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GROUP BENEFITS PLAN DISABILITY
 Source Document: Group Benefits Plan,
Board of Education for City of Valdosta,
Long Term Disability
Death and Survivor Benefit
Income Benefit

TABLE OF CONTENTS

Section I

PLAN OF INSURANCE

GENERAL PROVISIONS
THE GROUP INSURANCE POLICY: 5LT-66682
THE POLICY EFFECTIVE DATE: December 29, 1993
THE POLICYHOLDER: BOARD OF EDUCATION FOR CITY OF VALDOSTA

ELIGIBLE CLASSES:  All Active Full-Time Employees. ELIGIBILITY WAITING PERIOD: If you are working for the Policy holder on the Policy Effective Date - The date on which you enter the eligible class.
If you start working for the Policyholder after the Policy Effective Date - The date on which you enter the eligible class.

BASIS OF INSURANCE: This insurance is provided on a Non-Contributory Basis.

ANNIVERSARY DATES: December 29 of each year, beginning in1994.

INTERPRETATION OF POLICY TERMS AND CONDITIONS
The Hartford has full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy.

THE REWRITE OF THIS COVERAGE UNDER POLICY SLT-66682, EFFECTIVE DECEMBER 29, 1993, DOES NOT INTERRUPT COVERAGE BUT CONTINUES COVERAGE IN PLACE OF THE PREVIOUS PLAN PROVIDED UNDER POLICY SLT-60000, ACCOUNT NUMBER 66682, WITH AN EFFECTIVE DATE OF DECEMBER 29, 1980.

DEFINITIONS

ACTIVE FULL TIME EMPLOYEE: 30 hours per week. ELIMINATION PERIOD: The first 150 days of any one period of Total Disability.
If you cease to be Totally Disabled and return to work for a total of 14 days or less during an Elimination Period, the Elimination Period will not be interrupted or extended.
Except for the 14 days or less you work, you must be Totally Disabled by the same condition for the total Elimination Period.

OTHER INCOME BENEFITS: Family Social Security is included.

MONTHLY RATE OF BASIC EARNINGS: Commissions are not included.

DEFINITION OF TOTAL DISABILITY
Totally Disabled means that:

  1. during the Elimination Period; and
  2. for the next 24 months,

you are prevented by Disability from doing all the material and substantial duties of your own occupation on a full time basis. After that, and for as long as you remain Totally Disabled, you are prevented by Disability from doing any occupation or work for which you are or could become qualified by:

  1. training;
  2. education; or
  3. experience.

REPLACEMENT OF PRIOR GROUP LONG TERM DISABILITY PLAN
If you are eligible for benefits for a disability under a prior long term disability plan which:

  1. was sponsored by the Policyholder; and
  2. was terminated on the day before the effective date of this plan, then no benefits will be payable for the Disability under this plan.

BENEFIT PERCENTAGE: 50%
MAXIMUM MONTHLY BENEFIT: $3,500.00
TREATMENT FREE PERIOD: 90 days
PERIOD OF COVERAGE: 365 days
PRE-EXISTING CONDITION LIMITATION: No Loss/No Gain is not included.

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Section II

DEFINITIONS

The terms listed, if used, will have these meanings.

You means the Insured Person to whom this Booklet-certificate is issued.

Contributory Insurance means insurance for which you enroll and agree to pay all or part of the cost.

Non-Contributory Insurance means insurance for which you pay no part of the cost.

Active Full-time Employee means an employee who works for the Policyholder on a regular basis in the usual course of the Policy holder’s business. The employee must work the number of hours in the Policyholder’s normal work week. This must be at least the number of hours indicated in the Plan of Insurance.

Disability means any accidental bodily injury, sickness, or pregnancy.

Eligibility Waiting Period means the number of continuous days of service you must satisfy as an Active Full-time Employee in a class eligible for insurance before your coverage under the Group Insurance Policy becomes effective. See the Plan of Insurance for the Eligibility Waiting Period.

