COMPREHENSIVE WELFARE BENEFITS
PLAN
Effective as of January 1,
2002
Dynegy Inc.
Comprehensive Welfare Benefits Plan
WHEREAS , Dynegy Inc. (the “Company”) and
certain of its affiliates have established the welfare benefit
plans identified as the prior plans on Appendix A hereto (the
“Prior Plans”) for the benefit of their eligible
employees; and
WHEREAS , the Company desires to consolidate the Prior
Plans into a single comprehensive welfare benefit plan in the form
of this Dynegy Inc. Comprehensive Welfare Benefits Plan (the
“Plan”) intending thereby to provide an uninterrupted
and continuing program of benefits;
NOW, THEREFORE, the Prior Plans are merged into and consolidated
with the Plan such that each such Prior Plan transfers to the Plan
its benefit liability obligations and assets effective as of
January 1, 2002 and the Plan accepts and assumes such benefit
liability obligations and assets effective as of January 1,
2002 and each such Prior Plan becomes a part of and a
“Constituent Benefit Program” under, the Plan forming a
single comprehensive welfare benefit plan as follows, effective as
of January 1, 2002:
-i-
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I. DEFINITIONS AND CONSTRUCTION
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1
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1
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3
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3
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1.4
Reference to Plan Includes Constituent
Benefit Programs
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3
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1.5
Inconsistent Provisions in Constituent
Benefit Program Documents
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3
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1.6
Effect Upon Other
Plans
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3
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II. ESTABLISHMENT AND PURPOSE OF THE
PLAN
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4
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2.1
Establishment and Purpose of the
Plan
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4
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2.2
Intention to be Welfare Benefit
Plan
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4
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2.3
Incorporation of Constituent Benefit
Programs
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4
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III. PARTICIPATION AND DEPENDENT
COVERAGE
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5
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3.1
Eligible Employee
Coverage
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5
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3.2
Eligible Dependent
Coverage
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5
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3.3
Enrollment Without Regard To
Medicaid
Eligibility
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6
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3.4
Special Enrollment
Periods
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6
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IV. THIRD PARTY LIABILITY
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7
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7
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4.2
Third Party Liability Is
Primary As
to Covered
Expenses
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7
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4.3
Plan’s Rights of Reimbursement For
Covered Expenses Previously Paid
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7
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4.4
Plan’s Exclusion of Coverage For
Future Covered Expenses
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7
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4.5
Plan’s Rights of Independent Legal
Action
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7
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4.6
Attorney Fees, Costs and
Expenses
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7
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4.7
Obligations of
Participants
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8
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4.8
Limitations on Plan’s Rights of
Reimbursement
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8
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V. BENEFIT CLAIMS PROCEDURE
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9
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9
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9
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5.3
Filing of Benefit
Claim
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10
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5.4
Processing of Benefit
Claim
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11
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5.5
Notification of Adverse Benefit
Determination
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12
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5.6
Timing of Adverse Benefit Determination
Notification Regarding Health Benefit Claims
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12
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5.7
Timing of Adverse Benefit Determination
Notification Regarding Disability Benefit
Claims
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14
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5.8
Timing of Adverse Benefit Determination
Regarding Non-Health and Disability Claims
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14
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5.9
Review of Adverse Benefit Determination
Regarding Health
or Disability Benefit
Claims
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15
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5.10
Review of Adverse Benefit Determination
Regarding Non-Health and Disability Benefit
Claims
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16
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5.11
Notification of Benefit Determination on
Review
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17
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5.12
Timing of Notification Regarding Review
of Health Benefit Claims
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17
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5.13
Timing of Notification Regarding Review
of Disability Benefit Claims
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18
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5.14
Timing of Notification Regarding Review
of Non-Health or Disability Claims
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18
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5.15
Exhaustion of Administrative
Remedies
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18
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18
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5.17
Authorized
Representatives
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19
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20
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20
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6.2
Participant
Contributions
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20
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20
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20
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20
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VII. ADMINISTRATION OF PLAN
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21
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21
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7.2
Discretion to Interpret
Plan
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21
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21
