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BENEFIT PROVISIONS
LONG TERM DISABILITY INCOME INSURANCE
BENEFIT PROVISIONS
Total Disability Benefit formula
Partial Disability Benefit formula
What are Other Income
Benefits?
When does my monthly LTD
benefit cease?
What happens if I return
to full-time work and become disabled again?
What happens to my LTD
benefit if I die?
Who are my Eligible
Survivors?
CLAIM PROVISIONS
When does written Notice
of Claim have to be submitted?
When does written Proof
of Claim have to be submitted?
What is
considered Proof of Claim?
Can I assign my Life
Insurance?
How can statements made
in any application for insurance be used?
What happens if facts are
misstated?
What are Sun Life’s
examination and autopsy rights?
GENERAL PROVISIONS
What are the time limits
for legal proceedings?
Do these group benefits
affect Workers’ Compensation?
Can the Policyholder act
as a Sun Life agent?
DEFINITIONS
SUMMARY PLAN DESCRIPTION
What is the Long Term
Disability Benefit?
Long Term Disability Benefits (LTD) partially
replace your income if you become Totally or Partially Disabled while insured.
When do LTD benefits
become payable?
Sun Life will pay a monthly LTD benefit after
the end of your Elimination Period, if Sun Life receives proof that you are:
·
Totally or Partially Disabled due
to an injury or Sickness; and
What conditions must be
met for LTD benefits to continue?
Sun Life will pay you an LTD benefit, up to
the Maximum Benefit Period, if you provide proof that you continue to be Totally
or Partially Disabled and you require the regular and continuing care of a
Physician. You need to provide proof when Sun Life asks for it, but the proof is
at your expense.
How is the LTD benefit
calculated?
If you are Totally Disabled, your monthly LTD
benefit will be calculated based on the Total Disability Benefit formula. If you
are Partially Disabled, your monthly LTD benefit will be calculated based on the
Partial Disability Benefit formula. You need to provide Sun Life with proof of
your monthly earnings on a quarterly basis. Your monthly LTD benefit will never
be less than your Minimum Monthly Benefit shown in the Benefit Highlights.
BENEFIT PROVISIONS
LONG TERM DISABILITY INCOME INSURANCE
What is the Total
Disability Benefit formula?
To determine your Total Disability Benefit:
1.
Take the lesser of:
a. Your Total Monthly Earnings multiplied by the Benefit Percentage (shown in the Benefit Highlights); or
2.
Subtract Other Income Benefits from the amount determined in Step 1.
What is the Partial
Disability Benefit formula?
To determine your Partial Disability Benefit
for the first 24 months of your Partial Disability:
1.
calculate the LTD benefit you would receive if you were Totally Disabled
then
add your earnings
from employment plus your income received from Other Income Benefits to your
Total Disability Benefit.
if the sum is less
than 100% of your Indexed Total Monthly Earnings, your Total Disability Benefit
is your Partial Disability Benefit.
LONG TERM DISABILITY INCOME INSURANCE
If you continue to be Partially Disabled
after 24 months of Partial Disability Benefits, your Partial Disability Benefit
will be recalculated based on the following formula:
(A divided by B) multiplied by C
Where:
A = your Indexed Total Monthly Earnings minus
your monthly earnings
Received from your employment.
B = your Indexed Total Monthly Earnings.
C = your total Disability Benefit.
A Total Disability Benefit will be paid if
you are earning 20% or less of your Indexed Total Monthly Earnings.
What are Other Income
Benefits?
Other Income Benefits are those benefits
provided or available to you while your monthly LTD benefit is payable. These
Other Income Benefits, other than retirement benefits, must be provided to you
as a result of the same Total or Partial Disability payable under the Group
Policy. Other Income Benefits include:
1. The amount you are eligible for under:
a.
Worker’s Compensation Law; or
2. The Railroad Retirement Act (including any
dependent benefits).
1.
Any labor management trustee, union or employee benefit plans that are
funded in whole or in part by your Employer.
a.
any other group insurance plan of your Employer
3.
The benefits you receive under your Employer’s Retirement Plan as
follows:
a.
any disability benefits;
4.
The disability or retirement benefits under the United States Social
Security Act, or any similar plan or act, as follows:
a.
