General Information
This section describes information applicable to all benefits (except life insurance) described int his booklet.
Definitions
The following terms used throughout this website have the meanings listed:
"Benefit Period"
The term "benefit period" means that period of time during which a covered person may receive benefits. It begins on January 1st each year and ends on the date the coverage terminates OR on the December 31st of the calendar year in which it begins - whichever is earlier.
"Course Of Orthodontic Treatment"
The term "course of orthodontic treatment" is the period which begins when the first orthodontic appliance is installed and ends when the last appliance is removed. Two or more courses of treatment are treated as one course unless they are separated by at least two years.
"Dentist"
The term "dentist" means a doctor of dental surgery or a doctor of medical dentistry.
"Doctor"
The term "doctor" means:
A. a physician legally licensed to practice medicine and/or surgery;
B. any other legally licensed practitioner of the healing arts who renders services within the scope of his/her license.
NOTE: The term Doctor does NOT include:
A. a medical resident;
B. a medical intern;
C. a person in training.
"Medicare"
The term "Medicare" means TITLE XVIII of the Federal Social Security Act, as it now is or is later changed. A person who is eligible for coverage under Medicare will be deemed to have all the coverage for which he or she is eligible under Medicare.
"No-Fault" Motor Vehicle Plan"
The term ""no-fault" motor vehicle plan" means a compulsory motor vehicle plan that provides payments for medical or dental care which are payable - in whole or in part - without regard to fault.
"Plan"
The term "plan" means any plan that provides medical or dental care coverage...
A. By group insurance, or by any other method of coverage for persons in a group;
B. By any government plan;
C. Required by law;
D. By a "no-fault" motor vehicle plan.
NOTE: When beginning with a "capital" letter in this booklet, the term "Plan" refers to the provisions of the New York City Electrical Division's Health & Welfare Fund plan being described in the particular section.
"Coordination Of Benefits"
There will be an overall "coordination of benefits" so that the sum of benefits paid under this Plan - PLUS benefits paid under all other plans - will not exceed the actual cost charged for treatment(s) or service(s).
"Effect On Benefits"
Benefits otherwise payable under this Plan for allowable expenses during a policy year may be reduced if benefits are payable under any other plan(s) for the same allowable expenses. The rules listed below provide that benefits payable under the other plan(s) are to be determined before the benefits payable under this Plan. For this purpose, benefits payable under other plan(s) will include the benefits that would have been paid had a claim been made for them.
Non Duplication Of Benefits
If an insured person is entitled to benefits for medical or dental care under this Plan - and any other plan - the amount of benefits provided by this Plan for that care may be reduced as explained in the "ORDER OF PAYMENT" section below. The amount may be reduced to the extent that the total payment provided by all plans will not be more than 100% of any necessary, reasonable and customary item of expense covered by this Plan or any other plan(s).
Any item of expense covered by Medicare or a "No-fault" motor vehicle plan is subject to a further requirement. Such item will be considered in determining benefits under this provision only if a part of the cost of the item is covered by a plan other than Medicare or a "No-fault" motor vehicle plan.
Order Of Payment
When a person is covered under 2 or more plans, the rules below will apply to decide which plan's benefits are payable first:
A. A plan which does not have a provision like the "Non Duplication of Benefits" provision listed above, is payable before this Plan;
B. A plan which covers a person other than as a dependent is payable before a plan which covers a person as a dependent;
C. A plan which covers a person as a dependent of a spouse whose month and date of birth fall earlier in the calendar year is payable before a plan which covers a person under a spouse whose month and date of birth fall later in the calendar year.
If the above, three rules - "A" through "C" in this section - do not decide which plans benefits are payable first, the plan which has covered the person for the longest time will be payable first. However, if a person is a step-child or the child of legally-separated or divorced parents, the following rules also apply:
A. If the person for whom benefits are claimed is covered under a plan as a dependent child of a legally-separated or divorced parent who has custody of the child, the benefits payable under that plan wil be determined before the benefits payable under a plan that covers the child as a dependent of any other person, unless there is a court decree that assigns financial responsibility for the child's medical/dental care to that other person;
B. If the person for whom benefits are claimed is covered under a plan as a dependent child of a step-parent, the benefits payable under that plan will be determined before the benefits payable under a plan that covers a child as a dependent of a legally separated or divorced parent who does not have custody of the child, unless there is a court decree that assigns financial responsibility for the child's medical/dental care to that parent;
C. If the person for whom the benefits are claimed is covered under a plan as a dependent child of a person who has, by court decree, been assigned financial responsibility for the child's medical/dental care, the benefits payable under that plan will be determined before the benefits payable under the plan that covers the child as a dependent of any other person.
