HomeMy WebLinkAboutResolution - 2001-R0478 - Contract For Long Term Disability Insurance - Canada Life Assurance Company - 11/08/2001Resolution No. 2001-RO478
November 8, 2001
Item No. 31
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock, a Contract for long term
disability insurance, by and between the City of Lubbock and Canada Life Assurance
Company of Dallas, Texas. Said Contract is attached hereto and incorporated in this
resolution as if fully set forth herein and shall be included in the minutes of the City
Council.
Passed by the City Council this 8th day of November , 2001.
4N4D1'k1TON"4MAYOR
ATTEST:
Rebecca Garza, City Secretary �
APPROVED AS TO CONTENT:
4� -
Victor Kilman, Purchasing Manager
APPROVED AS TO FORM:
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gs/ccdocs/Contract-Canada Life Assurance Co.res
Oct. 29, 2001
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Resolution No. 2001-RO478
November 8, 2001
Item No. 31
AGREEMENT BY AND BETWEEN
THE CITY OF LUBBOCK, TEXAS AND
THE CANADA LIFE ASSURANCE COMPANY
THIS AGREEMENT entered into this 1 st day of January, 2002 by and between the
CITY OF LUBBOCK, TEXAS, a municipal home rule corporation (herein called "City")
and CANADA LIFE ASSURANCE COMPANY (herein called "Administrator") to provide
services for the purpose of the Group Long Term Disability Income Plan.
WHEREAS, the City desires to have services provided for group long term
disability; and
WHEREAS, the Administrator has demonstrated that it can provide said
services; and
WHEREAS, the City and the Administrator desire to enter into an Agreement
to provide said services.
NOW, THEREFORE, the parties agree as follows:
1. The City agrees to pay monthly premiums to the Administrator according
the rate schedule which is attached hereto as Exhibit "A" which is
incorporated as if fully set north herein. Administrator agrees to a three-year
rate guarantee.
2. The parties agree to abide by the terms and conditions of the "Group Long
Term Disability Income Policy" which is attached hereto as Exhibit `B"
which is incorporated as if fully set forth herein.
3. This agreement is for a term of one (1) year from the effective date and may
be extended for two (2) additional one (1) year terms at the mutual
agreement of both parties.
4. Notices or communications from the Company to the Administrator shall be
addressed to the Administrator and shall be deemed to be duly given or
served, if the same shall be sent by post office mail, telegraph, telex, FAX,
or other similar or analogous means, to the address shown below, unless the
Company has been requested to send such communications to another
address:
The Canada Life Assurance Company
Attn: Jay Beck
8201 Preston Road,. Suite 715
Dallas, TX 75225
y
Notices or communications from the Administrator to the Company
shall be addressed to the Company and shall be deemed to be duly given
or served if the same shall be sent by post office mail, telegraph, telex,
FAX, or other similar or analogous means, to the address shown below,
unless the Company has been requested to send such communication to
another address:
The City of Lubbock
Attn: Human Resources Benefits Department
P.O. Box 2000
Lubbock, TX 79457
Notices and communications described in this paragraph that are sent by
post office mail will be deemed duly given or served on the third
business day following the date the notice is mailed.
5. This contract shall be construed and enforced according to the laws of
the State of Texas. Venue shall be Lubbock County, Texas.
6. The City may terminate the services of the Administrator at any time
upon giving to the Administrator 90 days written notice of its intention
to do so. The Administrator may resign at any time upon 90 days notice
in writing to the City. The Administrator upon its resignation shall
complete the processing of all services de,,--;ribed in this Agreement
which have commenced prior to the effective date of the termination of
this Agreement.
SIGNED THIS DAY, the2�>-flf 5��'ro�3f�L , 2001.
&CITY.OF L401N,-Mayor
ATTEST:
4Recca Garza, City Secretary
CANADA LIFE
ASURANCE COMPANY
Title
APPROVED AS TO CONTENT:
Mary Hous , Managing Director
of Human Resources
APPROVED AS TO FORM:
William de Haas
Contract Manager
'EXHIBIT A" Resolution No. 2001- R0478
Canada Life Assurance Company
City of Lubbock #38432, LTD Contract
The LTD rates are as follows:
.27 for the employer paid portion
123 for the employee paid benefit
Resolution No. 2001-RO478
"EXHitifi
CITY OF LUBBOCK
GROUP LONG TERM DISABILITY
PLAN
GDC97
TABLE OF CONTENTS
STATEMENT TO INSUREDS.........................................................................1
IMPORTANTNOTICE.......................................................................................2
AVISOINTORTANTE....................................................................................... 2
SCHEDULE OF INSURANCE.........................................................................5
DEFINITIONS...................................................................................................7
GENERAL DEFINITIONS....................................................................7
DEFINITION OF DISABILITY AND DISABLED ...........................13
RECURRENT DISABILITY...............................................................15
CONCURRENT DISABILITY............................................................15
BECOMING INSURED..................................................................................16
WHi1N YOUR INSURANCE BEGINS...............................................16
C 3ANGEF IN INSURANCE..........................................................................17
CHt;NGE IN CLASS OR MONTHLY EARNINGS .........................17
WHEN YOUR INSURANCE ENDS..............................................................18
INCOME FROM OTHER SOURCES...........................................................20
COST OF LIVING FREEZE IN INCOME FROM OTHER
SOURCES.............................................................................................22
AMOUNT OF MONTHLY INCOME PAYMENT ....................................... 23
EXCLUSIONS AND LIMITATIONS............................................................ 28
PRE-EXISTING CONDITION EXCLUSION...................................28
GENERAL EXCLUSIONS..................................................................29
DISABILITY LIMITATIONS.............................................................30
WHEN YOUR MONTHLY INCOME BENEFITS END .............................32
BENEFITS AFTER POLICY CANCELLATION .............................34
PREMIUM WAIVER...........................................................................34
CONTINUITY OF COVERAGE UPON CHANGE OF INSURERS .........34
SURVIVORBENEFIT.................................................................................... 36
REHABILITATION FEATURE....................................................................37
CLAIM PROVISIONS....................................................................................39
NOTICE OF CLAIM...........................................................................39
PROOF OF DISABILITY....................................................................39
T 1VIE OF PAYMENT OF CLAIM.....................................................39
EXAMINATIONS................................................................................. 39
OUR RIGHT TO R ".QUIRE PROOF OF FINANCIAL LOSS .......40
PROOF OF CC NTINUING DISABILITY........................................40
IF YOUR CLAIM IS DENIED............................................................41
GENERAL PROVISIONS..............................................................................42
ASSIGNMENT......................................................................................
42
CURRENCY..........................................................................................
42
CLASS MEB!BERSHIP.......................................................................42
MISREPRESENTATION OF EMP7,OYEE INSURANCE..............42
INCONTESTABILITY OF EMPLC YEE INSURANCE..................42
MISSTATEMENT OF AGE OR OTHER FACTS ............................43
ERRORS................................................................................................
43
AGENCY...............................................................................................
43
CHANGES TO POLICY.....................................................................43
ENFORCEMENT OF POLICY TERMS ...........................................
44
LEGAL ACTIONS...............................................................................44
EFFECT ON WORKERS' COMPENSATION.................................44
SUMMARY PLAN DESCRIPTION INFORMATION................................45
STATEMENT TO INSUREDS
THE CANADA LIFE ASSURANCE COMPANY
HEAD OFFICE: 6201 POWERS FERRY RD., NW
ATLANTA, GEORGIA, 30339
HAS ISSUED
GROUP DISABILITY INCOME POLICY 38432 LTD
TO
CITY OF LUBBOCK
This Booklet -Certificate is issued to insured persons as evidence of their coverage.
