• Answer any questions you might have;
• Guide you through therapy options available to you and the benefits and adverse effects of each option;
• Make sure you get the medication, supplies, equipment and services that you need;
• Help you coordinate between all companies and people involved in your care including your medical coverage, prescription coverage, physicians and other healthcare providers;
• Help you monitor your health and assist you in managing symptoms and side effects; and
• Re-evaluate and customize your therapy and support based on your needs.

• The Plan will pay your benefits at 80% rather than the percentage listed on your Schedule of Benefits for Out-of-Network services; and
• Your deductible for Out-of-Area benefits will be $300.

5) Charges for services received as a result of Injury or Sickness caused by or contributed to by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, or felonious act. The lack of a conviction or issuance of a citation by a law enforcement body is not conclusive as to whether or not the charges for services were caused by or contributed to by engaging in an illegal act.

6) Treatment of Injuries sustained in a motor vehicle accident is excluded where there is sufficient evidence that the accident was a result of the claimant’s Blood Alcohol Content (B.A.C.) being at a level proscribed by the law of the state where the act occurred or was a result of the claimant’s illegal drug use. A breathalyzer, blood or urine test result that the claimant’s B.A.C. was prohibited by the law of the state where said motor vehicle accident occurred or that the claimant was utilizing an illegal drug at the time of the motor vehicle accident will be considered objective and conclusive evidence that alcohol or illegal drug use was a contributing cause of the Injury or Illness resulting from the motor vehicle accident. The claimant’s failure to take a breathalyzer, blood or urine test, or the lack of a conviction or issuance of a citation by a law enforcement body is not conclusive as to whether or not the alcohol or illegal drug use as a contributing cause of the injury.

5) Disability that is due to Injuries or Illnesses resulting directly or indirectly in the commission of or by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, or felonious act. The lack of a conviction or issuance of a citation by a law enforcement body is not conclusive as to whether or not the charges for services were caused by or contributed to by engaging in an illegal act.

6) Treatment of Injuries sustained in a motor vehicle accident is excluded where there is sufficient evidence that the accident was a result of the claimant’s Blood Alcohol Content (B.A.C.) being at a level proscribed by the law of the state where the act occurred or was a result of the claimant’s illegal drug use. A breathalyzer, blood or urine test result that the claimant’s B.A.C. was prohibited by the law of the state where said motor vehicle accident occurred or that the claimant was utilizing an illegal drug at the time of said motor vehicle accident will be considered objective and conclusive evidence that alcohol or illegal drug use as a contributing cause of the Injury or Illness resulting from the motor vehicle accident. The claimant’s failure to take a breathalyzer, blood or urine test, or the lack of a conviction or issuance of a citation by a law enforcement body is not conclusive as to whether or not the alcohol or illegal drug use was a contributing cause of the injury.

• Is receiving a pension from:
  The Central Laborers’ Pension Fund, or
  Another Fund that has entered into an agreement with the Central Laborers’ Pension Fund (and submits proof of the pension), and
  Meets the other eligibility requirements for Retiree Benefits.

• retire after reaching age 53, but before age 65 or at any age if your are disabled;
• exhaust your four quarterly self-payments at the active rate of insurance, including the use of the maximum hour bank accumulation of one quarter of coverage as one or a portion of one of your self-payments;
• submit proof that you are receiving a pension from Central Laborers’ Pension Fund or another pension fund that has entered into an agreement with the Central Laborers’ Pension Fund;
• have been eligible under Eligibility A for at least 10 consecutive years under either or both consecutively the Central Laborers’ Health and Welfare Fund (only years prior to July 1, 2003 will be credited for this purpose) and the North Central Illinois Laborers’ Health and Welfare Fund immediately before the effective date of your pension;
• are not eligible for Medicare; and
• make proper and timely self-payments to the Health and Welfare Fund for your coverage.

• your lawful spouse;
  
  
• your unmarried child, as child is defined on page 72, who:
  • is under the age of 19; and
  • has a principal place of residence with your for more than one-half of the calendar year; and
  • is dependent upon you for more than one-half of his or her support for the calendar year; and
  • if the child is under your legal guardianship, the child must have a principal place of residence with you and be a member of your household for the entire calendar year;
    
    
• an unmarried child who is under the age of 23 and is enrolled as a full-time student in an accredited education institution, as defined by that institution, as long as the child:
  • has a principal place of residence with you for more than one-half of the calendar year; and
  • is dependent upon you for more than one-half of his or her support for the calendar year; and
  • if the child is under your legal guardianship, the child must have a principal place of residence with you and be a member of your household for the entire calendar year

• your unmarried child who does not live with you, provided that:
  • the child’s parents are: 1) divorced or legally separated under a decree of divorce or separate maintenance; 2) separated under a written separation agreement; or 3) live apart at all times during the last six months of the calendar year;
  • the child’s parents provide over one-half of the child’s support; and
  • the child is in the custody of one or both of his or her parents for more than one-half of the calendar year;
    
    
• your unmarried child who is permanently or totally disabled, which means that the child is unable to engage in any gainful activity by reason of a medically determinable physical or mental impairment that is expected to result in death or last for a continuous period of 12 months or more who:
  • is dependent upon you for more than one-half of his or her support for the calendar year;
  • resides with you for more than one-half of the calendar year (for the entire year for a child under your legal guardianship); and
  • is dependent upon you for lifetime care and supervision; and
  • who was considered to be handicapped upon reaching age 19.
  • Upon request by the Plan, you may be required to furnish proof of such incapacity and dependency from time to time, but in no event more frequently than once a year.
    
    
• your child who is named as an alternate recipient of a Qualified Medical Child Support Order (QMCSO) approved by the Board of Trustees. Procedures for qualifying Medical Child Support Orders are available from the Health and Welfare Fund Office at no cost;
  
  
• For purposes of this definition of Dependent, a child includes your unmarried:
  • newborn child whose coverage becomes effective at birth if you enroll the newborn as a Dependent. If enrollment does not occur within 31 days of birth, the coverage effective date will be postponed until the first day of the month following the date you apply for the newborn’s coverage;
  • child who is placed with you for adoption or legally adopted and resides with you;
  • step-child for whom you have completed the Fund’s Dependent Eligibility Affidavit; or
  • child for whom you have been appointed legal guardian, provided the Plan has been presented with the order appointing guardianship, including grandchildren.

Physical examinations that are for purposes of meeting employment requirements will be covered by the Plan, but only if they are performed as part of the annual physical examinations. Such examinations will be subject to the benefit limitations in the Schedule of Benefits for wellness expense and will be subject to the provisions governing the Plan’s use and disclosure of your protected health information on page 69 of this booklet. These examinations must be performed in conjunction with an annual physical examination.

Examinations for the issuance of marriage licenses, insurance policies, maintenance of valid licenses or other ancillary examinations, under the examination is necessary to meet employment requirements.