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22
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22
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7.6
Reliance on Reports, Certificates, and
Participant Information
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23
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23
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23
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7.9
Compensation and
Bond
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23
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VIII. AMENDMENT AND TERMINATION OF
PLAN
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24
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24
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24
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S3 Effect
of Amendment or Termination
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24
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8.4
Delegation to Benefit Plans
Committee
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24
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8.5
Effect of Oral
Statements
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24
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IX. MISCELLANEOUS PROVISIONS
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25
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9.1 No Guarantee of
Employment
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25
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9.2
Payments to Minors and
Incompetents
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25
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9.3 No Vested Right to
Benefits
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25
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9.4
Nonalienation of
Benefits
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25
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26
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9.6
Participating
Employers
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26
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26
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9.8
Incorrect Information, Fraud,
Concealment, or Error
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27
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9.9
Medical
Responsibilities
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27
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9.10
Compromise of
Claims
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27
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9.11
Electronic
Administration
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27
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27
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9.13
Compensation and
Bond
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28
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28
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28
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-iii-
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X. QUALIFIED MEDICAL CHILD SUPPORT
ORDERS
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29
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XI. COBRA CONTINUATION COVERAGE
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30
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31
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32
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XIV. RESTRICTIONS REGARDING PROTECTED HEALTH
INFORMATION
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33
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33
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14.2
Provision of Information to the Company
Pursuant to Authorization
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33
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14.3
Provision of Summary Health Information
to Company
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33
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14.4
General Provision of Health Information
to Company
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34
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35
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36
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14.7
Coverage and Effective
Date
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38
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A-1
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B-1
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-iv-
I.
Definitions and Construction
1.1 Definitions . Where the following words and phrases appear
in the Plan, they shall have the respective meanings set forth
below, unless the context clearly indicates to the
contrary:
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(1)
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Administrative Services
Agreement : The agreement(s) entered into with
each individual or entity providing administrative services with
respect to one or more Constituent Benefit Programs.
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(2)
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Administrative Services
Provider : Any individual or entity operating
under an Administrative Services Agreement to provide
administrative services with respect to any benefits offered under
one or more of the Constituent Benefit Programs.
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(3)
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Board : The board of directors of the
Company.
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(4)
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Cafeteria Plan
: The cafeteria plan,
if any, established by the Employer under section 125 of the
Code.
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(5)
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Code : The Internal Revenue Code of
1986, as amended.
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(6)
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Benefit Plans
Committee : The Committee to which the Board
has delegated certain Plan sponsor powers.
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(7)
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Company : Dynegy Inc.
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(8)
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Compensation
: Unless otherwise
specifically provided in a Constituent Benefit Program, the annual
base pay paid by the Employer to or for the benefit of a
Participant for services performed for the Employer.
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(9)
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Condition
: Any sickness, injury,
or other mental or physical disability giving rise to the payment
of benefits under the Plan.
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(10)
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Constituent Benefit
Programs : The benefit programs listed on
Appendix B to the Plan, as such programs and such
Appendix B may be amended from time to time.
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(11)
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Constituent Benefit Program
Document(s) : The written document(s) setting
forth the terms of the applicable Constituent Benefit Program,
including, but not limited to, the benefits provided, the
eligibility and enrollment requirements, the conditions of
dependent coverage, if applicable, the termination of coverage, and
the terms and conditions of benefit payments under each Constituent
Benefit Program, as may be amended from time to time. Appendix B
describes the Constituent Benefit Program Document or Constituent
Benefit Program Documents for each Constituent Benefit Program.
Appendix B also describes which Employers maintain which
Constituent Benefit Programs for their Eligible
Employees.