It explains the features of the group plan. Canada Life urges You to read it with
care so that You will have a full understanding of the Plan and what it could mean
to You and Your family.
This Booklet -Certificate takes the place of all certificates which may have been
issued to You before. It is an important document and should be kept in a safe
place. It is void and of no effect if You are not entitled to or have ceased to be
entitled to the insurance coverage. No clerical error will invalidate Your insurance
coverage if it is otherwise validly in force.
Fraud:
It is a crime if, knowingly, and with intent to injure, You defraud or deceive Us, or
provide any information that contains any false, incomplete or misleading
information. These actions, as well as submission of materially false 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. Canada Life will pursue all
appropriate legal remedies in the event of Insurance fraud.
GDC97-02
IMPORTANT NOTICE
AVISO IMPORTANTE
To obtain information or make a Para obtener informacion o para
complaint: someter una queja:
1. You may call The Canada
Life Assurance Company's
toll-free telephone number
for information or to make a
complaint at
1-800-554-4026
2. You may contact the Texas
Department of Insurance to
obtain information on
companies, coverages, rights
or complaints at
1-800-252-3439
3. You may write the Texas
Department of Insurance
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
4. PREMIUM OR CLAIM
DISPUTES: Should you
have a dispute concerning
your premium or about a
claim you should contact the
company The Canada Life
Assurance Company first. If
the dispute is not resolved,
you may contact the Texas
Department of Insurance.
5. ATTACH THIS NOTICE
TO YOUR POLICY: This
notice is for information only
and does not become a part
or condition of the attached
document.
1. Usted puede llamar al numero
de telefono gratis de Canada
Life Assurance Company's para
informacion o para someter una
queja al
1-800-554-4026
2. Puede comunicarse con el
Departamento de Seguros de
Texas para obtener informacion
acerca de companias,
coberturas, derechos o quejas al
1-800-252-3439
3. Puede escribir al Departamento
de Seguros de Texas
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
4. DISPUTAS SOBRE PRIMAS
O RECLAMOS: Si tiene una
disputa concerniente a su
prima o a un reclamo, debe
comunicarse con la compania.
The Canada Life Assurance
Company primero. Si no se
resuelve la disputa puede
entonces comunicarse con el
departamento (TDI).
5. UNA ESTE AVISO A SU
POLIZA: Este aviso es solo
para proposito de informacion
y no se convierte en parte o
condicion del documento
adjunto.
IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS
LIFE, ACCIDENT, HEALTH AND HOSPITAL SERVICE INSURANCE
GUARANTY ASSOCIATION
Texas law establishes a system, administered by the Texas Life, Accident, Health
and Hospital Service Insurance Guaranty Association (the "Association"), to
protect policyholders if their life or health insurance company fails to or cannot
meet its contractual obligations. Only the policyholders of insurance companies
which are members of the Association are eligible for this protection. However,
even if a company is a member of the Association, protection is limited and
policyholders must meet certain guidelines to qualify.
(The law is found in the Texas Insurance Code, Article 21.28-D.)
BECAUSE OF STATUTORY LIMITATIONS ON POLICYHOLDER
PROTECTION, IT IS POSSIBLE THAT THE ASSOCIATION MAY NOT
COVER YOUR POLICY OR MAY NOT COVER YOUR POLICY IN FULL.
Eligibility for Protection by the Association
When an insurance company which is a member of the Association is designated
as impaired by the Texas Commissioner of Insurance, the Association provides
coverage to policyholders who are:
RESIDENTS OF TEXAS at the time that their insurance company is
impaired
• RESIDENTS OF OTHER STATES , ONLY if the following conditions are
met:
1) The policyholder has a policy with a company based in
Texas;
2) The company has never held a license in the policyholder's
state of residence;
3) The policyholder's state of residence has a similar guaranty
association; and
4) The policyholder is not eligible for coverage by the guaranty
association of the policyholder's state of residence.
Limits of Protection by the Association
Accident, Accident and Health, or Health Insurance:
• up to a total of $200,000 for one or more policies for each covered
individual.
Life Insurance:
• net cash surrender value up to a total of $100,000 under one or more
policies on any one life; or
• death benefits up to a total of $300,000 under one or more policies on
any one life.
Individual Annuities:
• net cash surrender amount up to a total of $100,000 under one or more
policies owned by one contractholder.
Group Annuities:
• net cash surrender amount up to $100,000 in allocated benefits under
one or more policies owned by one contractholder; or
• net cash surrender amount up to $5,000,000 in unallocated benefits
under one contractholder regardless of the number of contracts.
THE INSURANCE COMPANY AND ITS AGENTS ARE PROHIBITED BY
LAW FROM USING THE EXISTENCE OF THE ASSOCIATION FOR THE
PURPOSE OF SALES, SOLICITATION, OR INDUCEMENT TO PURCHASE
ANY FORM OF INSURANCE.
When you are selecting an insurance company, you should not rely on coverage by
the association.
Texas Life, Accident, Health and Hospital Texas Department of Insurance
Service Insurance Guaranty Association P.O. Box 149104
301 Congress, Suite 500 Austin, Texas 78714-9104
Austin, Texas 78701 (800)252-3439
(800)982-6362
SCHEDULE OF INSURANCE
Option: 1
Description: Each person electing Option 1
Service Waiting Period: Completion of a full bi-weekly pay period of
continuous employment provided that You were
Actively at Work on Your last scheduled work
day.
Benefit Percentage: 60%
Maximum Benefit: $5,000
Option:
2
Description: Each person electing Option 2
Service Waiting Period:
Completion of a full bi-weekly pay period of
continuous employment provided that You were
Actively at Work on Your last scheduled work
day.
Benefit Percentage:
662/3%
Maximum Benefit:
$5,000
Minimum Benefit: At no time will Your benefit be less than $100
unless otherwise provided under the terms and
conditions of this policy.
Your Monthly Income Benefit helps to protect You from loss of income due to a
Disability as defined in the Policy. Your Monthly Income Benefit is subject to
maximums and to reductions by Your Income From Other Sources. Refer to the
Amount of Monthly Income Benefit for Disability sections for details about how
Your Monthly Income Benefit is calculated.
Elimination Period: 180 days for you if you elect Option 1 and 90
days if you elect Option 2
5
Maximum Benefit Period:
AGE AT DATE MAXIMUM BENEFIT PERIOD
DISABILITY
COMMENCES
Under 60
to age 65 (a minimum of 60 Monthly Income
Benefit payments will be made).
60
60 Monthly Income Benefit payments
61
48 Monthly Income Benefit payments
62
42 Monthly Income Benefit payments
63
36 Monthly Income Benefit payments
64
30 Monthly Income Benefit payments
65
24 Monthly Income Benefit payments
66
21 Monthly Income Benefit payments
67
18 Monthly Income Benefit payments
68
15 Monthly Income Benefit payments
69 or over
12 Monthly Income Benefit payments
Premium Contributions: Option 1: Your coverage is non-contributory.
This means Your employer pays all of Your
premium for you.
Option 2: Your coverage is contributory. This
means You pay all of Your premium.
You must read this Schedule of Insurance in conjunction with the rest of the
Policy.
GDC97-03
0
DEFINITIONS
Below are the terms as defined in the Policy.
All male terms will include the female term, unless stated otherwise.
GENERAL DEFINITIONS
Accident means an occurrence causing Injury, damage or loss.
Actively at Work means that You are either:
(a) actually performing Your normal duties, if it is a scheduled work day; or
(b) capable of performing Your normal duties, if You are not at work due to a
non-scheduled work day, holiday or vacation day;
at Your normal place of employment or at some other location where Your
Employer's business requires You to be.
