cancel insurance back to its
effective date. In that event, the Company will refund all premium paid for the rescinded insurance, less any
benefits paid for the Insured Employee's Disability. The Company reserves the right to recover any claims
paid in excess of such premiums.
NON-PARTICIPATION. This is a non-participating Policy. It will not share in the divisible surplus of the
Company.
INFORMATION TO BE FURNISHED. The Employer is required to furnish the Company any information
needed to administer this Policy, including:
1. information about Employees who become eligible for insurance; whose amounts of coverage
change; and whose eligibility or coverage ends;
2. occupational information and other facts that may be needed to manage a claim; and
3. any other information that the Company may reasonably require.
The Company may inspect any of the Employer's records which relate to this Policy, at any reasonable time.
Clerical error by the Employer:
1. will not affect insurance which otherwise would be in effect; and
2. will not continue insurance which otherwise would be terminated.
Once an error is discovered, an equitable adjustment in premium will be made. If a premium adjustment
involves the return of unearned premium, the amount of the return will be limited to the 12-month period
which precedes the date the Company receives proof that such an adjusUnent should be made.
GL3001-LTD-7 98 MN
9 10/01/04
GENERAL PROVISIONS
(continued)
MISSTATEMENT OF AGE. If the Insured Employee's age has been misstated; then all amounts payable
under this Policy shall be the amounts that the premium paid would have purchased at the correct age.
ACTS OF THE POLICYHOLDER. In administering this Policy, the Policyholder must:
1. treat Employees the same in like situations; and
2. allow the Company, without inquiry, to rely on its acts.
POLICYHOLDER'S AGENCY. For all purposes of this Policy, the Policyholder acts on its own behalf or
as Agent of the Employee. Under no circumstances will the Policyholder be deemed the Agent of the
Company.
COMPANY'S DISCRETIONARY AUTHORITY. Except for those functions which this Policy specifically
reserves to the Policyholder or Employer, the Company has the authority to manage this Policy, to administer
claims, to interpret Policy provisions, and to resolve questions arising under this Policy. The Company's
authority includes (but is not limited to) the right to:
1. establish and enforce procedures for administering this Policy and claims under it;
2. determine Employees' eligibility for insurance and entitlement to benefits; and
3. determine what information the Company reasonably requires to make such decisions.
CERTIFICATES. The Employer will be furnished with individual Certificates for delivery to each Insured
Employee. These Certificates summarize the benefits provided by this Policy. If there is a conflict between
this Policy and the Certificate, this Policy will control.
CONFORMITY WITH STATE STATUTES. If, on its effective date, any provision of this Policy conflicts
with any applicable law; then the provision will be deemed to conform to the minimum requirements of the
law.
CURRENCY. In administering this Policy, all Predisability Income will be expressed in U.S. dollars; and all
premium and benefit amounts must be paid in U.S. dollars.
WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE. This Policy does not replace or
provide benefits required by Workers' Compensation laws or any state disability insurance plan laws.
ASSIGNMENT. The rights and benefits under this Policy may not be assigned.
GL3001-LTD-7 98 MN
10 10/01/04
CLAIMS PROCEDURES
NOTICE OF CLAIM. Written notice of claim must be given during the Elimination Period.
must be sent to the Company's Home Office. It should include:
1. the Insured Employee's name and address; and
2. the number of this Policy.
If this is not possible, written notice must be given as soon as it is reasonably possible.
The notice
CLAIM FORMS. When notice of claim is received, the Company will send claim forms to the Insured
Employee. If the Company does not send the forms within 10 business days; then the Insured Employee may
send the Company written proof of Disability in a letter. It should state the date the Disability began, its
cause and degree. The Company will periodically send the Insured Employee additional Claim Forms.
PROOF OF CLAIM. The Company must be given written proof of claim within 90 days after the end of
the Elimination Period. When it is not reasonably possible to give written proof in the time required, the
claim will not be reduced or denied solely for this reason; if the proof is filed: 1. as soon as reasonably possible; and
2. in no event later than one year after it was required.
These time limits will not apply while an Insured Employee lacks legal capacity.
Proof of claim must be provided at the Insured Employee's own expense.
Disability began, its cause and degree. Documentation must include:
1.
2.
It must show the date the
completed statements by the Insured Employee and the Employer;
a completed statement by the attending Physician, which must describe any restrictions on
the Insured Employee's performance of the duties of his or her regular occupation;
3. proof of any other income received;
4. proof of any benefits available from other income sources, which may affect Policy benefits;
5. a signed authorization for the Company to obtain more information; and
6. any other items the Company may reasonably require in support of the claim.
Proof of continued Disability, regular care of a Physician, and any other income benefits affecting the claim
must be given to the Company. This must be supplied within 45 days after the Company requests it. If it is
not, benefits may be denied or suspended.
EXAM OR AUTOPSY. At anytime while a claim is pending, the Company may have the Insured Employee
examined:
1. by a Physician, specialist or vocational rehabilitation expert of the Company's choice;
2. as often as reasonably required.
The Company may deny or suspend benefits for an Insured Employee who fails to attend an exam or to
cooperate with the examiner, without good cause. The Company may also have an autopsy done, where it is
not forbidden by law. Any such exam or autopsy will be at the Company's expense.
TIME OF PAYMENT OF CLAIMS. Benefits payable under this Policy will be paid:
1. immediately after the Company receives complete proof of claim and confirms liability; and
2. in no event more than 60 days after the Company receives acceptable proof of claim.
After that:
1. Any Long Term Disability benefits will be paid monthly, during any period for which the
Company is liable. If benefits are due for less than a month; then they will be paid on a pro
rata basis. The daily rate will equal 1/30 of the monthly benefit.
2. Any balance, which remains unpaid at the end of the period of liability, will be paid
immediately after the Company receives complete proof of claim and confirms liability.
TO WHOM PAYABLE. All benefits are payable to the Insured Employee, while living.
death, benefits will be payable as follows.