Elimination Period means the period of time you must be Totally Disabled before benefits become payable. See the Plan of Insurance for the Elimination Period.

Monthly Benefit means a monthly sum payable to you while you are Disabled, subject to the terms of the Group Insurance Policy.

Pre-existing Condition means any Disability, diagnosed or undiagnosed, for which you receive Medical Care during the 365 day period which ends on the day before:

  1. your effective date of insurance; and
  2. the effective date of a Change in Coverage.

All manifestations, symptoms or findings which result:

  1. from the same or related Disability; or
  2. from any aggravations of a Disability,

are considered to be the same Disability for the purpose of deter mining a Pre-existing Condition.

Medical Care means care which is received when:

  1. a Physician is consulted or medical advice is given; or
  2. treatment is recommended or prescribed by, or received from a Physician.

Treatment, as used above, includes, but is not limited to:

  1. any medical examinations, tests, attendance or observation;
  2. any medical services, supplies or equipment, including their prescription or use; or
  3. any prescribed drugs or medicines, including their prescription or use.

Physician means a legally qualified physician who is practicing within the scope of his license.

Other Income Benefits means the benefits shown below:

  1. The amount of disability, retirement, pension or annuity benefits from any:
  1. group insurance or pension plan;
  2. military retirement pension plan;
  3. Railroad Retirement Act;
  4. plan or arrangement of coverage, whether insured or not, as a result of employment by or association with the Policyholder or as a result of membership in or association with any:
    1. group;
    2. association;
    3. union; or
    4. other organization; or
  5. plan provided by law.
  1. The amount of benefits to which you are entitled under any:
  1. workers’ compensation law;
  2. occupational disease law;
  3. unemployment compensation law;
  4. compulsory benefit act or law; or
  5. other act or law of like intent.
  1. Any damages or settlement (exclusive of fees and interest) which is made in lieu of workers’ compensation benefits and paid to you, your employer, or a workers’ compensation insurer; but only to the extent that any damages or settlement represent you
  2. The amount of disability or retirement benefits under the United States Social Security Act to which you may be entitled because of disability or retirement.
  3. If Family Social Security is included in your Plan of Insurance, the amount of disability or retirement benefits under the United States Social Security Act to which your spouse and children may be entitled because of your disability or retirement.

Other Income Benefits will include:

  1. early retirement benefits if you so elect;
  2. disability income benefits under a group life insurance plan regardless of whether you may or may not elect to apply for such benefits even though you are Disabled; and
  3. temporary and permanent disability benefits provided under any Workers’ Compensation law or any other act or law of like intent.

If you are paid Other Income Benefits in a lump sum, The Hartford will pro-rate the lump sum:

  1. over the period of time it would have been paid if not paid in a lump sum; or
  2. if such period of time cannot be determined, over a period of 60 months.

If you are Disabled and you receive Other Income Benefits in a lump sum, they will be considered Other Income Benefits regardless of any roll-over provision or election into any fund, plan or arrangement. The Hartford may make a retroactive allocation of any retroactive Other Income Benefit payments.

Other Income Benefits will not include:

  1. any disability income received from a “no-fault” automobile policy;
  2. proceeds from any;
  1. source of personal investment income;
  2. personal disability income plan, unless the plan is obtained through a group-sponsored or employer-related program; or
  3. Veteran’s Administration Disability benefits.
  1. distribution from any form of profit sharing regardless of pre-tax or after-tax treatment as found under Section 401(k) of the Internal Revenue Code;
  2. proceeds or income from any:
  1. Individual- or employer- sponsored I.R.A., Individual Tax Sheltered Annuity, or any deferred compensation plan;
  2. Employee Stock Option Plan or any thrift plan;
  3. a partner or proprietor H.R. 10 (Keogh Plan) under the Self-Employed Individual Tax Retirement Act; or
  4. a capital account.
  1. the amount of any increase in benefits paid under any federal or state law, if the increase:
  1. takes effect after the date benefits become payable under the Policy; and
  2. is a general increase which:
    1. is required by law; and
    2. applies to all persons who are entitled to such benefits.

