Self-funded Medical Plan

1. Time Requirements
1. Written notice of a claim must be given to the Trust Administrative Office as soon as reasonably possible.
2. Proof of claim for Hospital confinement must be given to the Trust Administrative Office within ninety (90) days after release from the Hospital.
3. Proof of claim for any other service, supply or treatment must be given to the Trust Administrative Office within ninety (90) days after the service or treatment.
4. If proof of any claim is not given within ninety (90) days, the claim will not be denied or reduced if the proof of the claim was given as soon as reasonably possible. However, no claim will be paid if submitted to the Trust Administrative Office for more than one year after the date of service or treatment. “Proof” means proof satisfactory to the Board of Trustees.
2. Examination
1. The Board of Trustees, at the expense of the Trust, has the right to have You examined by a Provider, as often as it may require, whenever Your Illness or Injury is the basis of a claim.
2. The Board of Trustees has the right to require an autopsy, if not prohibited by law. A disputed Illness is a basis for this requirement.

Vision claims are processed and paid by:

If You are using Postal Prescription Services (PPS) mail-order prescription drug program, You must submit claim forms directly to Postal Prescription Services. Claim forms are available from the Trust Administrative Office or on the web at www.soundcommbenefits.com. Mail Your claim form to:

1. Semi-private room and board and routine nursing for confinement in a hospital.
2. Semi-private room and board and routine nursing for confinement in a skilled nursing facility (not to exceed the average semi-private room rate). Services must commence within 14 days after discharge from a stay of three (3) or more days in an acute care hospital.
3. Intensive Nursing Care for each day of confinement in a hospital as follows:
1. For those hospitals which make a separate charge for Intensive Nursing Care, the hospital’s specific charge for Intensive Nursing Care is covered;
2. For those hospitals which make a combined charge for Room and Board and Intensive Nursing Care, that part of the combined charge that is in excess of the hospital’s prevailing semi-private Room and Board rate will be the covered charge for Intensive Nursing Care.
4. Anesthetics and their administration.
5. The medical treatment is given by or at the direction of a physician if such treatment is within the scope of the provider.
6. Usual, Customary and Reasonable Charges of a physician or surgeon for the performance of an operation, the repair of a dislocation or fracture, and for medical services. Charges of an assistant surgeon are also covered.
7. Services of a Licensed Registered Nurse (R.N.) for private duty nursing services in a hospital.
8. Services of a Licensed Practical Nurse (L.P.N.) for private duty nursing services in a hospital.
9. Services of a licensed physiotherapist.
10. Charges by a doctor or speech therapist for rehabilitative speech therapy due to an illness (other than a functional nervous disorder), or due to surgery on account of illness. If the speech therapy is due to a congenital anomaly, surgery to correct the anomaly must have been performed prior to the therapy.
11. X-ray exams (other than dental), lab tests, and other diagnostic services.
12. X-ray and radiation therapy.
13. Charges for the repair of sound natural teeth (including their replacement) required as a result of, and within six (6) months of an accidental bodily injury that occurs while the person is covered under the Plan.
14. Transportation that is medically necessary and recommended by your attending physician within the United States and Canada of the covered individual by professional ambulance service, railroad, or scheduled airline to, but not returning from a hospital or sanitarium. These charges will be covered only if the covered individual’s
    illness cannot be adequately treated in the locale where the illness occurs.
15. Medical supplies as follows:
1. Drugs which require a written prescription from a doctor and must be dispensed by a licensed pharmacist or doctor;
2. Blood and other fluids to be injected into the circulatory system;
3. Artificial limbs and eyes for loss of natural limbs and eyes which occurred while coverage is in force;
4. Lens, each eye (contact or frames) immediately following and because of cataract surgery only;
5. Casts, splints, trusses, braces, crutches, and surgical dressings;
6. Purchase or rental of hospital-type equipment for kidney dialysis for your personal and exclusive use. The total purchase price considered will be on a monthly pro-rata basis during the first twenty-four (24) months of ownership, but only so long as a dialysis treatment continues to be medically necessary. Also covered are all charges for supplies, materials, and repairs necessary for the proper operation of such equipment and reasonable and necessary expenses for the training of a person to operate and maintain the equipment for your sole benefit. No benefits are paid on or after the day you are entitled to benefits under Medicare.
7. Rental (not to exceed the purchase price) or purchase (if the cost is less than the rental for the period required) of durable medical equipment such as oxygen, a wheelchair, or hospital bed for medically necessary therapeutic treatment of a covered illness or non-industrial injury.
8. Medically necessary prosthesis.
16. Maternity Expenses and Well Baby Coverage (Employee and spouses Only): Maternity expenses are covered the same as any other illness and cover only female Employees and dependent wives. Coverage must be in effect at the time of delivery. Hospital where baby nursery charges are covered only in BlueCross PPO contract hospitals and only during the mother’s normal maternity stay.

    Effective January 1, 1998, group health plans and health insurance issuers offering group health coverage generally may not, under federal law, restrict available benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or issuer for prescribing a length of time in excess of 48 hours (or 96 hours).

17. Breast reconstruction following a mastectomy. In accordance with the Women’s Health and Cancer Rights Act of 1998 (WHCRA), if you receive mastectomy-related benefits, coverage will be provided for the following mastectomy-related services as determined in consultation between you and your attending physician:
    1. All stages of reconstruction of the breast on which the mastectomy has been performed.
    2. Surgery, and reconstruction of the other breast to produce a symmetrical appearance.
    3. Prostheses.
    4. Treatment of physical complications, including lymphedemas, at all stages of mastectomy.

    Any exclusion of benefits for cosmetic services does not apply to this benefit. This benefit is subject to the annual deductible and copayments specified above.

18. Fees for chiropractic and acupuncture treatments are limited to $25 per call with a maximum of twenty calls per calendar year. Payments are subject to the Plan’s deductible and co-insurance. Maximum X-ray charges for chiropractic services are limited to $100 per calendar year.