Annual Earnings are based on the premium amount received at the time
Canada Life receives Proof of Your Disability.
Annual Earnings means Your annual gross base earnings. Annual Earnings
excludes any income You receive such as but not limited to, bonuses, dividends,
overtime and profit sharing.
However, if Your plan includes commissions, Your Annual Earnings will be
calculated as either.-
1.
ither.
1. If You have been employed by Your employer for at least 24 months, Your
average commissions as an employee during the immediately preceding 24
months as set forth on Your W-2 Withholding Statement will be used; or
2. If You have been employed by Your employer for less than 24 months, the
amount that is estimated by Your employer will be used. The estimate must
reflect a reasonable expectation of the income to be earned. Canada Life
will verify the estimate with Your Employer at the time a claim is
submitted.
Annual Enrollment Period means a period of time in which. you may elect in
writing to change your option. The annual enrollment period is December 1st
through December 31st of each year,
Appropriate Evaluation and Treatment means medical care and treatment
that meets all of the following:
1. It is received from a Physician whose expertise, medical training and
clinical experience are suitable for treating Your Disability; and
2. It is deemed medically necessary and appropriate to meet the needs of your
Disability; and
3. It is consistent in type, frequency and duration of treatment with relevant
guidelines based on national medical, research and health care
organizations and governmental agencies; and
4. It is consistent with the diagnosis of Your condition; and
5. Its purpose is maximizing Your medical improvement and aiding in your
return to work.
CPI -W means the Consumer Price Index for Urban Wage Earners and Clerical
Workers published by the United States Department of Labor. If the index is
discontinued or changed, another comparable index may be used by Us.
Disability means You have a Total Disability or a Residual Disability as defined
in this Policy.
Disabled means You are Totally Disabled or Residually Disabled as defined in
this Policy.
Effective Date means December lst, 1995 and was last revised on December
1 st, 2001.
Eligible Employee means each full-time employee working a minimum of 30
hours per week for the Employer on a regular basis. An Employee must be a
legal citizen or resident of the United States or Canada. This does not include
temporary, seasonal, or contract employees. An Employee who is not a citizen
is ineligible for Insurance if he leaves the United States or Canada for one
hundred eighty (180) or more consecutive days.
Elimination Period is the period that You must have been continuously
Disabled before You may receive payments under the policy as outlined in the
Schedule of Insurance. The Elimination Period begins on the day that You meet
the Definition of Disability under this Policy. If You cease to be Disabled for
30 days or less during the Elimination Period, those days will not interrupt the
Elimination Period and the Disability will be treated as continuous. With
respect to Option 1, You must serve the full 180 day Elimination Period within a
total period equal to 210 days. With respect to Option 2, You must serve the
full 90 day Elimination Period within a total period equal to 120 days. Any day
that You cease to be Disabled as defined under this Policy will not be
considered to satisfy the Elimination Period.
Employer means the Policyholder.
Hospital or medical facility means a facility accredited by JCAHO (Joint
Commission on Accreditation of Health Care Organizations) to provide medical
evaluation and treatment of patients under the direction of an active staff of
licensed physicians.
Hospitalization means being an in-patient 24 hours a day.
Indexed Pre -Disability Monthly Earnings means Your Monthly Earnings
immediately prior to the date You became disabled, increased by an index
factor. The index factor adjustment will be made starting on the 13th benefit
payment and on each anniversary of that date. The amount of each adjustment
will be the lesser of.
(a) 3%; or
(b) the percentage increase in the CPI -W during the prior Calendar Year.
Injury means bodily injury caused by an Accident.
Insurance means the group long term disability income insurance coverage
provided by the Policy.
Leave of Absence means an arrangement where You and the Employer agree
that You will not be Actively at Work for a specific period of time and You are
expected to be Actively at Work at the end of that period. If an Eligible
Employee becomes Disabled while on Leave of Absence, Monthly Income
Benefits will be based upon Monthly Earnings as last reported to Canada Life
immediately prior to the beginning of the Leave of Absence.
Legal Residence means a place of permanent residence. This is a fixed place of
residence which You intend to be Your home and to which You intend to return
desr ite temporary residences elsewhere or temporary absences.
Material and Substantial Duties means duties that:
a) are normally required for the performance of Your own or any
occupation; and
b) cannot be reasonably omitted or modified.
Monthly Earnings means Your Annual Earnings divided by 12.
Monthly Income Benefit means the lesser of:
a) the amount of Your Pre -Disability Monthly Earnings multiplied by the
Benefit Percentage; or
b) the Maximum Benefit as shown in the Schedule of Insurance.
Monthly Income Payment means Your Monthly Income Benefit as calculated
under the Amount of Monthly Income Payment provision.
No fault Auto Insurance means a motor vehicle plan or policy that pays
benefits without regard to who was at fault in any motor vehicle Accident that
occurs.
10
Own Occupation means the duties that You regularly performed for which You
were covered under this Policy immediately prior to the date Your Disability
began. The occupation may involve similar duties that could be performed with
Your Employer or any other employer.
Physician means a qualified doctor of medicine, other than You or a member of
Your family, who is both licensed by at least one state to practice medicine and
who is providing You with appropriate medical care within the area of his or her
medical training and qualifications.
Policy means the group long term disability income policy issued by Canada
Life to the Policyholder and described by this Certificate.
Pre -Disability Monthly E:;rnings means Your Monthly Earnings immediately
prior to the date you became Disabled.
Pregnancy includes childbirth or miscarriage and any disease or infirmity
resulting from or aggravated by the pregnancy. It also includes therapeutic
abortions or complications arising from any abortion.
Prior Plan means a policy or plan of group long term disability income benefits
which this Policy replaces and which was in force until the day before
December 1st, 1995.
Salary Continuation Plan means continued payments to You by Your
Employer of all or part of Your Monthly Earnings after You become Disabled.
This continued payment must be part of an established plan maintained by Your
Employer for the benefit of all employees. Salary continuation does not include
compensation paid to You by Your Employer for work You actually perform
after Your Disability begins.
Sickness means an illness, disease, or pregnancy.
11
Social Security Plan means disability or retirement benefits that You, Your
spouse or any of Your dependents have received or are eligible to receive
because of Your Disability under:
1. the United States Social Security Act;
2. the Canada Pension Plan;
3. the Quebec Pension Plan;
4. any other Federal, State, provincial or local government act or law.
We, Us, and Our mean the insurer, Canada Life Assurance Company.
Work Earnings means Your gross Monthly Earnings from work You perform
while Disabled, including Earnings from Your Employer, any other employer or
self-employment. If You are paid in a lump sum or on a basis other than
monthly, Canada Lift, will prorate Your Work Earnings over the period of time
to which they apply. If no period of time is stated, Canada Life will use a
reasonable period of time. Work Earnings will not include any renewal
commissions, overriding renewal commissions, or service fees received on
business sold before You became Disabled.
You and Your mean an Eligible Employee.
Other terms are defined elsewhere in the Policy.
GDC97-04
12
DEFINITION OF DISABILITY AND DISABLED
Totally Disabled and Total Disability mean during the Elimination Period and
the next 24 months because of an Injury or Sickness You meet all of the
following:
(a) You are unable to do the Material and Substantial Duties of Your Own
Occupation; and
(b) You are receiving Appropriate Evaluation and Treatment from a Physician
for that Injury or Sickness; and
(c) Your Work Earnings are less than 20% of Your Indexed Pre -Disability
Monthly Earnings.
