Commonwealth of Massachusetts Group Insurance Commission
Your Group Long Term Disability Plan
Policy No. 123741 011
Policy No. 125514 011
Policy No. 125515 011
Policy No. 125516 011
Underwritten by Unum Life Insurance Company of America
6/12/2014
CERTIFICATE OF COVERAGE
Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client.
This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in a safe place.
Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any questions about any of the terms and provisions, please consult Unum's claims paying office. Unum will assist you in any way to help you understand your benefits.
If the terms and provisions of the certificate of coverage (issued to you) are different from the policy (issued to the policyholder), the policy will govern. Your coverage may be cancelled or changed in whole or in part under the terms and provisions of the policy.
The policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. When making a benefit determination under the policy, Unum has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy.
For purposes of effective dates and ending dates under the group policy, all days begin at 12:01 a.m. and end at 12:00 midnight at the Policyholder's address.
Unum Life Insurance Company of America
2211 Congress Street
Portland, Maine04122
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TABLE OF CONTENTS
BENEFITS AT A GLANCE...... B@G-LTD-1
LONG TERM DISABILITY PLAN...... B@G-LTD-1
CLAIM INFORMATION...... LTD-CLM-1
LONG TERM DISABILITY...... LTD-CLM-1
GENERAL PROVISIONS...... EMPLOYEE-1
LONG TERM DISABILITY...... LTD-BEN-1
BENEFIT INFORMATION...... LTD-BEN-1
OTHER BENEFIT FEATURES...... LTD-OTR-1
OTHER SERVICES...... SERVICES-1
GLOSSARY...... GLOSSARY-1
TOC-1 (7/1/2014)2
BENEFITS AT A GLANCE
LONG TERM DISABILITY PLAN
This long term disability plan provides financial protection for you by paying a portion of your income while you are disabled. The amount you receive is based on the amount you earned before your disability began. In some cases, you can receive disability payments even if you work while you are disabled.
All terms bolded are defined in the GLOSSARY section.
EMPLOYER'S ORIGINAL PLAN
EFFECTIVE DATE:July 1, 2007
POLICY NUMBER:Refer to the front cover of the certificate
ELIGIBLE GROUP(S) AND MINIMUM HOURS REQUIREMENT:
All full-time and half-time employees who work at least 18 3/4 hours in a 37 1/2 hour work week or 20 hours in a 40 hour work week and who are in active employment in the United States with the Employer and who are not covered under any other Group Unum Long Term Disability policy with the Policyholder
WAITING PERIOD:
For employees in an eligible group on or before July 1, 2007: The first of the month following two full calendar months or 60 days of continuous active employment
For employees in an eligible group after July 1, 2007: The first of the month following two full calendar months or 60 days of continuous active employment
REHIRE:
If your employment ends and you are rehired while maintaining benefits under the Policyholder's COBRA plan, your previous work while in an eligible group will apply towards the waiting period. If your waiting period has been satisfied, you will be eligible to enroll for coverage on the first of the month following your rehire date. All other policy provisions apply.
WHO PAYS FOR THE COVERAGE:
You pay the cost of your coverage.
ELIMINATION PERIOD:
90 days
Benefits begin the day after the elimination period is completed.
MONTHLY BENEFIT:
55% of monthly earnings to a maximum benefit of $10,000 per month.
Your payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be covered or may have limited coverage under this plan.
MINIMUM BENEFIT:
The minimum monthly payment is the greater of:
- $100; or
- 10% of your gross disability payment.
Unum may apply this amount toward an outstanding overpayment.
MAXIMUM PERIOD OF PAYMENT:
Age at DisabilityMaximum Period of Payment
Less than Age 62To Age 65
Age 6242 months
Age 6336 months
Age 6430 months
Age 6524 months
Age 6621 months
Age 6718 months
Age 6815 months
Age 69 or older12 months
No premium payments are required for your coverage while you are receiving payments under this plan. Premium payment is required while you are satisfying your elimination period.
REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFIT:
10% of your gross disability payment to a maximum benefit of $1,000 per month.