Salaried Employee means an Active Full-time Employee who:

  1. does only tasks which are administrative, sales, clerical or supervisory; and
  2. is paid by the Policyholder on a regular salaried basis.

Non-Salaried Employee means an Active Full-time Employee who:

  1. is paid by the hour; or
  2. does not meet this plan’s definition of Salaried Employee.

Rehabilitative Employment means employment or service which:

  1. prepares a Disabled person to resume gainful work; and
  2. is approved, in writing, by The Hartford.

The term Rehabilitative Employment will include, when appropriate, any necessary and feasible:

  1. vocational testing;
  2. vocational training;
  3. work-place modification;
  4. prosthesis; and
  5. job placement.

Monthly Income means the sum of:

  1. your Monthly Rate of Basic Earnings; and
  2. any disability or retirement benefits which were being paid before you became Totally Disabled, except any benefits:
  1. provided by the Policyholder’s Employee Benefit Plan;
  2. paid by a personal policy; or
  3. received from the Veteran’s Administration.

Monthly Rate of Basic Earnings means your regular monthly pay, not counting:

  1. commissions*;
  2. bonuses;
  3. overtime pay; or
  4. any other fringe benefit or extra compensation.

If you become Totally Disabled, your Monthly Rate of Basic Earnings will be the rate in effect on your last day as an Active Full-time Employee before becoming Disabled.
*See the Plan of Insurance to determine whether Monthly Rate of Basic Earnings includes commissions.

Current Monthly Earnings means the monthly earnings you receive from any employer or for any work, while Disabled and eligible for Disability benefits under this plan.

Pre-disability Earnings means your Monthly Rate of Basic Earnings in effect on the date immediately prior to becoming Totally Disabled.

Disabled means Totally Disabled.

Totally Disabled: See the Plan of Insurance for the definition of Totally Disabled.

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Section III

DATES OF ELIGIBILITY AND COVERAGE

Eligible Persons: All persons who are in the class or classes which are shown on the Plan of Insurance will be considered Eligible Persons.

When You Are Eligible: You will become eligible for coverage on either:

  1. the Policy Effective Date, if you have completed the Eligibility Waiting Period; or if not
  2. the date on which you complete the Eligibility Waiting Period.

See the Plan of Insurance for the Eligibility Waiting Period.

When You Are Insured - Non-Contributory Insurance: Your coverage will begin on the date you become eligible.

When You Are Insured - Contributory Insurance: Your coverage will begin on the earliest to occur of the following dates:

  1. the date you become eligible, if you enroll or have enrolled by then;
  2. the date on which you enroll, if you do so within 31 days after the date you are eligible; or
  3. the date The Hartford approves evidence of insurability. Evidence is required if you enroll more than 31 days after you become eligible. Any evidence of insurability must be furnished at your own expense.

If you become ineligible for insurance before you submit any required evidence of insurability to The Hartford, and you later become eligible, you will still be required to furnish such evidence.
All of the above dates are subject to the Deferred Effective Date provision below.

Deferred Effective Date: If you are absent from work due to Disability on the date your insurance would otherwise have become effective, your effective date will be deferred. Your insurance will not become effective until you work one regular working day.

Enrollment: To enroll for insurance, you must:

  1. complete and sign a group insurance enrollment card which is satisfactory to The Hartford; and
  2. deliver it to the Policyholder.