The definition changes 24 months after the end of the Elimination Period. From
that point on, Totally Disabled and Total Disability mean because of an Injury
or Sickness, all of the following are true:
(a) You are unable to do the Material and Substantial Duties of any occupation
for which You are or may become reasonably qualified by education,
training, or experience; and
(b) You are receiving Appropriate Evaluation and Treatment from a Physician
for that Injury or Sickness; and
(c) Your Work Earnings are less than 20% of Your Indexed Pre -Disability
Monthly Earnings.
Residually Disabled and Residual Disability mean during the Elimination Period
and the next 24 months because of an Injury or Sickness, You meet all of the
following:
(a) You are unable to do the Material and Substantial Duties of Your Own
Occupation; and
(b) You are receiving Appropriate Evaluation and Treatment from a Physician
for that Injury or Sickness; and
(c) Your Work Earnings are between 20% to 80% of Your Indexed Pre -
Disability Monthly Earnings, this Condition is not applicable if you are
employed through the Modified Work Program.
13
The definition changes 24 months after the end of the Elimination Period. From
that point on, Residually Disabled and Residual Disability mean because of an
Injury or Sickness, all of the following are true:
(a) You are unable to do the Material aiad Substantial Duties of any occupation
for which You are or may become reasonably qualified by education,
training, or experience; and
(b) You are receiving Appropriate Evaluation and Treatment from a Physician
for that Injury or Sickness; and
(c) Your Work Earnings are between 20% to 60% of Your Indexed Pre-
Disability Monthly Earning, this Condition is not applicable if you are
employed through the Modified Work Program.
Modified Work Program means a program of employment through which a
disabled employee is temporarily reassigned to a productive position either in
their own occupation or any occupation.
Modified Duty Assignment means the temporary reassignment of a disabled
employee to duties that can be performed within the limitations of the
employee's medical condition.
The loss of a professional license, occupational license or certification does not
in itself mean You are Disabled.
Your loss of earnings must be a direct result of Your Sickness, Pregnancy or
Injury. Loss of earnings due to economic factors such as, but not limited to,
recession, jot elimination, pay cuts and job-sharing will not be considered.
GDC97-05
14
RECURRENT DISABILITY
Recurrent Disability means a Disability which has the same cause as the original
Disability and begins after you have returned to work for less than 6 months.
Canada Life will treat the Recurrent Disability as part of the original Disability,
subject to all of the following:
(a) You will not have to satisfy a new Elimination Period if You have already
satisfied the Elimination Period with Canada Life for the original Disability;
and
(b) Any benefit payments will be subject to the terms of this policy for the
original Disability; and
(c) You remain continuously insured under this Policy for the period between
the original Disability and the recurrent Disability.
Any disability that does not have the same cause as the original Disability that
occurs during the 6 month period will be treated as a new Disability and You
must satisfy a new Elimination Period.
If the Recurrent Disability begins more than 6 months after the end of the
original Disability, You must satisfy a new Elimination Period.
You will not receive benefits under this provision:
a) If You are entitled to receive benefits under any other group long
term disability policy or plan; or
b) Upon termination of this plan with Canada Life.
CONCURRENT DISABILITY
If a new Disability occurs while Monthly Income Benefits are payable, it will be
treated as part of the same period of Disability and is subject to both of the
following:
1. The Maximum Benefit Period; and
2. Exclusions and Limitations provisions.
GDC97-12
15
BECO HNG INSURED
WHEN YOUR INSURANCE BEGINS
You may elect in writing, to be insured for Option 1 or Option 2. If Your
Employer pcys the entire premium for Your Insurance, Your Insurance begins
on the first eay You are Actively at Work following the date that You become
an Eligible Employee and have satisfied the Service Requirement as outlined in
the Schedule. of Insurance. An application to become insured _ must be
completed on a form approved for that purpose by Us. It must be promptly
deposited with Us at Our Head Office.
GDC97-13
CHANGES IN INSURANCE
CHANGE IN CLASS OR MONTHLY EARNINGS
The amount of Your Monthly Income Benefit may change if-
(a)
f
(a) You elect to change your option; or
(b) the amount of Your Monthly Earnings changes; and
(c) Your Employer tells Canada Life in writing about a change in Option or a
change in the amount of Monthly Earnings no later than 31 days after the
change occurs; and
(d) the premium paid is based on the change.
Changes in amounts of insurance due to changes in earnings will take effect on
the first day You are Actively at Work following the later of the date:
(a) the change occurs; or
(b) Canada Life approves Your Proof of Good Health, if You are
required to give Proof of Good Health.
You may elect in writing to decrease your election from Option 2 to Option 1
only during an annual enrollment period.
You may elect in writing to increase your election from Option 1 to Option 2
only during an annual enrollment period. If the change would increase Your
amount of Insurance, the increase takes effect on the first day You are Actively
at Work following the later of the date:
(a) the change occurs; or
(b) Canada Life approves Your Proof of Good Health, if You are required to
give Proof of Good Health.
GDC97-14
17
WHEN YOUR INSURANCE ENDS
Your Insurance will end on the earliest of the date:
1. the Policy is canceled; or
2. You cease to be a member of a Class defined on the Schedule of Insurance;
or
3. the Policy is changed to end the Insurance for Your Class; or
4. that is the last day of the period for which premium was paid, if a premium
is not paid when due; or
5. You retire; or
6. You die; or
7. Your Monthly Income Benefits end, if You are not again Actively at Work;
or
8. You start full-time active duty with the armed forces of any country or
international organization; or
9. You cease to be an Eligible Employee as defined in the Definitions of this
policy; or
10. The end of the month following the month You cease to be Actively at
Work due to an Injury or Sickness for which you do not receive Monthly
Income Benefits.
11. You request, in writing, for Your Insurance to be terminated.
18
12. You cease to be Actively at Work. However, Your Employer may continue
Yo_u Insurance (unless it ends due to any of the above reasons) during the
following periods:
(a) until the end of the month following the month You cease to be
Actively at Work due to a temporary lay-off;
(b) until the end of the month following the month You cease to be
Actively at Work due to a Leave of Absence;
(c) until the end of the month following the month You cease to be
Actively at Work due to Your being called to active duty as a reservist
with the Armed Forces Reserve;
(d) during an absence from work due to a Leave of Absence that is in
compliance with the Family Medical Leave Act.
After Canada Life determines that You are Disabled, Your Monthly Income
Benefits will not be affected by:
1. termination or cancellation of the Employer's plan; or
2. termination of Your coverage; or
3. any amendment that is effective after the date You are Disabled.
GDC97-16
19
INCOME FROM OTHER SOURCES
As set out in the Amount of Monthly Income Benefit for Disability sections,
Canada Life takes into account the total of all Your Income From Other Sources
in determining the amount of Your Monthly Income Benefit. Your Income
From Other Sources is any amounts that You receive'or are eligible to receive as
a result of Your Disability from the following:
Any amounts from the Employer as commissions, severance
allowance, sick pay, or as part of any salary continuation plana Work
Earnings and Rehabilitative Benefits will not be used to reduce Your
Monthly Income Benefit except as described in any applicable Income
Offset Method, Proportionate Method and Rehabilitation Feature.
2. Any amounts from a retirement or pension plan for which any
Employer has paid any part of the cost, except for the portion of the
benefits that represent Your contribution to the plan. The following are
not considered to be retirement plans:
a) profit sharing plans;
b) thrift or savings plans;
C) non-qualified plans of deferred compensation;
d) plans under IRC Section 401(k) or 457;
e) individual retirement accounts (IRA);
f) tax sheltered annuities (TSA) under IRC Section 403 (b);
g) stock ownership plans; or
h) Keogh (HR -10) plans.