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(12)
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Covered Eligible
Dependent : Each Eligible Dependent who is
covered under the Plan pursuant to Section 3.2.
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-1-
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(13)
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Effective Date
: January 1, 2002,
except as otherwise stated herein and except that provisions of the
Plan required to have an earlier effective date by applicable
statute and/or regulation shall be effective as of the required
effective date in such statute and/or regulation.
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(14)
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Eligible Dependent
: With respect to an
Eligible Employee, each person who by virtue of a relationship to
such Eligible Employee is eligible for coverage under a Constituent
Benefit Program.
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(15)
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Eligible Employee
: Each individual who
is eligible for coverage under a Constituent Benefit Program
because of current or former employment with the Employer.
Notwithstanding any provision of the Plan to the contrary, no
individual who is designated, compensated, or otherwise classified
or treated by the Employer as an independent contractor, leased
employee, or other non-common law employee shall be an Eligible
Employee, unless a Constituent Benefit Program specifically and
expressly provides otherwise.
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(16)
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Employer
: The Company and each
Participating Employer.
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(17)
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ERISA : The Employee Retirement Income
Security Act of 1974, as amended.
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(18)
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Group Health Plan
: Each Constituent
Benefit Program, which is a group health plan within the meaning of
section 5000(b)(1) of the Code, and/or a group health plan within
the meaning of section 607(1) of ERISA, as applicable, and for
purposes of Article XII, is either a group health plan within
the meaning of section 5000(b)(1) of the Code or any Constituent
Benefit Program designated by the Employer as a “Group Health
Plan” for purposes of FMLA Leave.
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(19)
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HMO : Any health maintenance
organization or similar organization or network of individuals or
organizations that has contracted to provide medical, dental,
and/or other health-related benefits to Participants and Covered
Eligible Dependents.
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(20)
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Insured Constituent Benefit
Program :
Each Constituent Benefit Program whose benefits are provided by an
Insurer.
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(21)
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Insurer : Any insurance company that has
contracted to provide benefits under a Constituent Benefit
Program.
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(22)
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Participant
: Each Eligible
Employee who is a participant in the Plan pursuant to
Article III and, where reference is appropriate, each Covered
Eligible Dependent.
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(23)
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Participating
Employer : Any subsidiary or affiliate of the
Company, or any other entity permitted by law to do so, that has
been designated by the Company as a participating employer and
participates in the Plan with respect to one or more Constituent
Benefit Programs.
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(24)
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Plan : The Dynegy Inc. Comprehensive
Welfare Benefits Plan.
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(25)
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Plan Administrator
: An individual,
committee or entity appointed by the Board to perform, in a
fiduciary capacity as administrative fiduciary, certain identified
duties and responsibilities with respect to the administration of
the Plan and/or a Constituent Benefit Program.
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(26)
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Plan Year
: The
twelve-consecutive month period commencing on January 1 of each
year.
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(27)
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Recovery
: An amount obtained by
or for the benefit of a Participant or Covered Eligible Dependent
from a Third Party, such Third Party’s liability carrier, or
in the case of uninsured or underinsured motorist coverage, from
such Participant’s or Covered Eligible Dependent’s
automobile insurance carrier because of a Condition for which a
Third Party is legally liable. In the case of a Recovery which, in
whole or in part, includes assets other than cash or cash
equivalents, the Plan Administrator shall determine the monetary
value thereof.
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(28)
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Third Party
: Any individual or
entity who or which is or may be liable to a Participant or Covered
Eligible Dependent for a Condition or for payment of damages or
expenses related to a Condition.
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1.2 Number and Gender
. Wherever appropriate herein, words
used in the singular shall be considered to include the plural and
words used in the plural shall be considered to include the
singular. The masculine gender, where appearing in the Plan, shall
be deemed to include the feminine gender.
1.3 Headings . The headings of Articles and Sections herein
are included solely for convenience. If there is any conflict
between such headings and the text of the Plan, the text shall
control. All references to Sections, Articles, Paragraphs, and
Clauses are to this document unless otherwise indicated.