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Section IV

TERMINATION

Termination Date of Insurance

Your insurance will terminate on the earliest to occur of the following dates:

  1. the date the Group Insurance Policy terminates;
  2. the date premium payment is due but not paid by the Policy holder;
  3. the last day of the period for which you make any required premium contribution, if you fail to make any further required contribution;
  4. the date on which you attain age 70;
  5. the date on which you become a retired employee;
  6. the first day on which you receive benefits from a pension plan provided or sponsored by your employer;
  7. the date on which you receive benefits under any social security law, other than benefits which become payable solely because of disability;
  8. the date your employment terminates. Your employment terminates on the date you cease to be an Active Full-time Employee:
  1. in a class eligible for insurance; or
  2. due to temporary layoff, leave of absence or a general work stoppage (including a strike or lockout).

However, if you should be unable to work because of disability, you should inquire of the Policyholder as to your rights, if any, under the policy.

Continuation of Insurance

If you are Disabled and you cease to be an Active Full-time Employee, your insurance will be continued:

  1. during the Elimination Period while you remain Totally Disabled by the same Disability; and
  2. after the Elimination Period for as long as you are entitled to benefits under the Policy.

During the period for which you are so entitled to benefits, no premium will be due for you.

Extension of Benefits

If you are entitled to benefits while Disabled and the Group Insurance Policy terminates, benefits:

  1. will continue as long as you remain Disabled by the same Disability, but
  2. will not be provided beyond the date The Hartford would have ceased to pay benefits had the insurance remained in force.

Termination of the Group Insurance Policy for any reason will have no effect on The Hartford’s liability under this provision.

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Section V

BENEFITS

Article 1. Benefit Payment Due to Disability
You will be paid a monthly benefit if:

  1. you become Totally Disabled while insured under this plan;
  2. you are Totally Disabled throughout the Elimination Period;
  3. you remain Disabled beyond the Elimination Period; and
  4. you submit Proof of Loss satisfactory to The Hartford.

Benefits accrue as of the first day after the Elimination Period and are paid monthly. No benefit will be paid for any day on which you are not under the care of a Physician.

The Hartford will cease benefit payment on the first to occur of:

  1. the date you are no longer Disabled;
  2. the date you fail to furnish proof that you are continuously Disabled;
  3. the date you refuse to be examined, if The Hartford requires an examination;
  4. the date you die; or
  5. the date determined from the table below.

MAXIMUM DURATION OF BENEFITS TABLE

Age When Totally Disabled Benefits Payable
Prior to Age 60 To Age 65
Age 62 - 64 60 months
Age 65 - 67 To Age 70
Age 68 and over 24 months

 

Article 1.A Benefit Payment Due to Mental Illness or Substance Abuse

If you are Disabled because of:

  1. psychosis or neurosis;
  2. any condition caused, contributed to, or made disabling by a psychosis or neurosis;
  3. alcoholism; or
  4. the non-medical use of narcotics, sedatives, stimulants, hallucinogens, or any other such substance,

then, subject to all other Policy provisions, benefits will be payable:

  1. only for so long as you are confined in a hospital or other place licensed to provide Medical Care for your Disability; or
  2. when you are not so confined, a total of 24 months for all such Disabilities during your lifetime.

Article 1.B Benefit Payment due to Rehabilitative Employment
If you are Totally Disabled and if you are engaged in a program of Rehabilitative Employment, then you will continue to be paid a Monthly Benefit.
The amount payable will be based on the last Monthly Benefit payable prior to the commencement of Rehabilitative Employment and will be reduced by 60% of any income received from each month of Rehabilitative Employment.
The sum of your Monthly Benefit and total income received under this provision may not exceed 100% of your Pre-disability Earnings. If this sum exceeds your Pre-disability Earnings, the Monthly Benefit paid by The Hartford will be reduced proportionately.

Article 2. Successive Periods of Disability
If successive Periods of Disability are:

  1. due to the same cause; or
  2. due to a related cause; and
  3. separated by 6 months or less,

then they will be considered one Period of Disability, provided the Group Insurance Policy remains in force. The term Period of Disability as used in this provision means a continuous length of time during which you are Disabled under this plan.