3. Any amounts from another group disability insurance policy or plan for
which the Employer has paid any part of the cost.
4. Any amounts from another group insurance policy for which the
Employer has paid any part of the cost. A group Insurance policy is
one which the Employer contributes toward or makes payroll deduction
for any of the following:
a) other group health insurance policies to the extent that they
provide benefits for loss of time from work due to disability;
and
b) a group life policy that provides installment payments for
permanent total disability.
Ow
5. Any amounts under a Workers' Compensation law, an occupational
disease law, or any similar act or law.
6. Any amounts because of Your disability or retirement under the United
States Social Secarity Act or under any similar plan or act, including
similar plans or acts in other countries. This includes any amounts from
these sources because of Your disability or retirement that
a) You receive, are entitled to receive or would have been
eligible to revive upon making timely application because of
Your disability or retirement.
b) are available with respect to Your spouse and dependents
(regardless of marital status or their place of Legal Residence)
because of Your disability or retirement. If You are divorced
or legally separated, benefits paid directly to Your dependents
will be considered.
7. Where allowed under state law, any amounts for loss of income under
No-fault Auto Insurance.
8. Any amounts from a compromise, settlement, or damages whether
disputed or undisputed.
9. Any amounts from the Maritime Maintenance and Cure (Jones Act).
10. Any amounts from any Unemployment Insurance Law or Program.
11. Any amounts as loss of income awards or loss of income, settlements
involving liability insurance or court actions.
12. Any amount for which You are eligible and that is paid directly to a
third party.
21
CC ST OF LIVING FREEZE IN INCOME FROM OTHER SOURCES
After Your Monthly Income Benefit is reduced, it is not subject to further
reductions based on cost of living increases provided that the increase becomes
effective while You are disabled and eligible to receive the Income from Other
Sources.
Rules for Income From Other Sources
You must apply for all the Income From Other Sources for which You are
eligible and do what is needed to obtain them. If Your Social Security plan
application is denied, Canada Life will assist you in appealing the decision by
the Social Security plan to a level satisfactory to us.
As part of Your Proof of Disability, Canada Life requires that You furnish
evidence to Canada Life that You have duly applied for all Income From Other
Sources for which You are or may become eligible. This includes:
1. making the application for such benefits; and
2. if Your initial application is denied, and Canada Life so recommends,
making any and all available appeals.
Canada Life must receive written proof that all available appeals have been
exhausted.
Estimate of Potential Income From Cther Sources (or other Disability
Benefits)
Until you have given written proof to Canada Life that all available appeals
have been exhausted, Canada Life may:
1. estimate Your monthly Income from Other Sources; and
2. reduce the Monthly Income Benefit payment by that amount.
If Canada Life reduces Your benefit on this basis, and if all of Your appeals are
denied, Canada Life will restore the reduced amounts to You in one payment.
With proper authorization from You and your Physician, Canada Life will give
You or Your legal representative information from Canada Life's claim file to
assist in any appeal of denied disability or retirement benefits.
GDC97-17
22
AMOUNT OF MONTHLY INCOME PAYMENT
Canada Life determines the amount of Your Monthly Income Payment for Total
Disability as follows:
Calculate the value of E as follows:
A. Multiply the Benefit Percentage shown on the
Schedule of Insurance for the option for which
you are insured. I %
Times
Your Pre -Disability Monthly Earnings
Answer:
B. The Maximum Benefit shown on the Schedule
of Insurance for the option for which you are
insured:
C. The smaller of A or B:
D. Total all of Your Income from Other Sources:
E. Subtract D from C:
(C) -(D)
GDC97-18
23
Answer:
X
A=
B=
C=
D=
E=
Income Offset Method
Canada Life determines the amount of Your Monthly Income Benefit for
Residual Disability as follows:
Calculate the value of F as follows:
A.
Multiply the Benefit Percentage shown on the
Schedule of Insurance for the option for which
you are insured.
%
Times
Your Pre -Disability Monthly Earnings
X
Answer:
A =
B.
The Maximum Benefit shown on the Schedule
of Insurance for the option for which you are
insured:
B =
C.
The smaller of A or B:
C =
D.
You will subtract a percentage of Work
Earnings as follows:
For the first 12 monthly payments 0%
For the next 12 monthly payments 25%
For the remaining monthly payments 50%
The calculation is as follows:
The percentage from above:
%
Times
Work Earnings
X
Answer:
D =
E.
Total all of Your Income from Other Sources:
E_
F.
Subtract D and E from C:
(C) - (D) - (E)
F =
24
Calculate the value of J as follows:
G. Your Pre -Disability Monthly Earnings: G =
H. Total all of Your Income from Other Sources:
H=
I. Your Work Earnings I = _
J. Subtract H and I from G:
(G) - (H) - (I) J =
Your Monthly Income Payment equals the smaller of F or J as calculated above.
GDC97-20
25
No Text
As long as Canada Life has not made an overpayment, Your Monthly Income
Payment will not be less than the Minimum Benefit as shown on the Schedule of
Insurance.
You can not receive a Monthly Income Benefit for Total Disability and a
Monthly Income Benefit for Residual Disability at the same time.
Any time the total of..
(a) the Monthly Income Payment that You are receiving from this Policy; and
(b) Income from Other Sources; and
(c) any Work Earnings;
exceeds 100% of Indexed Pre -Disability Monthly Earnings, then the Monthly
Income Benefit under this Policy will be reduced so that the total Monthly
Income Benefit from all such sources does not exceed 100% of the Indexed Pre -
Disability Monthly Earnings.
Monthly Income Benefits are paid monthly in arrears. Monthly Income
Benefits are rounded to the nearest dollar.
PRORATION
Any Monthly Income Benefit payable for less than a month will be prorated
based on a 30 -day month. The prorated amount may be less than the Minimum
Benefit.
Underpayments and Overpayments
If Canada Life determines that you have been paid less than You are entitled to,
Canada Life will pay You the difference in one lump sum. If Canada Life
determines that You have been paid more than You are entitled to, You must
reimburse Canada Life in one lump sum.
If You do not reimburse Us, Canada Life may reduce or suspend Your Monthly
Income Benefits each month until the lump sum has been exhausted or take
other legal steps to recover the overpayment. If Canada Life reduces Your
Monthly Income Benefit, the Monthly Income Benefit may be less than the
Minimum Benefit shown in the Schedule of Insurance.
26
Awards of Damages
You will be required to reimburse Canada Life for any benefits Canada Life
pays to You if both of the following conditions are met:
1. Benefits are paid or payable under this policy with respect to You; and
2. You have a right to and do recover damages from any person, organization,
or legal entity that is or may be liable for any Injury, Accident, Sickness or
other event giving rise directly or indirectly, to the Disability for which
benefits are payable.
If the damages you are awarded, when added to the benefits paid under this
plan, exceed 100% of Your lost income, You must reimburse Us for the amount
that exceeds 100% of Your lost income. The amount You must reimburse will
not be more than the benefits paid under this Policy.
If You receive damages in one or more lump sum payments instead of in
monthly payments, the reimbursement amount will be based on the amount of
the award. You must provide satisfactory proof of the award to Canada Life, or
We will reasonably estimate the amount to be reimbursed.
Right of Reimbursement
Your lawyer may represent Canada Life's rights of reimbursement. However,
Canada Life reserves the right to:
1. Appoint another lawyer to act on the behalf of Canada Life; and
2. Commence an action to pursue Canada Life's rights of reimbursement
directly against a third party. You agree to fully co-operate with Canada
Life in pursuing Canada Life's claim against the third party.