1.4 Reference to Plan Includes Constituent
Benefit Programs .
Any reference herein to the Plan includes each Constituent Benefit
Program unless otherwise indicated, irrespective of the fact that
certain references herein specifically are to the Constituent
Benefit Programs.
1.5 Inconsistent Provisions in Constituent
Benefit Program Documents . In the event that any term, provision,
implication, or statement in a Constituent Benefit Program Document
conflicts with, contradicts, or renders ambiguous a term,
provision, implication, or statement in this document, such term,
provision, implication, or statement in this document shall
control.
1.6 Effect Upon Other Plans
. Except to the extent provided
herein, nothing in the Plan shall be construed to affect the
provisions of any other plan maintained by the Employer.
-3-
II.
Establishment and Purpose of the Plan
2.1 Establishment and Purpose of the
Plan . The Company
has adopted and established the Plan for the purpose of providing
the benefits under and coordinating the administration of the
Constituent Benefit Programs, which provide certain health,
accident, life, disability, and other welfare benefits for the
Eligible Employees of the Employer.
2.2 Intention to be Welfare Benefit
Plan . The Plan is
intended to be a program of benefits constituting an employee
welfare benefit plan within the meaning of section 3(1) of ERISA
and the regulations promulgated thereunder to the extent the
benefits provided by each individual Constituent Benefit Program so
permit. If any benefits provided under a Constituent Benefit
Program are determined to be other than benefits that are eligible
to constitute an employee welfare benefit plan within the meaning
of section 3(1) of ERISA, such determination shall not prevent the
remainder of the Plan from qualifying as an employee welfare
benefit plan within the meaning of such section.
2.3 Incorporation of Constituent Benefit
Programs . The
Constituent Benefit Programs and the Constituent Benefit Program
Documents in their entirety, as each may be amended from time to
time, are incorporated by reference herein and made a part of the
Plan. No Constituent Benefit Program is intended to be, nor will
any be interpreted to be, a separate employee benefit plan, except
that for the purpose of determining whether the Plan or any
Constituent Benefit Program is a “group health plan”
subject to or exempt from any law made applicable to “group
health plans,” each Constituent Benefit Program will be
considered to be a separate plan or “group health
plan,” and the fact that one Constituent Benefit Program will
be subject to or exempt from such law will not cause any other
Constituent Benefit Program to be so subject to or exempt from such
law.
-4-
III.
Participation and Dependent Coverage
3.1
Eligible Employee Coverage .
(a) Each Eligible Employee shall become a
Participant in the Plan coincident with the date such Eligible
Employee becomes enrolled in and covered under one or more of the
Constituent Benefit Programs.
(b) The rules pertaining to eligibility
for, enrollment and reenrollment in, coverage under and amendment
of coverage under, and termination of coverage of Eligible
Employees in a Constituent Benefit Program vary for each
Constituent Benefit Program and are set forth in the respective
Constituent Benefit Program Document. Enrollment and coverage of an
Eligible Employee in a Constituent Benefit Program shall be subject
to any required premium payment applicable to such coverage and any
and all other terms and conditions set forth in the applicable
Constituent Benefit Program Document.
(c) Except as otherwise specifically
provided by the Plan, an Eligible Employee shall cease to be a
Participant in the Plan upon the day following the earliest to
occur of the date he is no longer enrolled in and covered under at
least one Constituent Benefit Program or the effective date of
termination of the Plan. If an Eligible Employee ceases to be a
Participant in the Plan, he shall be entitled to recommence such
participation in accordance with Paragraphs (a) and
(b) of this Section 3.1 provided that the Plan has not
terminated.
3.2
Eligible Dependent Coverage .
(a) Each Eligible Dependent shall become a
Covered Eligible Dependent under the Plan coincident with the date
such Eligible Dependent becomes enrolled in and covered under at
least one Constituent Benefit Program.