1. Any Survivor Benefit will be payable in accord with that section.
2. Any other benefits will be payable to the Insured Employee's estate.
After his or her
GL3001-LTD-8 02 MN
11
DAP
10/01/04
CLAIMS PROCEDURES
(continued)
If a benefit becomes payable to the Insured Employee's estate, a minor or any other person who is not legally
competent to give a valid receipt; then up to $2,000 may be paid to any relative of the Insured Employee that
the Company finds entitled to payment. If payment is made in good faith to such a relative; then the
Company will not have to pay that benefit again.
NOTICE OF CLAIM DECISION. The Company will send the Insured Employee a written notice of its
claim decision. If the Company denies any part of the claim; then the written notice will explain:
1. the reason for the denial, under the terms of this Policy and any internal guidelines; and
2. how the Insured Employee may request a review of the Company's decision.
It will include the claim number and name, address and phone number of the Company's claim service office.
This notice will be sent within 15 days after the Company resolves the claim. It will be sent within 45 days
after the Company receives the first proof of claim, if reasonably possible.
Delay Notice. If the Company needs more than 15 days to process the claim, due to matters beyond its
control; then an extension will be permitted. If needed, the Company will send the Insured Employee a
written delay notice:
1. by the 15th day after receiving the first proof of claim; and
2. every 30 days after that, until the claim is resolved.
The notice will explain:
1. what additional information is needed to resolve the claim; and
2. when a decision can be expected.
If the Insured Employee does not receive a written decision by the 105~ day after the Company receives the
first proof of claim, or within 60 days after the Company receives complete proof of claim; then there is a
right to an immediate review, as if the claim was denied.
Exception: If the Company needs more information from the Insured Employee to process the claim; then it
must be supplied within 45 days after the Company requests it. The resulting delay will not count towards
the above time limits for claim processing.
REVIEW PROCEDURE. Within 180 days after receiving a denial notice, the Insured Employee may
request a claim review by sending the Company: 1. a written request; and
2. any written comments or other items to support the claim.
The Insured Employee may review certain non-privileged information relating to the request for review.
The Company will review the claim and send the Insured Employee a written notice of its decision. The
notice will state the reasons for the Company's decision, under the terms of this Policy and any internal
guidelines. If the Company upholds the denial of all or part of the claim; then the notice will also describe:
1. any further appeal procedures available under this Policy;
2. the right to access relevant claim information; and
3. the right to request a state insurance department review, or to bring legal action.
This notice will be sent within 45 days after the Company receives the request for review; or within 90 days,
if a special case requires more time.
Delay Notice. If the Company needs more than 45 days to process an appeal, in a special case; then an
extension of up to 45 more days will be permitted. In that event, the Company will send the Insured
Employee a written delay notice, by the 30~ day after receiving the request for review. The notice will
explain:
1. the special circumstances which require the delay;
2. whether more information is needed to review the claim; and
3. when a decision can be expected.
GL3001-LTD-8 02 MN
DAP
12 10/01/04
CLAIMS PROCEDURES
(continued)
Exception: If the Company needs more information from the Insured Employee to process an appeal; then it
must be supplied within 45 days after the Company requests it. The resulting delay will not count towards
the above time limits for appeal processing.
Claims Subject to ERISA (Employee Retirement Income Security Act of 1974). Before bringing a civil
legal action under the federal labor law known as ERISA, an employee benefit plan participant must exhaust
available administrative remedies. Under this Policy, the Insured Employee must first seek two
administrative reviews of the adverse claim decision, in accord with this provision. If an ERISA claimant
brings legal action under Section 502(a) of ERISA after the required reviews; then the Company will waive
any right to assert that he or she failed to exhaust administrative remedies.
RIGHT OF RECOVERY. If benefits have been overpaid on any claim; then full reimbursement to the
Company is required within 60 days. If reimbursement is not made; then the Company has the right to: 1. reduce future benefits until full reimbursement is made; and
2. recover such overpayments from the Insured Employee or his or her estate.
Such reimbursement is required whether the overpayment is due to:
1. the Company's error in processing a claim;
2. the Insured Employee's receipt of Other Income Benefits;
3. fraud or any other reason.
LEGAL ACTIONS. No legal action to recover any benefits may be brought until sixty days after the
required written proof of claim has been given. No legal action may be brought more than three years after
the date written proof of claim is required.
COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions
reserves to the Group Policyholder or Employer, the Company has the authority to:
1. manage this Policy and administer claims under it; and
2. interpret the provisions and resolve questions arising under this Policy.
that this Policy clearly
The Company's authority includes (but is not limited to) the right to:
1. establish and enforce procedures for administering this Policy and claims under it;
2. determine Employees' eligibility for insurance and entitlement to benefits;
3. determine what information the Company reasonably requires to make such decisions; and
4. resolve questions in accord with Policy provisions, when a claim review is requested.
Any decision the Company makes, in the exercise of its authority, shall be subject to the Insured Person's
rights to request a state insurance department review or to bring legal action.
GL3001-LTD-8 02 MN
13
DAP
10/01/04
ELIGIBILITY
ELIGIBLE CLASSES. The classes of Employees eligible for insurance are shown in the Schedule of
Benefits. The Company has the right to review and terminate any or all classes eligible under this Policy, if
any class ceases to be covered by this Policy.
ELIGIBILITY DATE. An Employee becomes eligible for coverage provided by this Policy on the later of:
1. the Policy's effective date; or
2. the date the Employee satisfies the Waiting Period.
Prior service in an Eligible Class will apply toward the Waiting Period, when:
1. a former Employee is rehired within one year after his or her employment ends; or
2. an Employee returns from a Family or Medical Leave within the leave period required by
federal or state law (whichever is greater).
EFFECTIVE DATES
EFFECTIVE DATE. Except as stated in the Delayed Effective Date provision, coverage for an Employee
becomes effective at 12:01 a.m. on the latest of:
1. the date the Employee becomes eligible for coverage;
2. the date the Employee makes written application for coverage; and signs:
(a) a payroll deduction order, if the Employees pay any part of the Policy
premmms; or
(b) an order to pay premiums from the Employee's Flexible Benefits Plan account,
if premiums are paid through such an account; or
3. the date the Company approves the Employee's evidence of insurability, if required.