Disability benefits you are eligible to receive;
If your Total or
Partial Disability begins after age 70, your Social Security Retirement Benefits
will not apply if, prior to your Total or Partial Disability, you were already
receiving Social Security Retirement Benefits.
1.
The amount you receive from any accumulated sick leave.
Other Income Benefits will include any amount
described above which would have been available to you had you applied for that
benefit.
What if I receive payment
of Other Income Benefits in lump sum?
If your receive a lump sum payment for any
Other Income Benefits, Sun Life will prorate the lump sum on a monthly basis
over the time period specified for the lump sum payment. If no time period is
stated, the lump sum payment will be prorated on a monthly basis over your
expected lifetime as determined by Sun Life.
What happens if I receive
increases in my Other Income Benefits?
After the first deduction for each of your
Other Income Benefits, sun Life will not reduce your monthly LTD benefit
payments due to cost of living increases. This does not apply to any increase in
earnings you receive from employment.
Are any of Other Income
Benefits estimated?
Sun Life will estimate the amount of any
Other Income Benefits if they have not yet been awarded or denied or if they
have been denied and are being appealed. This estimate will be used to reduce
the amount of your monthly LTD benefits payments. However, the estimate will not
be used if, within 6 months of becoming totally or Partially Disabled, you meet
both of the following conditions:
·
you have applied for the Other
Income Benefits; and
What happens when the
Other Income Benefits have been awarded or have been denied?
You must notify Sun Life of the amount of
Other Income Benefit when it is approved or adjusted (other than cost of living
increases) or if it has been denied on final appeal. Sun Life will make an
adjustment to the Net Monthly Benefit when Sun Life receives written notice of
the amount of the Other Income Benefit or when it has been denied. Written
Notice must be sent within 31 days after receipt of the Other Income Benefit
award or denial.
If after Sun Life makes as adjustment your
Net Monthly Benefit has been underpaid, Sun Life will make a lump Sum refund to
you of the amount that has been underpaid.
If after Sun Life makes an adjustment your
Net Monthly Benefit has been overpaid, you must reimburse Sun Life the amount of
the overpayment within 31 days of the award. Sun Life has the option to reduce
or eliminate your future monthly LTD benefit payments instead of requiring
reimbursement in a lump sum. During the overpayment reimbursement period, the
Minimum Monthly Benefit will not apply.
When does my monthly LTD
benefit cease?
Your monthly LTD benefit will cease on the
earliest of:
·
the date you are no longer Totally
or Partially Disabled;
·
the date you die;
·
the end of your Maximum Benefit
Period;
·
the date you do not provide proof
that you continue to be Totally or Partially Disabled as requested; or
·
the date your current earnings are
more than 80% of your Indexed Total Monthly Earnings;
·
the date Sun Life determines you
are able to perform on a fill-time basis all of the material and substantial
duties of your own occupation, even if you choose not to work (this applies to
the first 24 months of Total Disability or to your Partial Disability); or
What happens if I return
to full-time work and become disabled again?
Sun Life will treat this new disability as
apart of your prior Total or Partial Disability if you returned to work and were
Actively at Work for less than:
·
six months, if due to the same or
related causes;
You will not have to complete a new
Elimination Period.
Your monthly LTD benefit will be subject to
the same terms and conditions as were applicable to the original Total or
Partial Disability.
Your monthly LTD benefit will not continue
if:
·
you become eligible for benefits
under any other group LTD policy; or
If your new disability begins later than the
time periods specified, you will need to complete a new Elimination Period.
What happens to my LTD
benefit if I die?
A Survivor Benefit equal to 3 times your last
Gross Monthly Benefit is payable in a lump sum to your Eligible Survivor if Sun
Life receives satisfactory proof that you died:
·
after your Total or Partial
Disability had continued for 180 or more consecutive days; and
Who are my Eligible
Survivors?
Your spouse, if living, or your children
under age 25.
If you do not have an Eligible Survivor, the
Survivor Benefit will be payable to your estate.
No LTD benefit will be payable to you for any
Total or Partial Disability during any of the following periods:
·
any period you are no longer under
the regular and continuing care of a Physician providing appropriate treatment
by means of examination and testing in accordance with your disabling condition.
·
any period you do not submit to
any medical Examination requested by Sun Life.