GDC97-22
27
EXCLUSIONS AND LIMITATIONS
PRE-EXISTING CONDITION EXCLUSION
For you if you elect Option 1 or Option 2 within 30 days after first becoming
eligible:
No amount of Monthly Income Benefit will be payable for any disability which
is caused by, contributed to by, or resulting from a Pre -Existing Condition. A
Pre -Existing Condition is any Injury, disease, Sickness, Pregnancy or mental
disorder for which You did any of the following within 90 days prior to the date
on which You became insured under this policy:
1. visited or consulted a physician, hospital or medical facility or
2. took clinical tests or received treatment. This includes (but is not limited
to) tal=ing pills, injections or other medication to treat any condition.
This exclusion will not apply if the Elimination Period for the disability begins
after You have been Insured under this policy for at least 12 months.
For you if you elect Option 2 more than 30 days after first becoming eligible,
the amount provided in excess of Option 1 will be subject to the following:
No amount of Monthly Income Benefit will be payable for any disability which
is caused by, contributed to by, or resulting from a Pre -Existing Condition. A
Pre -Existing Condition is any Injury, disease, Sickness, Pregnancy or mental
disorder for which You did any of the following within 6 months prior to the
date on which You became insured under this policy:
1. visited or consulted a physician, hospital or medical facility or
2. took clinical tests or received treatment. This includes (but is not limited
to) taking pills, injections or other medication to treat any condition.
This exclusion will not apply if the Elimination Period for the disability begins
after the earlier of the following:
The date on which You have been insured under this policy for at least
twenty-four months, or
2. The date You have been free of treatment for a Pre -Existing Condition for a
period of twelve consecutive months while Insured under this policy.
GDC97-23
28
GENERAL EXCLUSIONS
Canada Life does not pay Monthly Income Benefits if Your Disability is caused
by or related to any of the following:
1. Intentional self-inflicted injury while sane or insane.
2. An act or Accident of war, declared or undeclared, whether civil or
international, and any substantial armed conflict between organized forces
of a military nature.
3. Taking part in a riot or civil commotion.
4. Committing or attempting to commit a felony, or engaging in an unlawful
act or illegal occupation, or committing or provoking an unlawful act.
5. Committing or attempting to commit an assault.
Canada Life does not pay Monthly Income Benefits for any of the following:
1. Any period v •hile You are no longer receiving Appropriate Evaluation and
Treatment from a Physician.
2. With respect to mental disorder, any period while You are not under the
continuing care of a Physician specializing in psychiatric care.
3. With respect to alcoholism and/or drug addiction, any period while You are
not being actively supervised by and receiving continuing treatment from a
rehabilitation center or a designated institution approved for such treatment
by an appropriate body in the governing jurisdiction, or, if none, by Us.
4. Any period in which You fail to submit to any medical examination
requested by Us.
5. Any period that You are confined to a penal or correctional institution.
6. When You have applied for Monthly Income Benefits under fraudulent
circumstances.
7. Any period that any other requirement of the Policy is not met.
GDC97-27
29
DISABILITY LMTATIONS
Mental Illness, Alcoholism, Substance Dependency
Payment of Monthly Income Benefits is limited to a maximum of 24 months
during Your lifetime for Disability caused by or related to any of the following:
(a) Mental Illness or
(b) Alcoholism or
(c) Substance Dependency
This is not a separate maximum for each condition or for each period of
Disability. This is a combined maximum for all periods of Disability and for all
of these conditions.
However, if You are confined to a Hospital because of Disability after the end
of the 24 months Canada Life will pay Monthly Income Benefits during Your
confinement and for up to 60 days after You are discharged if You are still
Disabled.
If within 60 days after You are discharged You are re -confined for at least 10
consecutive days because of the same Disability, then Canada Life will pay
Monthly Income Benefits during Your re -confinement and for up to 60 days
after You are discharged if You are still Disabled and for one additional
recovery period up to 90 days.
Payment of Monthly Income Benefits will end earlier than stated above subject
to the conditions of the When Your Monthly Income Benefits End section.
Mental Illness means a mental, nervous, stress-related, behavioral, or emotional
disease or disorder of any type and resulting from any cause, including organic
causes.
Alcoholism means an addictive relationship or pattern of use of alcohol.
Substance Dependency means an addictive relationship or pattern of use of
drugs, chemicals, or similar substances.
KUl
Special Conditions
PE yment of Monthly Income Benefits is limited to a maximum of 24 months
during Your lifetime for Disability caused by or related to Self-reported
Symptoms.
This is not a separate maximum for each condition or for each period of
Disability. This is a combined maximum for all periods of Disability and for all
of these conditions.
However, if You are confined to a Hospital because of Disability after the end
of the 24 nonths, Canada Life will pay Monthly Income Benefits during Your
confinemcnt and for up to 60 days after You are discharged if You are still
Disabled.
If within 60 days after You are discharged You are re -confined for at least 10
consecutive days because of the same Disability, then Canada Life will pay
Monthly Income Be:.efits during Your re -confinement and for up to 60 days
after You are discharged if You are still Disabled and for one additional
recovery period up to 90 days.
Payment of Monthly Income Benefits will end earlier than stated above subject
to the conditions of the When Your Monthly Income Benefits End section.
Self-reported Symptoms means the manifestations of Your condition which You
tell Your Physician, that are not verifiable using tests, procedures or clinical
examinations standardly accepted in the practice of medicine.
GDC97-29
31
WHEN YOUR MONTHLY INCOME BENEFITS END
Monthly Income Benefits end on the earliest of the date:
1. You are no longer Disabled as defined in the Definition of Disability
provision; or
2. You are no longer receiving Appropriate Evaluation and Treatment
from a Physician; or
3. that the Maximum Benefit Period ends; or
4. set out under the Disability Limitations section, if that section applies;
or
5. of Your death; or
6. that Canada Life asks You for proof that You are still Disabled if
Canada Life does not receive proof satisfactory to Canada Life 31 days
following the date of Canada Life's request; or
7. that Canada Life asks You for details about Your Income From Other
Sources, if You do not give Canada Life details within 31 days of
Canada Life's request; or
8. that Canada Life asks You to be examined by:
a) a Physician; or
b) health care professional; or
c) vocational evaluator;
of Canada Life's choice, if You do not agree within 31 days of the
request to be examined or if You do not cooperate with the examiner or
if You decline to attend the examination; or
9. that You work, unless You are Residually Disabled and working in
Rehabilitative Employment as part of a Rehabilitation Program
approved by us; or
10. that You cease to reside in the United States or Canada; or
11. that You decline to participate in a Rehabilitation Program that Canada
Life considers appropriate for Your situation and that is approved by an
independent Physician; or
32
12. that any other requirement of the Policy is not met; or
13. with respect to mental c?isorder, any period while You are not under the
continuing care of a Physician specializing in psychiatric care; or
14. with respect to alcoholism and/or drug addiction, any period while You
are not being actively s�ipervised by and receiving continuing treatment
from a rehabilitation center or a designated institution approved for
such treatment by an appropriate body in the governing jurisdiction, or,
if none, by Us; or
15. any period in which You fail to submit any medical information
requested by Us, including but not limited to Attending Physician's
Statements, medical test results, and medical, hospital, or psychiatric
records; or
16. any period that You are confined to a penal or correctional institution.
17. You have applied for Monthly Income Benefits under fraudulent
circumstances.
GDC97-30
33
BENEFITS AFTER POLICY CANCELLATION
Cancellation of the Policy does not by itself affect Your right to receive
Monthly Income Benefits for a Disability that begins while You were Insured.
You must continue to comply with all requirements set out in the Policy.