Evidence of insurability satisfactory to the Company must be submitted (at the Employee's expense) if:
1. written application for coverage (or an increased amount of coverage) is made more than 31
days after the Employee becomes eligible for such coverage;
2. coverage is elected after the Employee has requested:
(a) to terminate the insurance;
(b) to stop payroll deductions for the insurance; or
(c) to stop premium payments through a Flexible Benefits Plan account;
3. coverage is elected after the Employee has caused insurance to lapse by failing to pay the
required premium when due; or
4. optional, supplemental, voluntary or Buy-Up Benefit coverage is elected in excess of any
guaranteed issue amounts shown in the Schedule of Benefits.
DELAYED EFFECTIVE DATE. An Employee's Effective Date of any initial, increased or additional
coverage will be delayed; if such Employee is not Actively-at-Work on the date that coverage would
otherwise be effective. Coverage will take effect on the Employee's second consecutive day of Active Work.
GL3001-LTD-9 94
14 10/01/04
EFFECTIVE DATE FOR CHANGE IN ELIGIBLE CLASS. An Insured Employee may become a member
of a different Eligible Class. Except as stated in the Delayed Effective Date provision, coverage under the
different Eligible Class will be effective:
1. immediately, if the different Eligible Class involves any reduction in coverage; or
2. the first day of the month after the Insured Employee has been Actively-at-Work for at least
15 days, as a member of a different Eligible Class; if the different Eligible Class involves
enhancement of any coverage.
REINSTATEMENT AFTER FAMILY OR MEDICAL LEAVE. A new Waiting Period and evidence of
insurability will be waived for an Employee, upon return from an approved Family or Medical Leave,
provided:
1. the Employee returns within the leave period required by federal or state law (whichever is
greater);
2. the Employee applies for insurance or is enrolled under this Policy within 31 days after
resuming Active Work; and
3. the reinstated amount of insurance does not exceed the amount which terminated.
If the above conditions are met, the months of leave will count towards any unmet Pre-Existing Condition
Exclusion period; and a new Pre-Existing Condition Exclusion will not apply to the reinstated amount of
insurance. A new Pre-Existing Condition Exclusion will apply to any increased amount of insurance,
however.
GL3001-LTD-9 94
15 10/01/04
INDIVIDUAL TERMINATION
INDIVIDUAL TERMINATION OF COVERAGE. An Insured Employee's coverage will terminate at 12:00
midnight on the earliest of:
1. the date this Policy or the Employer's participation terminates; but without prejudice to any
claim incurred prior to termination;
2. the date the Insured Employee's Class is no longer eligible for insurance;
3. the date such Insured Employee ceases to be a member of an Eligible Class;
4. the end of the period for which the last required premium has been paid; or
5. the date on which the Insured Employee's employment with the Employer terminates; unless
coverage is continued as provided below.
CONTINUATION. Ceasing Active Work is deemed termination of employment; but insurance may be
continued as follows.
1. Disability. If an Insured Employee is absent due to Total Disability, or is engaged in Partial
Disability Employment; then Long Term Disability insurance may be continued during:
(a) the Elimination Period; provided the Company receives the required premium
from the Employer; and
(b) the period for which Long Term Disability benefits are payable, without
payment of premium.
2. Family or Medical Leave. If an Insured Employee goes on an approved Family or Medical
Leave, and is not entitled to continue insurance due to Disability, as provided above; then
Long Term Disability insurance may be continued, until the earliest of:
(a) the end of the leave period approved by the Employer;
(b) the end of the leave period required by federal or state law (whichever is
greater);
(c) the date the Insured Employee notifies the Employer that he or she will not
return; or
(d) the date the Insured Employee begins employment with another employer;
provided the Company receives the required premium from the Employer.
3. Lay-off or Other Leave. When an Insured Employee goes on a temporary lay-off, or an
approved leave of absence which is not subject to the federal Family and Medical Leave Act
(or any similar state law); then Long Term Disability insurance may be continued:
(a) until the end of the calendar month following the month in which the lay-off or
leave began;
(b) provided the Company receives the required premium from the Employer.
The Employer must not act so as to discriminate unfairly among Employees in similar situations. Insurance
may not be continued when an Insured Employee ceases Active Work due to a labor dispute, strike, work
slowdown or lockout.
INDIVIDUAL TERMINATION DURING DISABILITY. Termination of an Insured Employee's coverage
during a Disability will have no effect on benefits payable for that period of Disability.
POLICY TERMINATION
POLICY TERMINATION BY THE COMPANY. Until the premium rate has been in effect for at least 12
months, or any later Rate Guarantee Date agreed upon by the Company; the Company may terminate this
Policy on the due date of any premium if:
1. the number of Insured Employees totals less than 10;
2. part of the premium is paid by the Insured Employee and less than 75 % of those eligible for
coverage are insured;
3. all of the premium is paid by the Policyholder and less than 100% of those eligible for
coverage are insured;
GL3001-LTD-10 98 MN
16 10/01/04
POLICY TERMINATION
(continued)
4. the Policyholder fails to promptly furnish any information which the Company may
reasonably require;
5. the Policyholder, without good cause, fails to perform its duties pertaining to this Policy in
good faith.
6. the Company's liability is changed as a result of any change in federal, state or local law
which affects this Policy;
7. the Policyholder or any covered division, subsidiary or affiliated company relocates;
8. the Policyholder or any covered subsidiary or affiliated company dissolves or merges;
9. a division, subsidiary or affiliated company is added to or removed from this Policy;
10. any coverage for one or more classes of Insured Employees ceases to be provided under this
Policy;
11. the number of Insured Employees changes by 25 % or more from the number of Insured
Employees on the date this Policy took effect, or the most recent Rate Guarantee Date
expired, if later; or
12. the Employer ceases to be covered under the state Workers' Compensation program or any
other program of like intent.
After the premium rate has been in effect for at least 12 months, or any later Rate Guarantee Date
upon by the Company; the Company may terminate this Policy on the due date of any premium.
termination may be with respect to the Policy as a whole, to any coverage(s) provided under it, or
class of Insured Employees covered under it.