·
Any period of your Total or
Partial Disability that is due to Mental Illness (mental, nervous,
psychological, emotional diseases, or behavioral disorders of any type), unless
you are under the continuing care of a specialist in psychiatric care.
After you complete your Elimination Period,
LTD benefits are payable for 24
months.
Benefits after the first 24 months are
payable only if you are confined in a
Hospital or Institution licensed to provide
psychiatric treatment.
·
any period of your Total or
Partial Disability that is due to Drug and Alcohol Illness (an illness which
results from the abuse of alcohol, drugs or derivatives), unless you are
actively supervised by a Physician or Rehabilitation Counselor and are receiving
continuing treatment from a rehabilitation center or a designated institution
approved by Sun Life.
After you complete your Elimination Period,
LTD benefits are payable for 24
months if, during the Elimination Period you:
·
become confined in a Hospital or
Institution to provide Drug or Alcohol treatment; or
Benefits after the first 24 months are
payable only if you are confined in a
Hospital or Institution licensed to provide
Drug or Alcohol treatment.
·
any period of your Total or
Partial Disability which begins in the first 12 months after your LTD insurance
becomes effective that is caused by, contributed to by, or resulting from a
Pre-Existing Condition unless your Total or Partial Disability begins after a
period of 3 consecutive months after your LTD insurance becomes effective,
during which you have not received medical treatment, consultation, care or
services, including diagnostic measures, or taken prescribed drugs or medicines.
A Pre-Existing
Condition means any Injury or Sickness for which you have received medical
treatment, consultation, care or services, including diagnostic measures, or
took prescribed drugs or medicines within 3 months of the date your LTD
insurance becomes effective.
No LTD benefit is payable for any Total or
Partial Disability that is due to:
·
intentionally self-inflicted
injuries;
What happens when my
Employer transfers Insurance Carriers to Sun Life?
In order to prevent losing your insurance,
Sun Life will provide the following coverage.
If you are not Actively at work on January
1,1999 you will be insured if:
1.
you were insured under the prior insurer’s group LTD policy at the time
of the transfer; and
Any benefit payable will be determined as
following:
1.
if you have satisfied the Pre-Existing Condition Limitation under the
Group Policy, the LTD benefit will be based on the Group Policy’s benefit
provision.
2. if you cannot satisfy the Group Policy’s
Pre-Existing Condition Limitation, the prior insurer’s pre-existing condition
limitation will be applied.
a.
if you have satisfied the prior insurer’s pre-existing condition
limitation, considering time insured under both group policies, any benefit
payable will the lesser of:
i.
the LTD benefit payable under the Group Policy; or
a.
if you cannot satisfy the Pre-Existing Condition Limitation of the Group
Policy or that of the prior insurer’s group LTD policy, no LTD benefit will be
paid.
CLAIM PROVISIONS
To submit a claim, you or someone on your
behalf must send Sun Life written Notice and Proof of Claim within the time
limits specified. Your Employer has the Sun Life Notice and Proof of Claim
forms.
When does written Notice
of Claim have to be submitted?
for a Death Claim
(accidental or otherwise) – written notice of claim must be given to Sun Life
no later than 30 days after date of death.
for Life Waiver of Premium
– written notice of claim must be given to Sun Life no later than 12 months
after you cease to be Actively at Work.
for Accidental Dismemberment
– written notice of claim must be given to Sun Life no later than 12 months
after the date of your loss.
For Long Term Disability
– written notice of a claim must be given to Sun Life no later than 30 days
before the end of your Elimination Period or, within 30 days of the termination
of the Group Policy, if earlier.
If notice cannot be given within the
applicable time period, Sun Life must be notified as soon as it is reasonably
possible.
When Sun Life has received written notice of
claim, Sun Life will send the forms for proof of claim. If the forms are not
received within 15 days after written notice of claim is sent, proof of claim
may be sent to Sun Life without waiting to receive the proof of claim forms.
When does written Proof
of Claim have to be submitted?
for a death claim
(accidental or otherwise) – proof of claim must be given to Sun Life no later
than 90 days after date of death.
for Life Waiver of Premium
– proof of claim must be given to Sun Life no later that 15 months after you
cease to be Actively at Work.
for Accidental Dismemberment
– proof of claim must be given to Sun Life no later than 15 months after the
date of your loss.