GDC97-31
PREMIUM WAIVER
Canada Life does not require premiums to be paid for the period during which
You are eligible to receive Monthly Income Benefits. Premium payments will
be required after Your Monthly Income Benefits end if You continue to be
Insured. If Your claim is admitted by Us, premium will be refunded
retroactively through the Elimination Period.
GDC97-32
CONTINUITY OF COVERAGE UPON CHANGE OF INSURERS
In order to prevent loss of coverage when this policy replaces a group disability
policy Your Employer had in force with another insurer within 60 days of
termination of the prior policy, Canada Life will provide coverage in accordance
with the following provisions.
Benefits for a Disability due to a Pre -Existing Condition may be payable to You
provided:
(a) you were insured under the Prior Plan on the last day before the Effective
Date of this group policy; and
(b) you were continuously insured under the group policy from the Effective
Date of this Group Policy through the date the Pre -Existing Condition
became disabling; and
(c) benefits would have been payable under the prior plan if the prior plan had
remained in force, taking into consideration the Pre -Existing Condition
Exclusion or Limitation, if any, of the prior plan.
If the above conditions are met, the benefit Canada Life pays will be the
Monthly Income Benefit payable under this Policy. These benefits will be
reduced by the amount of any benefits for which the prior insurer is liable.
34
Any payment Canada Life makes will be reduced by any payments made for the
same Disability under the Prior Plan.
'f You cannot satisfy the above conditions and You were covered under the plan
'hat This Plan replaced at the time of transfer, benefits may be payable under
—his Plan. Canada Life will give consideration towards the continuous time
You were covered under the Prior Plan and This Plan. If You then satisfy the
above conditions, the maximum Monthly Income Benefit Payable under This
Plan will not exceed the lesser of (i) the Monthly Income Benefit under This
Plan; and (ii) the Monthly Income Benefit under the Prior Plan.
Payments will cease on the earlier of
a) the d,,to benefits cease under this Policy; or
b) the due benefits would have ceased under the Prior Plan.
The applicable Pre -Existing Condition Exclusion or Limitation will apply for
the amount of Monthly Income Benefits in excess of the Monthly Income
Benefit provided by the Prior Plan on the last day before the Effective Date of
this group policy.
GDC97-33
35
SURVIVOR BENEFIT
If You die while You are receiving Monthly Income Benefits, Canada Life will
pay a single lump -suns Survivor Benefit. Canada Life must receive proof of
Your death.
The Survivor Benefit e;,uals 3 times the Monthly Income Benefit reduced by
Income from Other Sauces. Any Survivor Benefit will be applied first to
reduce any outstanding overpayment of Monthly Income Payments.
Canada Life will pay the Survivor Benefit to Your legal spouse, if living. If
Your spouse is not living, Canada Life will pay the Survivor Benefit divided
into equal shares to Your children. Children must be under age 21, unmarried,
and dependent on You for support and rt,aintenance. Children include
step -children, adopted children, and foster children. If there is no person entitled
to the Survivor Benefit living at the time of Your death, we will not pay the
Survivor Benefit.
GDC97-38
36
REHABILITATION FEATURE
A Rehabilitation Program means a program of vocational rehabilitation
acceptable to Canada Life that will lead to returning to work for the Employer
or another employer.
Our rehabilitation specialists will make recommendations regarding Your
vocational ability with the co-operation of Your Physician and other appropriate
specialists. Canada Life will base the recommendation on all of the following:
(a) the nature of Your condition; and
(b) the expected length of Your Disability; and
(c) Your education, training, and experience; and
(d) Your work potential based on vocational assessments; and
(e) time and expense related to returning to work; and
(f) other factors related to Your own situation.
If, at any time, You decline to participate or cooperate in a rehabilitation.
evaluation/assessment or plan that Canada Life feels is appropriate and
approved by Your Physician, we will cease paying Monthly Income Benefits.
If the Rehabilitation Program is not developed by Us, You must receive written
approval from Canada Life before You start the program.
If You participate in an approved Rehabilitation program, Canada Life may:
(a) increase Your Monthly Income Benefit by 5% not to exceed the
Maximum Benefit as shown in the Schedule of Insurance; or
(b) reimburse the Policyholder 50% of Your Monthly Earnings during the
first 3 months of employment; or
(c) reimburse the Policyholder for reasonable modification/accommodation
expense.
GDC97-40
37
MEDICAL PREMIUM SUPPLEMENT BENEFIT
Canada Life will pay to Your Employer a monthly amount to be applied toward
Your premium for medical coverage under the Medical Plan sponsored by Your
Employer. The payments will be mae'e provided You are receiving Monthly
Income Benefits under this Policy for Risa? ility. Medical Premium Supplement
Benefit payments will be riade for a nuximum of 12 monthly payments with
respect to any continuous period of Disability.
The monthly amount of Medical Premium Supplement Benefit payable will be
equal to the lesser of:
(i) Your actual contribution toward the medical premium; or
ii $300.00.
For the purposes of this provision, Medical Plan means a program: (i) that
provides medical benefits to a person and (ii) for which You are eligible as of
result of employment with Your Employer.
GDC97-54
38
CLAIM PROVISIONS
NOTICE OF CLAIM
You must give written notice to Canada Life of a claim within 30 days after the
date You complete the Elimination Period. If this is not reasonably possible,
You must give Canada Life the written notice as soon as it becomes reasonably
possible. Such notice must include Your name, Your address and policy
number. When Canada Life receives Your written notice, Canada Life will send
You claims forms that You must complete.
PROOF OF DISABILITY
You must give Canada Life written Proof of Disability within 90 days after the
end of the Elimination Period. If this is not reasonably possible, You must give
Canada Life Proof of Disability as soon as it becomes reasonably possible, but
not later than one year after the end of that 90 day period unless You lack legal
capacity. If the Policy ends, You must give written notice and Proof of
Disability for a Disability that began before the Policy ended within 90 days
after the Policy ends.
Proof of Disability will include information from Your Physician about Your
condition. You must authorize the release of Your medical information. You
must give Canada Life any other information and items that Canada Life
requires to support Your claim. Canada Life reserves the right to determine if
Your Proof of Disability is satisfactory.
TIME OF PAYMENT OF CLAIM
When We receive satisfactory Proof of Disability, benefits payable under this
Policy will be paid monthly during any period for which we are liable. Any
balance which remains unpaid at the end of the period for which we are liable
will be paid at that time.
EXANIINATIONS
Canada Life may require You to be examined at the expense of Canada Life by
one or more Physicians, health care professionals, or vocational evaluators of
Canada Life's choice. Canada Life may require examinations at any time and as
often as reasonably necessary. Canada Life will deny or stop Monthly Income
Benefits if You do not attend an examination or if You do not cooperate with
the examiner. Additionally, Canada Life reserves the right to have the Eligible
Employee interviewed by an authorized representative of Canada Life.
39
OUR RIGHT TO REQUIRE PROOF OF FINANCIAL LOSS
Canada Life has the right to require written proof of financial loss. This
includes, but is not limited to:
1. statements of Pre -Disability Income;
2. stateme js of income received from All Sources while disabled;
3. evidence that due application has been made for all other available
benefits;
4. tax returns, tax statements, and accountants' statements; and
5. any other proof Canada Life reasonably may require.
Canada Life may perform financial audits at the expense of Canada Life as often
as it reasonably may require. Payment of benefits may be contingent upon the
proof of financial loss being satisfactory to us.
17ROOF OF CONTINUING DISABILITY
From time to time You must give proof satisfactory to Canada Life at Your
expense that You are still Disabled. Canada Life will ask You for this proof at
reasonable intcrvals. Canada Life will stop Monthly Income Benefits if You do
not give proof" satisfactory to Canada Life that You are still Disabled. Canada
Life may investigate Your claim at any time.