In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while:
- you are participating in the Rehabilitation and Return to Work Assistance program; and
- you are not able to find employment.
DEPENDENT CARE EXPENSE BENEFIT:
While you are participating in Unum's Rehabilitation and Return to Work Assistance program, you may receive payments to cover certain dependent care expenses limited to the following amounts:
Dependent Care Expense Benefit Amount: $350 per month, per dependent
Dependent Care Expense Maximum Benefit Amount: $1,000 per month for all eligible dependent care expenses combined
TOTAL BENEFIT CAP (also found on LTD-BEN-2):
The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. However, if you are participating in Unum's Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings.
OTHER FEATURES:
Continuity of Coverage
Disability Plus (Catastrophic Benefit)
Minimum Benefit
Pre-Existing: 12/24
Survivor Benefit
The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section.
The plan includes enrollment, risk management and other support services related to your Employer's Benefit Program.
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CLAIM INFORMATION
LONG TERM DISABILITY
WHEN DO YOU NOTIFY Unum OF A CLAIM?
We encourage you to notify us of your claim as soon as possible, so that a claim decision can be made in a timely manner. Written notice of a claim should be sent within 30 days after the date your disability begins. However, you must send Unum written proof of your claim no later than 90 days after your elimination period. If it is not possible to give proof within 90 days, it must be given no later than 1 year after the time proof is otherwise required except in the absence of legal capacity.
The claim form is available from Unum by calling (877) 226-8620. If you do not receive the form from Unum within 15 days of your request, send Unum written proof of claim without waiting for the form.
You must notify us immediately when you return to work in any capacity.
HOW DO YOU FILE A CLAIM?
You and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum.
WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM?
Your proof of claim, provided at your expense, must show:
- that you are under the regular care of a physician;
- the appropriate documentation of your monthly earnings;
- the date your disability began;
- the cause of your disability;
- the extent of your disability, including restrictions and limitations preventing you from performing your regular occupation; and
- the name and address of any hospital or institution where you received treatment, including all attending physicians.
We may request that you send proof of continuing disability indicating that you are under the regular care of a physician. This proof, provided at your expense, must be received within 45 days of a request by us.
In some cases, you will be required to give Unum authorization to obtain additional medical information and to provide non-medical information as part of your proof of claim, or proof of continuing disability. Unum will deny your claim, or stop sending you payments, if the appropriate information is not submitted.
TO WHOM WILL Unum MAKE PAYMENTS?
Unum will make payments to you.
WHAT HAPPENS IF Unum OVERPAYS YOUR CLAIM?
Unum has the right to recover any overpayments due to:
- fraud;
- any error Unum makes in processing a claim; and
- your receipt of deductible sources of income.
You must reimburse us in full. We will determine the method by which the repayment is to be made.
Unum will not recover more money than the amount we paid you.
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GENERAL PROVISIONS
WHAT IS THE CERTIFICATE OF COVERAGE?
This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you:
- the coverage for which you may be entitled;
- to whom Unum will make a payment; and
- the limitations, exclusions and requirements that apply within a plan.
WHEN ARE YOU ELIGIBLE FOR COVERAGE?
If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of:
- the plan effective date; or
- the day after you complete your waiting period.
WHEN DOES YOUR COVERAGE BEGIN?
Employees eligible for coverage prior to July 1, 2007
You pay 100% of the cost of your coverage. You will be covered at 12:01 a.m. on the latest of:
- the date you are eligible for coverage, if you apply for insurance before that date and had been covered under your Employer's prior carrier plan at any time prior to July 1, 2007, and had not been previously declined with evidence of insurability; or
- the October 1, 2007 following the date you apply for insurance prior to July 1, 2007, and had not been covered under your Employer's prior carrier plan just prior to July 1, 2007, and had not been previously declined with evidence of insurability; or
- the October 1, 2007 following the date you apply for insurance prior to July 1, 2007, if Unum approves your evidence of insurability had you been previously declined by your Employer's prior carrier plan and Unum approves your application prior to October 1, 2007; or
- beyond October 1, 2007, upon Unum's approval date should you apply for insurance prior to July 1, 2007, and the approval of your evidence of insurability, for whatever reason, is after October 1, 2007 had you been previously declined by your Employer's prior carrier plan.