For Long Term Disability
– proof of claim must be given to Sun Life no later than 90 days after the end
of your Elimination Period.
If proof cannot be given within these time
limits, proof must be given as soon as reasonably possible. Proof of claim may
not be given later than one year after the time proof is otherwise required
unless the individual is legally incompetent.
What is
considered Proof of Claim?
Proof of Claim consists of at least the
following information:
·
what the loss or disability is;
(For example: a Death Claim would include at
least the Death Certificate for Proof of Claim)
Proof of Claim for Long Term Disability
Insurance includes, but is not limited to, Hospital records; Physician records;
Psychiatric records; X-rays, narrative reports, or other diagnostic testing
materials as required.
Sun Life may require as part of the proof,
authorization to obtain medical and non-medical information.
Proof of your continued Total Disability and
regular and continuous care by a Physician must be given to Sun Life within 30
days of the request for proof.
Proof must be satisfactory to Sun Life.
Benefits are payable when Sun Life receives
satisfactory Proof of Claim.
Benefits payable upon your death are payable
to your Beneficiary living at the time (other than your Employer). Unless you
otherwise specify, if more than one Beneficiary survives you, all surviving
Beneficiaries will share equally. If no Beneficiary is alive on the date of your
death, payment will be made to your estate.
Survivor Benefit are payable to your Eligible
Survivor as defined in the Long Term Disability Income Benefit Provision.
All other benefits payable during your
lifetime are payable to you.
If a benefit is payable to your estate, if
you are a minor, or you are not competent, Sun Life has the right to pay an
amount of the benefit up to $5,000 to any of your relatives that Sun Life
considers entitled. If Sun Life pays benefits in good faith to a relative, Sun
Life will not have to pay those benefits again.
If your Beneficiary is a minor or is not
competent, Sun Life has the right to pay up to $1,000 to the person or
institution that appears to have assumed custody and main support for the minor,
until the appointed legal representative makes a formal claim. If Sun Life pays
benefits in good faith to a person or institution, Sun Life will not have to pay
those benefits again.
You can change your Beneficiary at any time
on the form provided by Sun Life, unless you have stated your choice of
Beneficiary is irrevocable or you have assigned your interest in you Life
Insurance to another person. Any request for change of Beneficiary must be in
written form and will take effect on the date you sign and file the change with
your Employer. If Sun Life has taken any action or made payment before receiving
notice of that change, your change of Beneficiary will not affect any action or
payment made by Sun Life. The consent of you Beneficiary is not required to
change any Beneficiary.
Can I assign my Life
Insurance?
You can transfer ownership of your Life
Insurance under the Group Policy by means of an absolute assignment. You cannot
make an absolute assignment to your Employer. All your rights and duties as
owner are transferred to the new owner. The new owner can make any change the
Group Policy allows, such as a change of Beneficiary.
Any assignment must be in a written form and
will take effect on the date you sign and file the assignment with your
Employer. If Sun Life has taken any action or made payment before receiving
notice of that change, the assignment will not affect any action or payment made
by Sun Life. Sun Life will not be responsible for the legal, tax or other
effects of any assignment.
How can statements made
in any application for insurance be used?
All statements made in any application are
considered representations and not warranties. No representation by you in
applying for insurance under the Group Policy will be used to reduce or deny a
claim unless a copy of your written application for insurance is or has been
given to you or to your Beneficiary, if any.
No statement made by you or any of your
Dependents, relating to Evidence of Insurability for an initial, increased or
additional amount of insurance, will be used in contesting the validity of that
insurance, after such initial, increased or additional amount of insurance has
been in force for a period of two years during that individual’s lifetime.
This statement must be contained in a form signed by that individual.
What happens if facts are
misstated?
If relevant facts about you or any one of
your Dependents are not accurate:
If the amount of benefit depends on your age,
the benefit will be the amount you would have been entitled to if your correct
age were known.
What are Sun Life’s
examination and autopsy rights?
Sun Life, at its own expense, has the right
to have any person, whose Injury or Sickness is the basis of a claim:
This right may be used as often as reasonably
required.
GENERAL PROVISIONS
Sun Life has the right, in the case of death,
to request an autopsy.