The Company will give the Policyholder at least 31 days' advance written notice of its intent to terminate this
Policy.
POLICY TERMINATION BY THE POLICYHOLDER. The Policyholder may terminate this Policy at any
time by giving the Company written notice. This Policy will then terminate on: 1. the date the Company receives the notice; or
2. some later date on which the Policyholder and the Company have agreed.
However, termination will not become effective during any period for which premium has been paid to the
Company. The Policyholder remains liable for the payment of premiums to the date of termination.
AUTOMATIC POLICY TERMINATION. If any premium is not paid before the Grace Period ends, then
this Policy will terminate:
1. at the end of the Grace Period, if the Company has reasonable evidence that the coverage is
being replaced; or
2. 30 days after the Company sends the employee notice described below, if the Company does
not have such evidence.
EMPLOYEE NOTICE OF POLICY TERMINATION. The provision applies when this Policy: 1. is terminated by the Company or the Policyholder; or
2. would otherwise terminate automatically, due to failure to pay premium by the end of the
Grace Period.
In that event, the Company will send each Insured Employee a written notice of Policy termination: 1. at his or her last known address;
2. at least 30 days before Policy termination takes effect;
unless the Company has reasonable evidence that the coverage will be replaced by a similar group plan within
31 days of termination.
If this employee notice is not sent as required, this coverage will continue:
1. for 120 days beyond the date insurance would otherwise terminate, in accord with the terms
of this Policy; or
2. until this coverage is replaced by a similar group plan, if sooner.
POLICY TERMINATION DURING DISABILITY. Termination of this Policy or an Employer's
participation during a Disability shall have no effect on benefits payable to the Insured Employee for that
period of Disability.
agreed
Such
to any
GL3001-LTD-10 98 MN
17
10/01/04
PREMIUMS AND PREMIUM RATES
PAYMENT OF PREMIUM. No coverage provided by this Policy will be in effect until the first premium
for such coverage is paid. For coverage to remain in effect, the Employer must pay each subsequent
premium on or before its due date at the Company's Home Office. The premium must be paid in U.S.
dollars.
PREMIUM RATES. The initial premium rates for this Policy are shown on the Face Page of this Policy.
Premium rates are subject to change.
PREMIUM RATE CHANGE. The Company may change any premium rate:
1. when this Policy's terms are changed:
(a) as agreed upon by the Policyholder and the Company; or
(b) as a result of a change in federal, state or local law which affects this Policy;
2. when the Company's liability is changed as a result of a change in federal, state, or local
law;
3. when the Policyholder or any covered division, subsidiary or affiliated company relocates;
4. when a division, subsidiary, or affiliated company is added to or removed from this Policy;
5. when the number of Insured Employees changes by 25 % or more from the number of
Insured Employees on the date this Policy took effect or the most recent Rate Guarantee Date
expired, if later;
6. when the Employer ceases to be covered by the state Workers' Compensation program or
any other program of like intent; or
7. on any premium due date on or after:
(a) this Policy's first anniversary; or
(b) any later Rate Guarantee Date agreed upon by the Company.
Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 31 days'
advance written notice of any increase in premium rates.
MONTHLY PREMIUM AMOUNT. The amount of monthly premium due on each due date will be the
Total Covered Payroll multiplied by the premium rate. Changes will not be pro-rated daily. Instead,
premium will be adjusted as. follows.
1. When an Insured Employee's insurance (or increased amount of insurance) takes effect,
premium will be charged from the monthly due date coinciding with or next following that
change.
2. When all or part of an Insured Employee's insurance terminates, the applicable premium will
cease on the monthly due date coinciding with or next following that termination.
3. When premiums are paid other than monthly, increases or decreases will result in an
adjustment from the premium due date coinciding with or next following that change.
The above manner of charging premium is for accounting purposes only. It will not extend insurance
coverage beyond a date it would have otherwise terminated.
Each premium payment will include any adjustments in past premiums, which are needed due to changes that
have not yet been taken into account. If a premium adjustment involves a return of unearned premium, the
amount of the return will be limited to the prior 12-month period.
GRACE PERIOD. A Grace Period of 31 days from the due date will be allowed for the payment of each
premium after the first. This Policy will remain in effect during the Grace Period. The Policyholder will be
liable to the Company for the payment of all premiums due for the period this Policy remains in effect,
however.
WAIVER OF PREMIUM. Premium will be administered as follows during any period for which benefits are
payable.
1. Long Term Disability premium payments are waived for an Insured Employee who is
Disabled, during any period for which benefits are payable.
2. If coverage is to be continued following a period during which premiums were waived; then
premium payments must be resumed, as they become due.
GL3001-LTD-11 98
18 10/01/04
TOTAL DISABILITY MONTHLY BENEFIT
BENEFIT. The Company will pay a Total Disability Monthly Benefit to an Insured Employee, after the
completion of the Elimination Period; if he or she: 1. is Totally Disabled;
2. is under the regular care of a Physician; and
3. at his or her own expense, submits proof of continued Total Disability and Physician's care
to the Company upon request.
The Total Disability Monthly Benefit will cease on the earliest of:
1. the date the Insured Employee ceases to be Totally Disabled or dies;
2. the date the Maximum Benefit Period ends;
3. the date the Insured Employee is able, but chooses not to engage in Partial Disability
Employment:
(a) in his or her regular occupation, during the Own Occupation Period; or
(b) in any gainful occupation, after the Own Occupation Period;
4. the date the Insured Employee fails to take a required medical exam, without good cause; or
5. the 60th day after the Company mails a request for additional proof, if not given.
AMOUNT. The amount of the Total Disability Monthly Benefit equals:
1. the Insured Employee's Basic Monthly Earnings multiplied by the Benefit
(limited to the Maximum Monthly Benefit); minus
2. Other Income Benefits.
Percentage
The amount of the Total Disability Monthly Benefit will not be less than the Minimum Monthly Benefit. The
Benefit Percentage, Maximum Monthly Benefit, Minimum Monthly Benefit and Maximum Benefit Period are
shown in the Schedule of Benefits.