(b) The rules pertaining to eligibility
for, enrollment and reenrollment in, coverage under and amendment
of coverage under, and termination of coverage of Eligible
Dependents in a Constituent Benefit Program vary for each
Constituent Benefit Program and are set forth in the respective
Constituent Benefit Program Document. Enrollment and coverage of an
Eligible Dependent in a Constituent Benefit Program shall be
subject to any required premium payment applicable to such coverage
and any and all other terms and conditions set forth in the
applicable Constituent Benefit Program Document.
(c) Coverage of a Covered Eligible
Dependent of a Participant shall terminate upon the day following
the earliest to occur of the date such Participant ceases to be
enrolled in and covered under at least one Constituent Benefit
Program or the effective date of the termination of the Plan. If
coverage of a Covered Eligible Dependent under the Plan terminates,
such Eligible Dependent shall be entitled again to be covered under
the Plan in accordance with Paragraphs (a) and (b) of this
Section 3.5 provided that the Plan has not
terminated.
-5-
3.3 Enrollment Without Regard To Medicaid
Eligibility .
Contrary Plan provisions notwithstanding, each Group Health Plan
shall enroll an individual in the Plan without regard to the fact
that such individual is eligible for, or is provided medical
assistance under, a state plan for medical assistance approved
under title XIX of the Social Security Act, but only to the extent
any such Group Health Plan is subject to such mandate by
law.
3.4 Special Enrollment Periods
. Contrary Plan provisions
notwithstanding, each Group Health Plan shall permit an individual
to enroll under the conditions, and during the periods, set forth
in section 701(f) of ERISA.
-6-
IV.
Third Party Liability
4.1 Effect of Article
. The provisions of this
Article IV shall apply only with respect to a Constituent
Benefit Program which is a Group Health Plan and shall supercede
and replace entirely any and all provisions of such Plan’s
Constituent Benefit Program Document which pertain to reimbursement
or subrogation rights.
4.2 Third Party Liability Is Primary As to
Covered Expenses .
The Plan shall not be primarily responsible or liable for the
payment of Covered Expenses incurred by a Participant or because of
a Condition caused by the fault of a Third Party. Accordingly and
in accordance with the provisions of this Article IV, the Plan
shall be and is entitled to the benefit of any Recovery or right of
Recovery which a Participant may have which relates to a Condition
for which a Third Party was, is or may become liable without regard
to any characterization between such Third Party and the
Participant, a court, a jury or any other person or entity of such
liability as being predicated upon pain and suffering, mental
anguish, punitive damages, wrongful death or any other basis other
than for medical or other welfare benefits and without regard to
whether the liability of such Third Party is reduced to a Recovery
as a result of legal proceedings, arbitration, compromise
settlement or otherwise.
4.3 Plan’s Rights of Reimbursement For
Covered Expenses Previously Paid . If the Plan has paid Covered Expenses of a
Participant because of a Condition caused by the fault of a Third
Party and Recovery is obtained by the Participant with respect to
such Condition, the Participant shall be obligated to reimburse the
Plan for all such Covered Expenses which were paid by the Plan
provided, however, that the Participant shall have no obligation of
reimbursement in excess of the total amount of such
Recovery.
4.4 Plan’s Exclusion of Coverage For
Future Covered Expenses . If a Condition of a Participant is or has been
caused by the fault of a Third Party and a Recovery is obtained by
the Participant with respect to such Condition, the Plan shall have
no obligation to pay and there shall be excluded from future
coverage by this Plan any and all Covered Expenses thereafter
incurred by such Participant for, in connection with or relating to
such Condition until such expenses exceed in the aggregate the
total amount of such Recovery remaining after reimbursement of the
Plan pursuant to Section 4.3.