What are the time limits
for legal proceedings?
No legal action may start:
·
until 60 days after Proof of Claim
has been given; nor
Do these group benefits
affect Workers’ Compensation?
The Group Policy is not in lieu of, and does
not affect, any requirement for coverage by Workers’ Compensation Insurance.
Can the Policyholder act
as a Sun Life agent?
For all purposes of the Group Policy, the
policyholder acts on its own behalf or as your agent. Under no circumstances
will the Policyholder be deemed a Sun Life agent.
DEFINITIONS
These are some of the
general terms you need to know.
Actively at Work
means that you perform all the regular duties of your job for a full work day
scheduled by your Employer at your Employer’s normal place of business or a
site where your Employer’s business requires you to travel.
You are considered Actively at Work on any
day that is not your regular scheduled work day (i.e., you are on vacation,
layoff or an approved leave of absence) as long as you:
·
are not hospital confined; or
are not disabled due to an injury or sickness; and
were Actively at Work on your immediately proceeding scheduled work
day.
You are considered Actively at Work if you
usually perform the regular duties of your job at your home as long as you;
·
are not hospital confined; or
Eligibility Date
means the date or dates you become eligible for insurance under the Group
Policy. Classes eligible for insurance are shown in the Benefit Highlights.
Employee (You)
means a person who is employed by the Employer working at least the number of
hours shown in the Benefit Highlights, and paid regular earnings.
Employer means
Mountain Adventures and includes any Subsidiary, Affiliated or
Associated company insured under the Group Policy.
Evidence of Insurability
means a statement or proof of your or your Dependent’s medical history upon
which acceptance for insurance will be determined by Sun Life.
Guaranteed Issue Amount
means the maximum amount of insurance available to you or your Dependent without
Evidence of Insurability.
Injury means bodily impairment resulting directly from an accident and
independently of all other causes. Any Injury must occur and Disability must
begin while you are insured under the Group Policy.
Physician
means an individual who is operating within the scope of his license and is
either:
·
licensed to practice medicine and
prescribe and administer drugs or to perform surgery; or
The Physician cannot be you, your spouse or
the parents, brothers, sisters or children of you or your spouse.
Pregnancy means
childbirth, miscarriage, abortion or any disease resulting from or aggravated by
the pregnancy.
Sickness
means illness, disease or pregnancy. A disability, because of sickness, must
begin while you are insured under the Group Policy.
Waiting Period
means the continuous length of time immediately before your Eligibility Date
during which you must be Actively at Work for your Employer before you can apply
for benefits. Any period of time before the Group Policy Effective Date that you
were Actively at Work for your Employer as a full-time Employee will count
towards completion of your Waiting Period. The Waiting Period is shown in the
Benefit Highlights.
These are Life Insurance
terms you need to know.
Basic Maximum Benefit
means the largest amount of Basic Insurance available to you. The Basic Maximum
Benefit is shown in the Benefit Highlights.
Beneficiary
means the person (it cannot be your Employer) who is entitled to receive death
benefit proceeds as they become due under the Group Policy. A person becomes
your Beneficiary only if you have named that person on a signed form acceptable
to Sun Life.
Certified or Certification
means a written statement made by a Physician, on a form provided by Sun Life,
as to your Terminal Illness.
Retirement for
the purposes of your being considered retired means the first of the following
dates to occur:
1.
the effective date of your retirement benefits under:
a.
any plan of a federal, state, county, municipal or an association
retirement system which you are eligible as a result of your employment with
your Employer;
1.
The effective date of your retirement benefits under the Social Security
Act or any similar plan or act. However, if you meet the definition of an
Employee Actively at Work and you are receiving retirement benefits under Social
Security Act or similar plan or act, you will not be considered retired.
Terminally Ill or Terminal Illness
means your Sickness or physical condition that is Certified by a Physician to
reasonably be expected to result in your death within twelve months or less.
Total Disability or Totally Disabled
means because of your Injury or Sickness, you are unable to perform the material
and substantial duties of any occupation for which you are or become reasonably
qualified for by education, training or experience.
These are Dependent Life
Insurance terms you need to know.