Article 3. Calculation of Monthly Benefit
To determine the Monthly Benefit The Hartford will pay each month while you are Disabled:

  1. multiply your Monthly Income by the Benefit Percentage;
  2. take the lesser of:
  1. the resulting product; or
  2. the Maximum Monthly Benefit;
  1. carry forward the amount in item (2) above and from it subtract:
  1. all Other Income Benefits, including those for which you could collect but did not apply;
  2. 50% of income from Rehabilitative Employment; and (C) all other income from any employer or for any work.

The resulting sum will be your Monthly Benefit.
If a Monthly Benefit is payable for less than a month, The Hartford will pay 1/30 of the Monthly Benefit for each day you were Disabled.
See the Plan of Insurance for the Benefit Percentage factor and Maximum Monthly Benefit.
See Section II, Definitions for the meanings of Monthly Income and Other Income Benefits.
 

Article 4. Change in Coverage
Change in Class or Monthly Rate of Basic Earnings
Your coverage may increase or decrease on the date there is a change in your class or Monthly Rate of Basic Earnings. However, no increase in coverage will be effective unless on that date you:

  1. are an Active Full-time Employee; and
  2. were not absent from work due to Disability during the 30 day period before the change in class or earnings.

A change in your Rate of Basic Earnings will become effective on the date The Hartford receives notice of the change.

Change in the Plan of Insurance
Any decrease in coverage because of a change in the Plan of Insurance will become effective on the date of the change.
Any increase in coverage because of a change in the Plan of Insurance will become effective on the date of the change, subject to the following limitations:

  1. If you are absent from work due to Disability, the increase will not become effective until you return to work as an Active Full-time Employee.
  2. If you are Disabled due to or contributed to by a Pre-existing Condition which commenced prior to the increase, the increase will not be effective for Disabilities beginning on or after the effective date of the increase until the earlier of:
  1. the last day of a Treatment Free Period which begins while insured and during which you did not receive Medical Care for the Pre-existing Condition; or
  2. the last day of a Period of Continuous Coverage under the Group Insurance Policy.

See the Plan of Insurance for the Treatment Free Period and Period of Continuous Coverage.

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Section VI

EXCLUSIONS

Exclusions
The plan does not cover and no benefit will be payable for any Disability which:

  1. is caused by your commission of or attempt to commit assault, battery, or felony;
  2. is due to:
  1. war;
  2. any act of war (declared or not);
  3. insurrection;
  4. rebellion; or
  5. your taking part in a riot or civil disorder; or
  1. is due to or contributed to by a Pre-existing Condition.

Pre-existing Conditions Limitations
The following exception(s) will apply to Exclusion (3):

  1. Exclusion (3) will not apply if you become Disabled on or after the first to occur of the following dates:
  1. the last day of a Treatment Free Period which begins while insured and during which you did not receive Medical Care for the Pre-existing Condition; or
  2. the last day of a Period of Continuous Coverage under the Group Insurance Policy.

See the Plan of Insurance for the Treatment Free Period and Period of Continuous Coverage.

This paragraph applies only if No Loss/No Gain is included in your Plan of Insurance.

  1. If you:
  1. become insured under the Group Insurance Policy on the Policy Effective Date; and
  2. were insured under the long term disability insurance (here called the Prior Plan) carried by the Policyholder on the day before the Policy Effective Date;

then Exclusion (3) will cease to apply if you are Disabled due to or contributed by a Pre-existing Condition on the first to occur of the following dates:

  1. the Policy Effective Date, if your coverage for the Disability was not limited by a Pre-existing Condition restriction under the Prior Plan; or
  2. the date this restriction would have ceased to apply had the Prior Plan stayed in force.

If Exclusion (3) does not apply or ceases to apply only because of the preceding terms of this Pre-existing Condition Limitation, benefit payments will be subject to both limitations below:

  1. No Monthly Benefit payment will exceed the lesser of the Monthly Benefit:
    i.    which would have been paid by the Prior Plan; or
    ii.    provided by this plan.
  2. No payment shall be made after the earlier to occur of:
    i.    the date payments would have ceased under the Prior Plan; or
    ii.    the date payments cease under this plan.