Employees first eligible for coverage on or after July 1, 2007
You pay 100% of the cost of your coverage. You will be covered at 12:01 a.m. on the latest of:
- the date you are eligible for coverage, if you apply for insurance on or before that date;
- the date you apply for insurance, if you apply within 31 days after your eligibility date; or
- the date Unum approves your application, if evidence of insurability is required.
All Employees
Evidence of insurability is required if you:
- are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or
- voluntarily cancelled or declined your coverage and are reapplying.
An evidence of insurability form will be requested by your Employer and mailed directly to you from Unum.
will my policy premium payments change?
Premium payments are subject to change and all negotiations will be handled solely through Unum and the Policyholder.
As a new applicant, WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN?
If you are absent from work due to injury, sickness or approved leave of absence, your coverage will begin on the date you return to active employment.
ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING?
If you are on an approved leave of absence (including a military leave), and if premium is paid, you will be covered for up to 12 months following the date your approved leave of absence begins.
All policy provisions (including exclusions and limitations) while on an approved leave of absence will apply.
ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING DUE TO A PLANT CLOSING?
If you are not working due to a plant closing (as defined in Section 71A of Chapter 151A of the Massachusetts Insurance Statutes), and if premium is paid, you will be covered up to 90 days from the date you were no longer in active employment. If you become covered under any other group disability plan, your coverage under this policy or plan will end.
WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT?
Any change in coverage:
a. due to a change in monthly earnings will take effect on the later of:
- the first day of the second month following the change; or
- when the Policyholder can make the applicable payroll deduction.
b. due to a plan change will take effect immediately.
Any decrease in coverage will not affect a payable claim that occurs prior to the decrease.
You must be in active employment or on a covered approved leave of absence. If you are not in active employment due to injury or sickness, any increase, decrease or additional coverage due to a change in items a. or b. will begin on the date you return to active employment.
WHEN DOES YOUR COVERAGE END?
Your coverage under the policy or a plan ends on the earliest of:
- the date the policy or a plan is cancelled;
- the date you no longer are in an eligible group;
- the date your eligible group is no longer covered;
- the last day of the period for which you made any required contributions; or
- the last day you are in active employment except as provided under the covered approved leave of absence and plant closing provisions, or as noted below.
If you end employment, coverage will be extended for 31 days. But if you become eligible for any other group disability insurance or any other arrangement, this extension of coverage will end.
Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.
WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS?
You can start legal action regarding your claim 60 days after proof of claim has been given and up to 3 years from the time proof of claim is required.
HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED?
Unum considers any statements you or your Employer make in a signed application for coverage a representation and not a warranty. If any of the statements you or your Employer make are not complete and/or not true at the time they are made, we can:
- reduce or deny any claim; or
- cancel your coverage from the original effective date.
We will use only statements made in a signed application as a basis for doing this. No statement of the Employer will be used to void the Policy after it has been in force for 2 years, except in the case of fraud.
If the Employer gives us information about you that is incorrect, we will:
- use the facts to decide whether you have coverage under the plan and in what amounts; and
- make a fair adjustment of the premium.
HOW WILL Unum HANDLE INSURANCE FRAUD?
Unum wants to ensure you and your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution.
It is a crime if you knowingly, and with intent to injure, defraud or deceive Unum, or provide any information, including filing a claim, that contains any false, incomplete or misleading information. These actions, as well as providing false material information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law; including but not limited to, fines, denial or termination of insurance benefits, recovery of any amounts paid, civil damages, criminal prosecution and confinement in state prison. Unum will pursue all appropriate legal remedies in the event of insurance fraud.
DOES THE POLICY REPLACE OR AFFECT ANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE?
The policy does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance.
DOES YOUR EMPLOYER ACT AS YOUR AGENT OR Unum'S AGENT?
For purposes of the policy, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deemed the agent of Unum, nor will Unum be deemed an agent of your Employer.