Dependent
means your:
·
Spouse;
Your unmarried step-child, foster child or
adopted child are included as a Dependent if he/she depends on you for 50% or
more of his/her support and are living with you in a regular parent-child
relationship. A child is considered adopted if in your legal custody under an
interim court order or adoption, whether or not a final adoption order is ever
issued.
Dependent does not include:
·
Any person who is insured as an
Employee; or
No person may be considered to be a Dependent
of more than one Employee.
This is an Accidental
Death and Dismemberment Insurance term you need to know.
Accidental Bodily Injury means bodily harm
caused solely by external, violent and accidental means which is sustained
directly and independently of all other causes.
These are Long Term
Disability Insurance Terms you need to know.
Elimination Period means
a period of continuous days of your Total or Partial Disability when no LTD
benefit is payable. Your Elimination Period is shown in the Benefit Highlights
and begins on your first day of Total or Partial Disability.
If you return to work for 15 days or less
during your Elimination Period and cannot continue working, your Total or
Partial Disability will be treated as continuous. Only those days that you are
Totally or Partially Disabled will count toward satisfying your Elimination
Period.
Family Social Security
means benefits that are paid under the Federal Social Security Act to your
Eligible spouse and/or children as a result of your Total or Partial Disability.
Indexed Total Monthly Earnings
means your Total Monthly Earnings immediately before the first date your Total
or Partial Disability began adjusted on the first of the month following 12
months of Partial Disability Benefit payments each annual anniversary
thereafter. Each adjustment to the Indexed Total Monthly Earnings is the lesser
of 10% or current annual percentage increase in the Consumer Price Index for
Wage Earners and Clerical Workers as published monthly by the U.S. Department of
Labor. Sun Life reserves the right to use some other similar measurement if the
Department of Labor changes or stops publishing the Consumer Price Index.
Maximum Monthly Benefit
means the largest amount payable monthly to you. The Maximum Monthly Benefit is
shown in the Benefit Highlights. If Evidence of Insurability has not been
approved for amounts over your Guaranteed Issue Amount, your Maximum Monthly
Benefit is the maximum amount of insurance approved in writing by Sun Life or
the Guaranteed Issue Amount shown in the Benefit Highlights, whichever is
greater.
Partial Disability or Partially Disabled
means because of your Injury or sickness, you are unable to perform all of the
materials and substantial duties of your own occupation on a full-time basis,
but you are:
The loss of your professional or occupational
license or your inability to obtain or qualify for a license for any reason does
not, in itself, constitute Partial Disability.
To qualify for benefits, you must satisfy
your Elimination Period with the required number of days of Total Disability,
Partial Disability or a combination of Total or Partial days of Disability.
Retirement Plan
means a program which provides retirement benefits to you and is not funded
wholly by your contributions. The term does not include a 401(k) plan, a profit
sharing plan, a thrift plan, an individual retirement account (IRA), a
tax-sheltered annuity (TSA), a stock ownership plan, or a nonqualified plan of
deferred compensation.
Your Employer’s Retirement Plan includes
any Retirement Plan which:
·
is part of any federal, state,
county, municipal or association retirement system; and
Disability Benefit when used with the term
Retirement Plan, means a benefit which;
·
is payable under a Retirement Plan
due to a disability as defined in that Plan; and
Social Security
means the Federal Social Security Act which provides social insurance on a
national scale.
Total Disability or Totally Disabled
means during your Elimination Period and the next 24 months of your Total
Disability, you, because of your Injury or Sickness, are unable to perform all
of the material and substantial duties of your own occupation. After benefits
have been paid to you for 24 months you will continue to be considered Totally
Disabled if you are unable to perform all of the material and substantial duties
of any occupation for which you are or become reasonably qualified for by
education, training or experience.
The loss of your professional or occupational
license or your inability to obtain or qualify for a license for any reason does
not, in itself, constitute Total Disability.
To qualify for benefits, you must satisfy
your Elimination Period with the required number of days of Total Disability,
Partial Disability or a combination of Total or Partial days of Disability.
Mountain Adventures Employee
Benefit Plan (The Plan) has been established to provide welfare benefits for its
employees.
The Employee Retirement Income Security Act
of 1974 (ERISA) requires that the Plan Administrator provide you with a Summary
Plan Description which discloses required information about the employee benefit
plan. The following section entitled "Summary Plan Description" is not
part of the Group Insurance Policy. The Information in the Summary Plan
Description is provided by the Policyholder and is included in this
Booklet/Certificate for your convenience for the accuracy or sufficiency of the
information in the Summary Plan Description.