40
IF YOUR CLAIM IS DENIED
If Canada Life wholly or partly denies Your claim, Canada Life will give You
written notice of Canada Life's decision. Canada Life will:
tell You the specific reason or reasons for the denial; and
refer to the Policy provisions on which the denial is based; and
describe any additional information or documentation You must submit to
support Your claim.
If You want Canada Life to review a denial, You must ask Canada Life in
writing within 60 days after receiving notice of the denial. When You request a
review, You may give Canada Life written comments and additional items to
support Your claim. Canada Life will review Your claim after receiving Your
written request. Canada Life will give You written notice of Canada Life's
decisic n within 60 days after Canada Life receives Your request, or within 120
days if special circumstances make an extension necessary.
The Plan Administrator grants to Canada Life full discretion to interpret all
claims evidence and materials, and to make all claims decisions under the
contract, except as otherwise provided by law.
GDC97-44
41
GENERAL PROVISIONS
ASSIGNMENT
You cannot assign Your rights or benefits under the Policy.
CURRENCY
All payments made to or by Canada Life will be made in United States dollars.
CLASS MEMBERSHIP
You may only be Insured under one Class only at any time.
MISREPRESENTATION OF EMPLOYEE INSURANCE
Any statement You make in an application to become Insured is a representation
and not a warranty. No representation made by You in an application to become
Insured will be used to reduce or deny Your claim or contest the validity of
Your Insurance unless:
(a) your Insurance would not have been approved except for Your
misrepresentation; or
(b) your misrepresentation is contained in a written instrument signed by you;
or
(c) we give You or Your representative a copy of the written instrument that
contains Your misrepresentation.
INCONTESTABILITY OF EMPLOYEE INSURANCE
After Your Insurance has been in force for twenty-four months, Canada Life
will not use misrepresentations made by You in an application to become
Insured to reduce or deny Your claim for a Disability beginning after the end of
the two year period or to contest the validity of Your Insurance, unless the
misrepresentations are fraudulent._ This section does not prevent Canada Life
from using at any time a defense based on:
(a) non-payment of premium; or
(b) any other provision of the Policy; or
(c) any other defense that is allowed by law.
42
MISSTATEMENT OF AGE OR OTHER FACTS
If Your age or any other fact was misstated, Canada Life will use the correct
facts to determine whether You are Insured and if so, for what amount and
duration.
ERRORS
You must be properly Insured under the Policy. An error or omission by the
Plan Administrator or the Claims Administrator will not cause You to become
Insured. An error or omission by the Plan Administrator or the Claims
Administrator will not cancel Insurance that should continue nor continue
Insurance that should end. The requirements of the Policy must be properly met
for any change in the amount of Your Insurance to take effect.
AGENCY
The Employer and any administrator appointed by the Employer are not agents
of Canada Life for any purpose. Canada Life is not liable for any of their acts or
omissions.
CHANGES TO POLICY
This policy may be amended at any time by written agreement between the
Policyholder and Canada Life without the consent of or notice to any other
individual. Any amendment to this policy must be in writing and be attached to
it. The amendment must bear the signature or a reproduction of the signature of
one or both of the President or Secretary of Canada Life.
If a person who is insured is not Actively at Work on the Effective Date of the
amendment, the effective date with respect to that person will be on the date that
he is again Actively at Work. However, if the amendment reduced the amount
of insurance to which the person is entitled, the effective date will be the
effective date of the amendment.
It is understood that, if this policy is amended during a person's continuous
period of Disability, the amendment will have no effect on the amount of his
Insurance during that same continuous period of Disability.
43
ENFORCEMENT OF POLICY TERMS
If at any time Canada Life does not enforce a provision of the Policy, Canada
Life still retains its right to enforce eat provision at its option after providing
notice.
LEGAL ACTIONS
You may not begin a legal action until 60 days after You have given Canada
Life written proof of claim. You may not begin a legal action more than 36
months after giving the proof of clam. If these time limits for legal actions are
shorter than that required by the law of the Applicable Jurisdiction, the time
limits will be extended to the minimum requirements of that law.
EFFECT ON WORKERS' COMPENSATION
The coverage provided by the Policy is not a substitute for coverage under a
workers' compensation or state disability income benefit law and does not
relieve the Employer of any obligation to provide such coverage.
GDC97-45
44
SUMMARY PLAN DESCRIPTION INFORMATION
1. The Name of the Plan is Group Long Term Disability Plan.
2. The Name and Address of the Policyholder is:
City of Lubbock
1625 13th Street
Lubbock, TX 79401
3. The Employer Identification Number is 75-6000590.
4. The type of Plan is Group Long Term Disability Benefits.
5. The type of Administration is Policyholder Administered.
Benefits under this plan are provided through insurance in accordance with
the terms and conditions of the group contract issued by the Claims
Administrator who is The Canada Life Assurance Company, Atlanta,
Georgia 30348.
You must be eligible in order to be entitled to benefits under the plan. The
eligibility requirement of the plan and the benefits You are insured for are
explained in detail in the General Definitions portion of this booklet.
6. The Name, Address and phone number of the Plan Administrator is:
City of Lubbock
1625 13th Street
Lubbock, TX 79401
(806)775-2317
45
7. The Agent for Service of Legal process on the Policyholder is:
City of Lubbock
1625 13th Street
Lubbock, TX 79401
The Plan Administraor is responsible for the administration of the plan and
is designated agent for the service of legal process for the plan. Functions
performed by the Plzen Administrator include: the receipt and deposit of any
required contributions, maintenance of records of plan participants,
ar thorization and payment of plan administrative expenses, selection of
itsurance consultants, selection of the insurance carrier, and the
do termination of eligibility of individual claimants for receipt of benefits.
8. The source of contribution to the Plan is the Employer -Employee.
9. The Plan Year begins on December lst.
10. This Plan is not maintained pursuant to one or more collective bargaining
agreements.
You must continue to be a member of an eligible class and continue to make any
required contributions in order to remain insured. The events which will cause
Your insurance to terminate and the circumstances under which benefits after
termination are payable are described in this booklet.
When You have a claim, Your Human Resources Office will assist You and
provide the claim forms needed to file for benefits. To avoid loss of benefits
due to late filing You should take care to file Your claim within the required
time period. Canada Life authorizes and makes payment of benefits. If a claim
is not paid in full, Canada Life will furnish notice which will specify the reason
or describe the additional information required to perfect the claim. If any claim
for benefits under the Plan is denied, You will be given the reason for denial in
writing usually within 90 days after receipt of the claim by the Plan or within
180 days under special circumstances requiring a delay in processing the claim.
If such extension is required, you will be given written notice of the extension
prior to the initial 90 day period. This notice of extension shall state the special
circumstances that require the extension and the date by which a final decision
will be made.
ER
You, or a person on your behalf, may ask for a review of the denied claim in
writing within 60 days of receipt of the denial notice. This written request for
review should ,'.:ate the reasons why you feel your claim should not have been
denied. It should include any additional documents which you feel support your
claim. You may also ask additional questions or make comments and you may
review pertinent documents. In normal cases, you will receive the final decision
within 60 days of the date your request for review is received. In special cases
requiring a delay, you will receive notice of the final decision no later than 120
days after your request for review is received.
The plan of insurance will teminate at the earliest occurrence of the following
events:
1. When the Policyholder delivers or mails to Canada Life a written notice
requesting termination; or
2. 31 days following the Policyholder's failure to make a premium payment;
or
3. Canada Life elects not to renew the contract.
GDC97-46