4.5 Plan’s Rights of Independent Legal
Action . If a
Participant has incurred, incurs or may incur Covered Expenses
because of a Condition caused or possibly caused by the fault of a
Third Party, the Plan shall have the right but not the duty to
protect its interests by (1) bringing an action in the name of the
Plan or of the Participant against the Third Party, such Third
Party’s liability carrier, or in the case of uninsured or
under-insured motorist coverage, against such Participant’s
automobile insurance carrier or (2) joining or intervening in
any action by a Participant against any Third Party, such Third
Party’s insurer or in the case of uninsured or underinsured
motorist coverage, against such Participant’s automobile
insurance carrier. The Plan’s failure to bring an action or
to join or intervene in litigation pursuant to its rights under
this Section 4.4 shall not affect or impair the Plan’s
rights under this Article IV.
4.6 Attorney Fees, Costs and
Expenses . The
Plan’s rights of reimbursement, recovery and Covered Expense
exclusion pursuant to this Article IV shall not be limited or
reduced pro rata or otherwise for attorney’s fees, costs or
expenses incurred by a Participant in seeking a Recovery except
with the express written consent of the Plan
Administrator.
-7-
4.7 Obligations of
Participants . The
Participant shall have an affirmative obligation to cooperate in
reimbursing the Plan and in otherwise assuring the Plan’s
rights of reimbursement pursuant to this Article IV, shall
execute and deliver to the Plan Administrator all assignments and
other documents requested by the Plan Administrator for enforcing
the Plain’s rights under this Article IV, shall not take
any action which might prejudice the Plan’s right under this
Article IV, and shall not release any Third Party (even if the
release purports to be partial release or release for the excess
liability over Plan benefits) without the consent of the Plan
Administrator, which consent shall not be unreasonably withheld.
The Plan’s rights of reimbursement under this Article IV
shall not be affected by a release of any Third Party entered into
without the consent of the Plan Administrator. If a Participant
initiates a liability claim against any Third Party or such Third
Party’s liability carrier or reimbursement is sought from
such Participant’s own automobile insurance carrier under the
uninsured or underinsured motorist endorsement, the amounts
described in Section 4.3 and amounts to cover all future
medical expenses which otherwise would be Covered Expenses relating
to the Condition which is the basis of such liability claim must be
included in the claim. If a Participant receives a Recovery, the
Participant shall hold such money in trust for the Plan to the
extent of the Plan’s rights under this Article IV. Each
Participant who incurs any Condition shall inform the Plan
Administrator whenever it appears that a Third Party is or may be
liable to the Participant.
4.8 Limitations on Plan’s Rights of
Reimbursement . In
the event that a Recovery relating to a Condition is insufficient
to cover all medical expenses paid or payable by both the Plan and
the Participant, as applicable, for services and supplies incurred
in treating such Condition, the amount of the Recovery relating to
such Condition which shall be subject to the Plan’s rights of
reimbursement pursuant to this Article IV shall be reduced by
such medical expenses incurred and paid by the Participant in
connection with the treatment of such Condition which were not
reimbursed or will not be subject to reimbursement by the Plan as
the Plan Administrator may, in its sole discretion and on a
case-by-case basis, determine.
-8-
V.
Benefit Claims Procedure
5.1 Claims For Benefits
. Claims for benefits or
reimbursement under the Plan shall be submitted and processed in
accordance with this Article V except that this Article V
shall not apply to any Constituent Benefit Program (a) which
is not regulated by ERISA or (b) which has in its Constituent
Benefit Program Document provisions which address claims procedures
and appeals and which the Plan Administrator that has powers and
duties of benefits claims administration has determined to be
applicable in lieu of the provisions of this Article V.
Completion by a Participant or Covered Eligible Dependent of his
responsibilities and obligations under the claims procedures
applicable with respect to a Constituent Benefit Program shall be a
condition precedent to the commencement of any legal or equitable
action in connection with a claim for benefits under such program
by a Participant or Covered Eligible Dependent, or by any other
person or entity claiming rights through such Participant or
Covered Eligible Dependent; provided, however, that the Plan
Administrator having powers and duties of benefits claims
administration in its discretion may waive compliance with such
claims procedures as a condition precedent to any such
action.