SUMMARY PLAN DESCRIPTION
Plan Sponsor:
Mountain Adventures
P.O. Box 123
Coeur d’Alene, Idaho 83816
Plan Administrator: Mountain Adventures
P.O. Box I
Coeur d’Alene, Idaho 83816
The Plan Administrator has authority to
control and manage the operation and administration of the Plan.
Employer Identification Number (EIN): 12-3456789
Plan Number for Life Insurance:
101
Plan Number for Long Term Disability
Insurance: 103
End of Plan Year: December
31st
Type of Administration:
The Plan is administered by the Plan Administrator. The benefits provided by the
Group Insurance Policy issued by Sun Life Assurance Company of Canada are
included in the Plan.
Participants:
The Insured employees described in the Sun Life Assurance Company of Canada
Booklet/Certificate.
Plan Changes and Termination:
The Plan Administrator may amend, modify or terminate the Plan.
Contributions:
The cost of your benefits under the Plan is paid for by your employer and (if
applicable) include the cost of any insurance premiums contributed by you.
Funding:
Sun Life provides the Plan Administrator with certain insurance benefits in
connection with the Plan. Those insurance benefits are described in your
Booklet/Certificate.
Claim Procedure:
When you or your beneficiary wish to file a claim under the Plan, you should
contact your personnel office for claim forms and instructions for filing. Your
Booklet/Certificate explains the procedure for filing a claim under the Group
Insurance Policy.
If your claim for benefits is denied in whole
or in part, you will receive a written notice within 90 days from the date you
filed your claim, stating the reasons why your claim was denied. You will then
have the right, upon written notice from you or your authorized representative,
to review that claim denial. The claim denial notice will include the name and
address of the person you may ask for such a review. Additional information
about claims submitted and review procedures may be obtained by contacting your
Plan Administrator.
ERISA Rights: As
a participant in the plan, you are entitled to certain rights and protections
under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA
provides that all plan participants shall be entitled to:
Examine, without charge, at the Plan
Administrator’s office, all Plan documents filed by the Plan with the U.S.
Department of Labor, such as detailed annual reports and plan descriptions.
Obtain copies of all Plan documents and other
information upon written request to the Plan Administrator. The Administrator is
required under ERISA to furnish each participant with a copy of this summary
annual report.
In addition to creating rights for Plan
participants, ERISA imposes duties upon the people who are responsible for the
operation of the Plan. The people who operate your plan, called
"Fiduciaries" of the Plan, have a duty to act prudently, in your
interest and that of the other Plan participants and Beneficiaries.
No one, including your employer, may
terminate you or otherwise discriminate against you in any way to prevent you
from obtaining a benefit or exercising your rights under ERISA. If your claim
for a benefit is denied in whole or in part, you must receive a written
explanation of the reason for the denial. You have the right to have the Plan
Administrator review and reconsider your claim.
Under ERISA, there are steps you can take to
enforce the above rights.
For instance, if you request materials from
the Plan and do not receive them within 30 days, you may file suit in a federal
court. In such a case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day until you receive the materials,
unless the materials were not sent because of reasons beyond the control of the
Plan Administrator.
If you have a claim for benefits which is
denied or ignored, in whole or in part, you may file suit in a state or federal
court. If it should happen that Plan Fiduciaries misuse the Plan’s money, or
if you are discriminated against for asserting your rights, you may seek
assistance of the U.S. Department of Labor, or you may file suit in a federal
court. The court will decide who should pay court costs and legal fees. If you
are successful the court may order the person you have sued to pay these costs
and fees. If you lose, the court may order you to pay these costs and fees, for
example, if it finds your claim is frivolous.
If you have questions about your Plan, you
should contact the Plan Administrator. If you have any questions about your
rights under ERISA, you should contact the nearest office of the Pension and
Welfare Benefits Administration, U.S. Department of Labor, listed in your
telephone directory of the Division of Technical Assistance and Inquiries,
Pension and Welfare Benefits Administration, U. S. Department of Labor, 200
Constitution Avenue, N.W., Washington, DC 20210.
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