DEFINITION
"Total Disability" or "Totally Disabled" will be defined as follows.
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or
Sickness the Insured Employee is unable to perform each of the main duties of his or her
regular occupation.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured
Employee is unable to perform each of the main duties of any gainful occupation which his
or her training, education or experience will reasonably allow.
The loss of a professional license, an occupational license or certification, or a driver's license for any reason
does not, by itself, constitute Total Disability.
GL3001-LTD-12A 98
Standard Integration, Any Occ. Disability Definition
19 10/01/04
PARTIAL DISABILITY MONTHLY BENEFIT
BENEFIT. The Company will pay a Partial Disability Monthly Benefit to an Insured Employee, after
completion of the Elimination Period; if he or she: 1. is Disabled;
2. is engaged in Partial Disability Employment;
3. is earning at least 20 % of Predisability Income when Partial Disability Employment begins;
4. is under the regular care of a Physician; and
5. at his or her own expense, submits proof of continued Partial Disability, Physician's care and
reduced earnings to the Company upon request.
The Insured Employee does not have to be Totally Disabled prior to receiving Partial Disability Monthly
Benefits. The Elimination Period may be satisfied by days of Total Disability, Partial Disability or any
combination thereof.
The Partial Disability Monthly Benefit will cease on the earliest of:
1. the date the Insured Employee ceases to be Partially Disabled or dies;
2. the
3. the
(a)
date the Maximum Benefit Period ends;
date the Insured Employee earns more than:
99% of Predisability Income, until Partial Disability Monthly Benefits have
been paid for 24 months for the same period of Disability; or
(b)85% of Predisability Income, after Partial Disability Monthly Benefits have
been paid for 24 months for the same period of Disability;*
the date the Insured Employee is able, but chooses not to work full-time:
(a) in his or her regular occupation, during the Own Occupation Period; or
(b) in any gainful occupation, after the Own Occupation Period;
the date the Insured Employee fails to take a required medical exam, without good cause; or
the 60th day after the Company mails a request for additional proof, if not given.
*If the Insured Employee's earnings from Partial Disability Employment fluctuate, the Company has the
option to average the most recent three months' earnings and continue the claim; provided that average does
not exceed the percentage of Predisability Income allowed above. A Monthly Benefit will not be payable for
any month during which earnings exceeded that percentage, however.
DEFINITIONS
"Full-Time" means the average number of hours the Insured Employee was regularly scheduled to work, at
his or her regular occupation, during the month just prior to:
1. the date the Elimination Period begins; or
2. the date an approved leave of absence begins, if the Elimination Period begins while the
Insured Employee is continuing coverage during a leave of absence.
"Partially Disabled" or "Partial Disability" will be defined as follows.
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or
Sickness the Insured Employee:
(a) is unable to perform one or more of the main duties of his or her regular
occupation, or is unable to perform such duties full-time; and
(b) is engaged in Partial Disability Employment.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured
Employee:
(a) is unable to perform one or more of the main duties of any gainful occupation
which his or her training, education or experience will reasonably allow; or is
unable to perform such duties full-time; and
(b) is engaged in Partial Disability Employment.
GL3001-LTD-13A 98
20
Residual Disability, Any Occ. Disability Definition
10/01/04
PARTIAL DISABILITY MONTHLY BENEFIT
(Continued)
BENEFIT AMOUNT. The Partial Disability Monthly Benefit will replace the Insured Employee's Lost
Income; provided it does not exceed the Total Disability Monthly Benefit, which would otherwise be payable
during Total Disability without the Partial Disability Employment.
Thus, the amount of the Partial Disability Monthly Benefit will equal the lesser of A or B below.
LOST INCOME: The Insured Employee's Predisability Income, minus all Other Income
Benefits (including earnings from Partial Disability Employment).
TOTAL DISABILITY MONTHLY BENEFIT otherwise payable:
1. The Insured Employee's Predisability Income multiplied by the Benefit
Percentage (limited to the Maximum Monthly Benefit); minus
2. Other Income Benefits, except for earnings from Partial Disability Employment.
The Partial Disability Monthly Benefit will never be less than the Minimum Monthly Benefit. The Benefit
Percentage, Maximum Monthly Benefit, Minimum Monthly Benefit, and Maximum Benefit Period are shown
in the Schedule of Benefits.
GL3 001-LTD- 13.4
Progressive Calculation
21 10/01/04
OTHER INCOME BENEFITS
OTHER INCOME BENEFITS means those benefits shown below:
1. Any temporary or permanent benefits or awards for which the Insured Employee is eligible
under:
(a) Worker's or Workmen's Compensation Law;
(b) occupational disease law; or
(c) any other act or law of like intent.
2. Any disability income benefits for which the Insured Employee is eligible under any
compulsory benefit act or law (except for benefits under any state or federal Motor Vehicle
"No Fault" coverage).
3. Any disability income benefits for which the Insured Employee is eligible under:
(a) any other group plan, sick leave or salary continuance plan of the Employer; or
(b) any governmental retirement system as a result of the Insured Employee's job
with the Employer.
4. Any Disability Benefits or Retirement Benefits the Insured Employee receives under a
Retirement Plan.
5. Benefits under the United States Social Security Act, the Canada Pension Plan, the Quebec
Pension Plan or any similar plan or act as follows:
(a) disability or unreduced retirement benefits for which the Insured Employee and
any spouse or child is eligible, because of the Insured Employee's Disability or
eligibility for unreduced retirement benefits; or
(b) reduced retirement benefits received by the Insured Employee and any spouse or
child because of the Insured Employee's receipt of reduced retirement benefits.
Social Security or other benefits received by a noncustodial child will not be considered
Other Income Benefits.
6. Earnings the Insured Employee earns or receives fi'om any form of employment.
These Other Income Benefits, except Retirement Benefits, are benefits resulting from the same Disability for
which a Monthly Benefit is payable under this Policy.