These exceptions will not apply to a period of Total Disability which commences on or after the earlier of the dates stated in item (1).

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Section VII

GENERAL PROVISIONS

Incontestability
Except for non-payment of premium, the Group Insurance Policy can not be contested after two years from the Policy’s Effective Date.  No statement made by a Covered Person relating to his or her insurability will be used to contest the insurance for which the statement was made after the insurance has been in force for two years during the Covered Person’s lifetime. In order to be used, the statement must be in writing and signed by the Covered Person.

CLAIMS
Notice of Claim
You must give The Hartford written notice of a claim within 20 days after the loss happens or starts. If notice cannot be given within that time, it must be given as soon as possible. Such notice must include your name, your address and the Policy number.

Claim Forms
When The Hartford receives a Notice of Claim, you will be sent forms for providing The Hartford with Proof of Loss. The Hartford will send these forms within 15 days after receiving a Notice of Claim. If The Hartford does not send the forms within 15 days, you may submit any other written proof which fully describes the nature and extent of your claim.

Proof of Loss
Written proof of loss must be sent to The Hartford within 90 days after the start of the period for which The Hartford owes payment. After that, The Hartford may require further written proof that you are still Disabled. If proof is not given by the time it is due, it will not affect the claim if:

  1. it was not possible to give proof within the required time; and
  2. proof is given as soon as possible; but
  3. not later than 1 year after it is due, unless you are not legally competent.

The Hartford has the right to require, as part of Proof of Loss:

  1. your signed statement identifying all Other Income Benefits; and
  2. proof satisfactory to The Hartford that you and your dependents have duly applied for all Other Income Benefits which are available.

The Hartford reserves the right to determine if Proof of Loss is satisfactory.
You will not be required to claim any retirement benefits which you may only get on a reduced basis.

Payment of Claims
All payments are payable to you. Any payments owed at your death may be paid to your estate. If any payment is owed to your estate, a person who is a minor or a person who is not legally competent, then The Hartford may pay up to $1 ,000 to any of your relatives who is entitled to it in the opinion of The Hartford. Any such payment shall fulfill The Hartford’s responsibility for the amount paid.

Time Payment of Claims
If written Proof of Loss is furnished, accrued benefits will be paid at the end of each month that you are Disabled. If payment for a part of a month is due at the end of the claim, it will be paid as soon as written Proof of Loss is received.

Appeal of Claims Denied
If a claim for benefits is wholly or partly denied, you will be furnished with written notification of the decision. This written decision will:

  1. give the specific reason(s) for the denial;
  2. make specific reference to the policy provisions on which the denial is based;
  3. provide a description of any additional information necessary to prepare a claim and an explanation of why it is necessary; and
  4. provide an explanation of the review procedure.

On any denied claim, you or your representative may appeal to The Hartford for a full and fair review. You may:

  1. request a review upon written application within 60 days of the claim denial;
  2. review pertinent documents; and
  3. submit issues and documents in writing.

A decision will be made by The Hartford no more than 60 days after the receipt of the request, except in special circumstances (such as the need to hold a hearing), but in no case more than 120 days after the request for review is received. The written decision will include specific references to the policy provisions on which the decision is based.

Legal Actions
Legal action cannot be taken against The Hartford:

  1. sooner than 60 days after due Proof of Loss has been furnished; or
  2. after the shortest period allowed by the laws of the state where the Policy is delivered. Except as noted below, this is 3 years after the time written Proof of Loss is required to be furnished according to the terms of the Policy.
EXCEPTIONS: Kansas — 5 years
S. Carolina — 6 years		 after the time
written proof of
loss is required
to be furnished

Physical Examination
The Hartford may have you examined to determine if you are Disabled. Any such examination will be:

  1. at The Hartford’s expense; and
  2. as reasonably required by The Hartford.

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