5.2 Definitions . For purposes of this Article V, the
following terms, when capitalized, will be defined as
follows:
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(1)
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Adverse Benefit
Determination : Any denial, reduction or
termination of or failure to provide or make payment (in whole or
in part) for a Plan benefit, including any denial, reduction,
termination or failure to provide or make payment that is based on
a determination of a Claimant’s eligibility to participate in
the Plan, and including with respect to health benefits a denial,
reduction, termination or failure to provide or make payment
resulting from the application of any utilization review, as well
the failure to cover an item or service for which benefits are
otherwise provided because it is determined to be experimental,
investigational or not medically necessary or appropriate. Further
and with respect to health benefits, any reduction or termination
of an ongoing course of treatment prior to its scheduled expiration
will be treated as an Adverse Benefit Determination regarding a
Concurrent Care Claim. Further, any invalidation of a claim for
failure to furnish written proof of loss or to comply with the
claim submission procedure will be treated as an Adverse Benefit
Determination.
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(2)
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Benefits Administrator
: The person or office
to whom the Plan Administrator that has powers and duties of
benefit claims administration has delegated day-to-day Plan
administration responsibilities and who, pursuant to such
delegation, processes Plan benefit claims in the ordinary course or
if none has been so designated, the Plan Administrator that has
powers and duties of benefits claims administration.
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(3)
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Claimant : A Participant or beneficiary or an
authorized representative of such Participant or beneficiary who
has filed or desires to file a claim for a Plan benefit.
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-9-
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(4)
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Concurrent Care Claim
: Any request to extend
an ongoing course of a health benefit treatment beyond the period
of time or number of treatments that has previously been approved
under the Plan.
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(5)
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Health Care Professional
: A physician or other
health care professional licensed, accredited or certified to
perform specified health services consistent with State
law.
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(6)
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Independent Fiduciary
: The person or entity
retained by the Plan Administrator to perform the review of an
Adverse Benefit Determination, who will be an individual other than
(a) the individual who made the Adverse Benefit Determination
that is the subject of the review and (b) the subordinate of
such individual.
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(7)
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Post-Service Claim
: Any claim for a Plan
health benefit that is not a Pre-Service Claim.
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(8)
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Pre-Service Claim
: Any claim for a Plan
health benefit the terms of which condition receipt thereof, in
whole or in part, on approval of the benefit in advance of
obtaining medical care.
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(9)
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Urgent Care Claim
: Any Plan health
benefit claim for medical care or treatment with respect to which
the application of the time periods otherwise applicable to such
claim (a) could seriously jeopardize, as determined either by
a physician with knowledge of the Claimant’s medical
condition or by the Benefits Administrator (applying the judgment
of a prudent layperson who possesses an average knowledge of health
and medicine), the Claimant’s life, health or ability to
regain maximum function, or (b) would subject the Claimant, in the
opinion of a physician with knowledge of the Claimant’s
medical condition, to severe pain that cannot be adequately managed
without the care or treatment that is the subject of the
claim.