An Insured Employee who may be entitled to some Other Income Benefit is required to actively pursue it; if
he or she does not, Policy benefits may be denied or suspended.
PROTECTION OF MONTHLY BENEFIT AMOUNT. After the first deduction for each of the Other
Income Benefits, the Monthly Benefit will not be further reduced due to any cost-of-living increases payable
under these Other Income Benefits, including:
1. the federal Social Security Act;
2. the Railroad Retirement Act;
3. any Veteran's Disability Compensation and Survivor Benefits Act;
4. Worker's Compensation; or
5. any similar federal or state law, as amended after such benefits begin.
LUMP SUM PAYMENTS. Other Income Benefits which are paid in a lump sum will be prorated on a
monthly basis over the time period for which the sum is given. If no time period is stated, the sum will be
prorated on a monthly basis over the time the Company expects the Insured Employee to live.
ESTIMATED PAYMENTS. When the Insured Employee may qualify for certain Other Income Benefits, the
Company may estimate the amount of such benefits. The Company may reduce the Insured Employee's
Monthly Benefits by such estimated amounts, which: 1. have not yet been awarded or denied; or
2. have been denied, if the denial is being appealed.
If an Insured Employee's Monthly Benefits have been reduced by an estimated amount; then such payments
will be adjusted when the Company receives proof:
1. of the amount actually awarded; or
2. that benefits have been denied, and that any appeal the Company deems necessary has been
completed. (In that event, a lump sum will be refunded to the Insured Employee.)
GL3001-LTD-14 98 MN
22
Full SS Integ.
10/01/04
RECURRENT DISABILITY
"Recurrent Disability" means a Disability due to an Injury or Sickness which is the same as, or related to, the
cause of a prior Disability for which Monthly Benefits were payable. A Recurrent Disability will be treated
as follows.
A Recurrent Disability will be treated as a new period of Disability, and a new Elhnination
Period must be completed before further Monthly Benefits are payable; if the Insured
Employee returns to his or her regular occupation on a full-time basis for six months or
more.
A Recurrent Disability will be treated as part of the prior Disability, if an Insured Employee
returns to his or her regular occupation on a full-time basis for less than six months.
To qualify for a Monthly Benefit, the Insured Employee must earn less than the percentage of Predisability
Income specified in the Partial Disability Monthly Benefit section. Monthly Benefit payments will be subject
to all other terms of this Policy for the prior Disability.
If an Insured Employee becomes eligible for coverage under any other group Long Term Disability policy,
this Recurrent Disability provision will cease to apply to that Insured Employee.
GL3001-LTD-15 98
23 10/01/04
EXCLUSIONS
GENERAL EXCLUSIONS. This Policy will not cover any period of Total or Partial Disability:
1. due to war, declared or undeclared, or any act of war;
2. due to intentionally self-inflicted injuries;
3. due to active participation in a riot;
4. due to the Insured Employee's committing of or the attempting to commit a felony; or
5. during which the Insured Employee is not under the regular care of a Physician.
PRE-EXISTING CONDITION EXCLUSION. This Policy will not cover any Total or Partial Disability:
1. which is caused or contributed to by, or results fi'om a Pre-Existing Condition; and
2. which occurs in the first 12 months after the Insured Employee's Effective Date.
"Pre-Existing Condition" means a Sickness or Injury for which the Insured Employee received treatment
within 3 months prior to the Insured Employee's Effective Date.
"Treatment" means consultation, care or services provided by a Physician. It includes diagnostic measures
and the prescription, refill of prescription, or taking of any prescribed drugs or medicines.
GL3001-LTD-16.0 99 MN
24
3/12 Pre-Ex.
10/01/04
SPECIFIED INJURIES OR SICKNESSES LIMITATION
LIMITATION. If an Insured Employee is Disabled primarily due to one or more of the Specified Injuries or
Sicknesses defined below; then Partial or Total Disability Monthly Benefits:
1. will be payable subject to the terms of this Policy; but
2. will be limited to 24 months for any one period of Disability; unless the Insured Employee is
confined to a Hospital.
"Specified Injuries or Sicknesses" include any Mental Sickness, or Substance Abuse, as defined below.
CONDITIONS
1. If the Insured Employee is confined in a Hospital at the end of the 24th month for which
Policy benefits are paid for the Specified Injury or Sickness; then benefits will be payable
until he or she is discharged from that facility.
2. In no event will the Monthly Benefit be paid beyond the Maximum Benefit Period shown in
the Schedule of Insurance, however.
DEFINITIONS
"Hospital," as used in this provision, means:
1. a general hospital which:
(a) is licensed, approved or certified by the state where it is located;
(b) is recognized by the Joint Commission on the Accreditation of Hospitals; or
(c) is operated to treat resident inpatients; has a registered nurse always on duty;
and has a lab, x-ray facility and place where major surgery is performed; and
2. a skilled nursing care facility or unit, which provides convalescent or nursing care; and
which is recognized as a skilled nursing care facility under Medicare.
The term Hospital also includes:
1. a Mental Hospital when treatment is for a Mental Sickness; and
2. a Treatment Center when treatment is for Substance Abuse.
"Mental
1.
2.
3.
Hospital" means a health care facility (or its psychiatric unit) which:
is licensed, certified or approved as a mental hospital by the state where it is located;
is equipped to treat resident inpatients' mental diseases or disorders; and
has a resident psychiatrist on duty or on call at all times.
"Mental Sickness" means any emotional, behavioral, psychological, personality, adjustment, mood or stress-
related abnormality, disorder, disturbance, dysfunction or syndrome; regardless of its cause. It includes, but
is not limited to:
1. schizophrenia or schizoaffective disorder;
2. bipolar affective disorder, manic depression, or other psychosis; and
3. obsessive-compulsive, depressive, panic or anxiety disorders.
These conditions are usually treated by a psychiatrist, a clinical psychologist or other qualified mental health
care provider. Treatment usually involves psychotherapy, psychotropic drugs or similar methods of
treatment.