To administer claims, the Plan, without the consent of any person, will have the right...
A. To get any data needed to determine benefits under this provision;
B. To recover any sum paid above that is required by this provision;
C. To pay any organization the sum it paid, but which should have been paid by the Welfare Fund.
NOTE: Amounts so paid will be deemed benefits paid under this Plan, and to the extent so paid, there will be no more liability under this Plan.
Medicare Exception
Benefits payable under Medicare will normally be determined before the benefits payable under this Plan. However, if the person for whom benefits are claimed is a member aged 65 to 70 years or any such member's dependent spouse aged 65 to 70 years, benefits payable under this Plan will be determined before the benefits payable under Medicare, but only with respect to treatment or service's received during the period beginning on the first day of the month in which the person attains age 65 and ending on the last day of the month in which the person attains age 70.
Exchange Of Information
Any person who claims benefits under this Plan must, upon request, provide all information needed to coordinate the benefits of this Plan. In addition, all information needed to coordinate benefits may be exchanged with other companies, organizations or persons.
Facility Of Payment
The Plan may reimburse any other plan if benefits were paid by that other plan, but should have been paid under this Plan in accordance with this section.
NOTE: In such instances, the reimbursement amounts will be considered benefits paid under this Plan and, to the extent of those amounts, will discharge the Plan from further liability.
How To File A Claim
In filing a claim, the member must:
DENTAL CLAIMS ONLY:
United Healthcare +1 (877) 816-3596
- OR -
ALL OTHER CLAIMS:
NEW YORK CITY ELECTRICAL DIVISION HEALTH & WELFARE FUND
Post Office Box 650479
Fresh Meadows, NY 11365
Payment Of Claims
When a claim form or information is needed by a member or his/her dependent(s), the member should contact the Welfare Fund office at the address or phone numbers listed above.
The initial claim form for dental treatment must be submitted within 30 days of the date that each course of treatment first begins. If treatment for any one condition is continuous, it will be necessary for the member to have another claim form completed at least every 90 days (...or upon earlier completion of dental work, if less). Unless otherwise specified on the form, the benefit will be made payable to the member - except for vendors participating in the optical plan.
NOTE: If a check is to be made payable to the provider of goods and/or services, the member must insure that such method of payment is specified on the claim form.
If a payment or other settlement is not received within 30 days of the member's having returned a completed claim form, he/she should contact the appropriate office (above) according to the type of claim submitted.
How To Appeal A Claim
If a member's claim is denied, in whole or in part, and he/she does not agree with the reason given, the member should - within 60 days of the date you were notified of the denial - contact the person in writing who informed the member of said denial. The member should be sure to include the reason(s) why the claim should not have been denied, and submit any supportive data, questions or comments deemed appropriate. The appeal will be reviewed by the specific insurance carrier (...or by the board of trustee's of the Welfare Fund if it is a self insured benefit).
Following the appeal, the member will be notified in writing of the final decision within 60 days of the date the appeal was received by the person or office contacted - unless there are special circumstances, in which case the member will be notified in writing within 60 days of the date the appeal is received - or the date by which the final decision will be made.
Loss Of Benefits
The Plan administrator reserves the right to terminate the Plan. Furthermore, the Welfare Fund may modify, amend or change the provisions, terms and conditions of the Plan.
A member's individual coverage terminates when he/she leaves New York City employment, when you are no longer eligible or when the Plan terminates - whichever occurs first.
Coverage of a member's dependent(s) terminates on the earliest of the following dates:
A. The date on which the member ceases to be eligible for any particular benefit(s);
-OR-
B. The date coverage is dropped for any dependent(s)
-OR-
C. The date the individual ceases to be an eligible dependent.
Funding
The New York City Electrical Division Health & Welfare Fund is self funded through employer contributions.