| Actively at Work
At work on a full time basis and is performing usual duties at customary place of employment during a regular work week
of not less than the number of hours required under the terms of the applicable collective bargaining agreement or Subscriber's Agreement.
Calendar Year
A period beginning January 1 and ending on December 31 of each year.
Chemical Dependency
Psychological or physical dependency on alcohol or mind altering drugs that require diagnosis, care and treatment.
COBRA (Consolidated OmniBus Reconciliation
Act)
A federal law that extends health and welfare benefits.
Contract Provider
A contracting hospital, doctor, laboratory group, etc. who has contracted with the
Fund to provide health services to eligible participants of the Fund.
Contribution
The amount your employer pays to the Fund for your health and welfare benefits.
Co-payments
An amount which the participant is obligated to pay to the provider for services up to an annual maximum.
Covered Charges
The charge of a physician, radiologist, pathologist, laboratory, hospital or other professional that is reimbursable under the terms of this Plan.
Deductible
An amount of covered charges which must be incurred by a Participant before benefits will be paid by the Fund. (No benefits are payable for covered charges applied toward a deductible.)
Dependent
Your wife or husband and your unmarried children up to age 19 (living with you in a parent-child relationship), but extended up to age 26 for full-time students (i.e. a minimum of 12 units), are eligible dependents if they are supported by you and are not on active duty in any armed forces.
Employee
A person employed by, actively at work, and on the payroll of a subscribing employer.
Fund
The Teamsters Miscellaneous Security Trust Fund.
Gender
The masculine term (his/him) shall also apply to the feminine.
HMO
Health Maintenance Organization - The HMO provides all medical services on a prepaid basis. Certain
co-payment charges may be involved. Each HMO has its own rules and requirements.
Medically Necessary
Means that the services, supplies, treatment and confinement must be generally recognized in the physician's profession as effective and essential for treatment of the injury or illness for which it is ordered; and that they must be rendered at the appropriate level of care in the most appropriate setting based on diagnosis. To be considered "Medically Necessary", the care must be based on generally recognized and accepted standards of medical practice in the United States and it must be the type of care that could not have been omitted without an adverse effect on the patient's condition or the quality of medical care. In addition, services, treatment, supplies or confinement shall
not be considered "Medically Necessary" if they are an Experimental Procedure, or if investigational or primarily limited to research in their application to the injury or illness; or if primarily for scholastic, educational, vocational or developmental training; or if primarily for the comfort, convenience or administrative ease of the provider or the patient or his or her family caretaker.
If as and when "Medically Necessary" appears to be ambiguous or in dispute, the Trustees grant the Administrator the discretion to determine what is "Medically Necessary".
Medical Reimbursement Plan (MRP)
The Medical Reimbursement Plan (MRP) is the Indemnity or Fee-For-Service Plan option available on some benefit plans.
Non-Contracting Provider
A hospital, doctor, laboratory, etc. with whom the Fund has no contract to provide services at a savings to the Fund and participants. Use of such providers will cost the participants more money as
co-payments will be increased or all services may be denied.
Participants
Employee, his dependents or a COBRA eligible person or a retiree when covered under the Fund.
Physician (Doctor)
Only a person who is practicing within the scope of his license or certification as a Doctor of Medicine or a Doctor of Osteopathy, or to the extent that benefits are provided, as a Doctor of Dentistry, Doctor of Podiatry, Doctor of Optometry, Doctor of Chiropractic, Licensed Acupuncturist, Licensed Optician, Psychologist, and, when performing services upon referral by a licensed or certified Doctor of Medicine or Doctor of Osteopathy, a Licensed Clinical Social Worker, or a Psychiatric Mental Health Registered Nurse who has a Master's Degree and two years supervised experience in psychiatric mental health nursing and who is included on the State Board of Registered Nurses' list of such nurses.
Psychiatric Treatment
Services and supplies furnished to diagnose or treat a mental, nervous or emotional disorder or condition.
Retired
A participant who has met all of the rules of the Fund to become an eligible Retiree and whose last employer continues to make contributions to this Fund for Retiree coverage on behalf of his active employees.
Subscribing Employer
A Subscribing Employer is an employer who makes contributions on behalf of employees in accordance with a collective bargaining agreement or an approved application for non-contract personnel.
Total
Disability
For employees, "total disability" as used by the Fund means
the complete inability of the employee due solely to disease, illness or
bodily injury to perform the regular and customary work of the employee. For
dependents, "total disability" means the complete inability of the
dependent due solely to disease, illness or bodily injury to engage in the
normal activities of a person in good health and of the same sex and age.
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