Mental Sickness does not include irreversible dementia resulting from: 1. stroke, trauma, viral infection, Alzheimer's disease; or
2. other conditions which are not usually treated by a mental health care provider using
psychotherapy, psychotropic drugs, or similar methods of treatment.
"Substance Abuse" means alcoholism, drug abuse, or chemical dependency of any type.
"Treatment Center" means a health care facility (or its medical or psychiatric unit) which:
1. is licensed, certified or approved by the state where it is located;
2. has a program for inpatient treatment of substance abuse; and
3. provides such treatment based upon a written plan approved and supervised by a Physician.
GL3001-LTD-17 98
25
Specified Limit.
10/01/04
VOLUNTARY VOCATIONAL REHABILITATION BENEFIT PROVISION
BENEFIT. If an Insured Employee is Disabled and is receiving Policy benefits; then he or she may be
eligible for a Vocational Rehabilitation Benefit. This Benefit consists of services which may include:
1. vocational evaluation, counseling, training or job placement;
2. job modification or special equipment; and
3. other services which the Company deems reasonably necessary to help the Insured Employee
return to work.
The Company will determine the Insured Employee's eligibility and the amount of any Benefit payable.
ELIGIBILITY. An Insured Employee may be eligible for this Benefit, if the Company finds that he or she:
1. has a Disability that prevents the performance of his or her regular occupation; and, after the
Own Occupation Period, also lacks the skills, training or experience needed to perform any
other gainful occupation;
2. has the physical and mental abilities needed to complete a Program; and
3. is reasonably expected to return to work after completing the Program; in view of his or her
degree of motivation and the labor force demand for workers in the proposed occupation.
The Company must also find that the cost of the proposed services is less than its expected claim liability.
AMOUNT. The amount of any Vocational Rehabilitation Benefit will not exceed the Company's expected
claims liability. This benefit will not be payable for services covered under the Insured Employee's health
care plan or any other vocational rehabilitation program. Payment may be made to the provider of the
services, at the Company's option.
CONDITIONS. Either the Company, the Insured Employee, or his or her Physician may first propose
vocational rehabilitation. When a Program is approved by the Company, this Policy's definition of
"Disability" will be waived during the rehabilitation period; but it will be reapplied after the Program ends.
The Company will determine the amount and duration of any Long Term Disability benefits payable after the
Program ends.
LIMITATION. This Policy will not cover any period of Disability for an Insured Employee who has
received a Vocational Rehabilitation Benefit and has failed to complete the Program, without Good Cause.
DEFINITIONS
"Good Cause", as used in this provision, means the Insured Employee's:
1. documented physical or mental impairments, which render the Insured Employee unable to
take part in or complete a Program;
2. involvement in a medical program, which prevents or interferes with the Insured Employee's
taking part in or completing a Program; or
3. participating in good faith in some other vocational rehabilitation program, which:
(a) conflicts with taking part in or completing a Program developed by the
Company; and
(b) is reasonably expected to return the Insured Employee to work.
"Program" means a written vocational rehabilitation program:
1. which the Company develops with input from the Insured Employee; his or her Physician;
and any current or prospective employer, when appropriate; and
2. which describes the Program's goals; each party's responsibilities; and the times, dates and
costs of the rehabilitation services.
GL3001-LTD-17.3 98
Voluntary Rehab.
26 10/01/04
REASONABLE ACCOMMODATION BENEFIT
If an Insured Employee of the Employer is Disabled, and is receiving Policy benefits; then the Employer may
be eligible for a Reasonable Accommodation Benefit. This Benefit reimburses the Employer for 50% of the
expense incurred for reasonable accommodation services for the Insured Employee; but will not exceed:
1. a maximum benefit of $5,000 for any one Insured Employee; or
2. the Company's expected liability for the Insured Employee's Long Term Disability claim
(whichever is less).
Such services may include:
1. providing the Insured Employee a more accessible parking space or entrance;
2. removing barriers or hazards to the Insured Employee from the worksite;
3. special seating, furniture or equipment for the Insured Employee's work station;
4. providing special training materials or translation services during the Insured Employee's
training; and
5. other services the Company deems reasonably necessary to help the Insured Employee return
to work with the Employer.
ELIGIBILITY FOR BENEFIT. The Company will determine the Employer's eligibility to receive the
Benefit. To qualify for the Benefit, the Employer must have an Insured Employee:
(a) whose Disability prevents the performance of his or her regular occupation at the Employer's
worksite;
(b) who has the physical and mental abilities needed to perform his or her own or another
occupation at the Employer's worksite; but only with the help of the proposed
accommodation; and
(c) who is reasonably expected to return to work with the help of the proposed accommodation.
The Company must also find that the requested Reasonable Accommodation Benefit is less than the expected
liability for the Insured Employee's Long Term Disability claim.
WRITTEN PROPOSAL. The reasonable accommodation services must be provided in accord with a written
proposal, which is developed with input from: 1. the Employer;
2. the Insured Employee; and
3. his or her Physician, when appropriate.
The proposal must state the purpose of the proposed accommodation; and the times, dates and costs of the
services.
CONDITIONS. Either the Company, the Employer, the Insured Employee, or his or her Physician may first
propose an accommodation.
The proposal must be approved by the Company in writing.
The Company will then reimburse the Employer, upon receipt of proof that the Employer:
1. has provided the services for the Insured Employee; and
2. has paid the provider for the services.
G L3001 -LTD- 17.3
27 10/01/04
PRIOR INSURANCE CREDIT UPON TRANSFER OF INSURANCE CARRIERS
To prevent loss of coverage for an Employee because of a transfer of insurance carriers, this Policy will
provide Prior Insurance Credit for employees insured under the prior carrier's policy on its termination date
as follows.
FAILURE TO BE ACTIVELY-AT-WORK DUE TO INJURY OR SICKNESS. Subject to premium
payments, this Policy will provide coverage to an Employee:
1. who was insured by the prior carrier's policy at the time of transfer; and
2. who was not Actively-At-Work due to Injury or Sickness on this Policy's Effective Date.
The coverage will be that provided by the prior carrier's policy, had it remained in force.
pay:
1. the benefit that the prior carrier would have paid; minus
2. any amount for which the prior carrier is liable.
The Company will
DISABILITY DUE TO A PRE-EXISTING CONDITION. Benefits may be payable for a Total Disability
due to a Pre-Existing Condition for an Employee who:
1. was insured by the prior carrier's policy at the time of transfer; and
2. was Actively-At-Work and insured under this Policy on this Policy's Effective Date.
The benefits will be determined as follows:
1. The Company will apply this Policy's Pre-Existing Condition Exclusion.
If the Insured
Employee qualifies for benefits, such Insured Employee will be paid according to this
Policy's benefit schedule.
If the Insured Employee cannot satisfy this Policy's Pre-Existing Condition Exclusion, but
can satisfy the prior carrier's pre-existing condition exclusion giving cOnsideration towards
continuous time insured under both policies; then he or she will be paid in accord with the
benefit schedule and all other terms, conditions and limitations of:
(a) this Policy without applying the Pre-Existing Condition Exclusion; or
(b) the prior carrier's policy;
whichever is less.
If the Insured Employee cannot satisfy the Pre-Existing Condition Exclusion of this Policy or
that of the prior carrier, no benefit will be paid.
GL3001-LTD-18 99
Prior h~surance Credit
28 10/01/04
FAMILY INCOME BENEFIT
The Company will pay a lump sum benefit to the Eligible Survivor, when proof is received that an Insured
Employee died:
1. after Disability had continued for 180 or more consecutive days; and
2. while receiving a Monthly Benefit.
The benefit will be equal to three times the Insured Employee's Last Monthly Benefit.
"Last Monthly Benefit" means the gross Monthly Benefit payable to the Insured Employee immediately prior
to death. Any reductions for Other Income Benefits, or for earnings the Insured Employee received for
Partial Disability Employment, will not apply.
"Eligible Survivor" means the Insured Employee's: 1. surviving spouse; or, if none
2. surviving children who are under age 25, on the Insured Employee's date of death.
If payment becomes due to the Insured Employee's children; then payment will be made to:
1. the surviving children, in equal shares; or
2. a person named by the Company to receive payments on the children's behalf.
This payment will be valid and effective against all claims by others representing, or claiming to represent,
the children.
GL3001-LTD- 19 94
Three Month Sm-vivor Benefit
29 10/01/04
COST-OF-LIVING ADJUSTMENT
The Company will make a Cost-of-Living Adjustment to the Employee's Total Disability Monthly Benefit if
such Insured Employee:
1. has been Totally Disabled for 12 straight months following the Elimination Period; and
2. is receiving Total Disability Monthly Benefits on July 1st.
The Insured Employee will be eligible for an additional Cost-of-Living Adjustment on each subsequent July
1st if such Insured Employee is continuously receiving Total Disability Monthly Benefits. However, no more
than the maximum number of adjustments (shown in the Schedule of Benefits) will be made during the
Insured Employee's benefit period.
The Cost-of-Living Adjustment equals the Cost-of-Living Percentage (shown in the Schedule of Benefits)
times the Insured Employee's Total Disability Monthly Benefit. For the purpose of calculating the Cost-of-
Living Adjustment, the Total Disability Monthly Benefit will include any prior Cost-of-Living Adjustments.
Each Cost-of-Living Adjustment will be added to the Insured Employee's Total Disability Monthly Benefit
and will be paid monthly. The Cost-of-Living Adjustments are not subject to the Maximum Monthly Benefit.
GL3001-LTD-23
COLA Option I
30 10/01/04
Jefferson Pilot Financial Insurance Company
8801 Indian Hills Drive
Omaha, NE 68114-4066
800-423-2765
NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN
INSOLVENCY UNDER THE MINNESOTA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION LAW
The maximum amount the guaranty association will pay for all policies issued on one life by the same insurer
is limited to $300,000. Subject to this $300,000 limit, the guaranty association will pay up to $300,000 in
life insurance death benefits, $100,000 in net cash surrender and net cash withdrawal values for life
insurance, $300,000 in health insurance benefits, including any net cash surrender and net cash withdrawal
values, $100,000 in annuity any net cash surrender and net cash withdrawal values, $300,000 in present value
of annuity benefits for annuities which are part of a structured settlement or for annuities in regard to which
periodic annuity benefits, for a period of not less than the annuitant's lifetime or for a period certain of not
less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no
coverage limit has been specified for a covered policy or benefit, the coverage limit shall be $300,000 in
present value. Unallocated annuity contracts issued to retirement plans, other than defined benefit plans,
established under section 401, 403(b) or 457 of the Internal Revenue code of 1986, as amended through
December 31, 1992, are covered up to $100,000 in net cash surrender and net cash withdrawal values, for
Minnesota residents covered by the plan provided, however, that the association shall not be responsible for
more than $7,500,000, in claims from all Minnesota residents covered by the plan, If total claims exceed
$7,500,000, the $7,500,00 shall be prorated among all claimants. These are the maximum claim amounts.
Coverage by the guaranty association is also subject to other substantial limitations and exclusions and
requires continued residency in Minnesota. If your claim exceeds the guaranty association's limits, you may
still recover a part or all of that amount form the proceeds of the liquidation of the insolvent insurer, if any
exist. Funds to pay claims may not be immediately available. The guarantee association assesses insurers
licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from this
assessment.
THE COVERAGE PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR
USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND
FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD
NOT RELY ON COVERAGE BY THE GUARANTY ASSOCIATION.
THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF
LIFE, ANNUITY, OR HEALTH INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR
INSURANCE CARRIER BECOMES FINANCIALLY INSOLVENT. THIS NOTICE IN NO WAY
IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL
LIFE, ANNUITY, AND HEALTH INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS
NOTICE.
The address of the Guarantee Association is:
Minnesota Life and Health Insurance Guaranty Association
750 Northwest Center
55 East Fifth Street
St. Paul, MN 55101
(612) 222-2799 Fax: (612) 228-7369
Executive Director Gerald Backhaus
MN NOTICE - POL 95
31
L,A&H
10/01/04