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5.3 Filing of Benefit Claim
. A Claimant must file with the
Benefits Administrator a written claim for benefits under the Plan
with written proof of loss no later than March 31 of the Plan
Year following the Plan Year in which the related expense was
incurred on the form provided by, or in any other manner approved
by, the Benefits Administrator. For purposes of applying the time
periods for benefit determination pursuant to Section 5.6. 5.7
or 5.8 below, filing a claim with the Benefits Administrator will
be treated as filing a claim with the Plan Administrator. In
connection with the submission of a claim, the Claimant may examine
the Plan and any other relevant documents relating to the claim,
and may submit written comments relating to such claim to the
Benefits Administrator coincident with the filing of the benefit
claim form. Failure of a Claimant to furnish written proof of loss
or to comply with the claim submission procedures and rules
established by the Plan Administrator (including rules as to what
information relating to a claim is required to be submitted by a
Claimant) will invalidate such claim submission and such
invalidation will not be considered as or treated as an Adverse
Benefit Determination for purposes of this Article V unless
the Benefits Administrator in its discretion determines that it was
not reasonably possible to provide such proof or comply with such
procedure. Notwithstanding the foregoing, if a Claimant’s
communication regarding a Pre-Service Claim is received by the
Benefits Administrator and names the Claimant, his specific medical
condition or symptom, and the specific treatment, service or
product for which approval is requested, but otherwise fails to
follow the claims submission procedure, the Benefits Administrator
will notify the Claimant of the failure and the proper procedures
to be followed to file a claim for benefits. Such notification will
be provided as soon as possible, but not later than five days
(twenty-four hours in the case of an Urgent Care Claim) following
the failure and may be oral unless the Claimant requests written
notification.
-10-
5.4 Processing of Benefit
Claim . Upon receipt
of fully completed benefit claim forms from a Claimant, the
Benefits Administrator shall determine if the Claimant’s
right to the requested benefit, payable at the time or times and in
the form requested, is clear and, if so, shall process such benefit
claim without resort to the Plan Administrator. In the case of
either an Urgent Care Claim other than a Concurrent Care Claim or a
Pre-Service Claim, the Benefits Administrator shall affirmatively
notify the Claimant of the approval of the claim not later than
seventy-two hours after receipt of the benefit claim in the case of
an Urgent Care Claim other than a Concurrent Care Claim and not
less then fifteen days after receipt of the benefit claim in the
case of a Pre-Service Claim. If the Benefits Administrator
determines that the Claimant’s right to the requested
benefit, payable at the time or times and in the form requested, is
not clear, it shall refer the benefit claim to the Plan
Administrator for review and determination, which referral shall
include:
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(1)
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All materials submitted to the
Benefits Administrator by the Claimant in connection with the
claim;
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(2)
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A written description of why the
Benefits Administrator was of the view that the Claimant’s
right to the benefit, payable at the time or times and in the form
requested, was not clear;
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(3)
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A description of all Plan
provisions pertaining to the benefit claim;
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(4)
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Where appropriate, a summary as to
whether such Plan provisions have in the past been consistently
applied with respect to other similarly situated Claimants;
and
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(5)
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Such other information as may be
helpful or relevant to the Plan Administrator in its consideration
of the claim.
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If the
Claimant’s claim is referred to the Plan Administrator, the
Claimant may examine any relevant document relating to his claim
and may submit written comments or other information to the Plan
Administrator to supplement his benefit claim. Within the time
period described in Section 5.6, 5.7 or 5.8, whichever is
applicable to a claim, the Plan Administrator shall consider the
referral regarding the claim of the Claimant and make a decision as
to whether it is to be approved, modified or denied. If the claim
is approved, the Plan Administrator shall direct the Benefits
Administrator to process the approved claim as soon as
administratively practicable and in the case of either an Urgent
Care Claim other than a Concurrent Care Claim or a Pre-Service
Claim, the Plan Administrator shall affirmatively notify the
Claimant of the approval of the claim not later than seventy-two
hours after receipt of the benefit claim in the case of an Urgent
Care Claim other than a Concurrent Care Claim and not less then
fifteen days after receipt of the benefit claim in the case of a
Pre-Service Claim.
-11-
5.5 Notification of Adverse Benefit
Determination . In
any case of an Adverse Benefit Determination of a claim for a Plan
benefit, the Plan Administrator shall furnish written notice to the
affected Claimant within the notification periods described in
Section 5.6, 5.7 or 5.8, whichever is applicable to such claim
below. Any notice that denies a benefit claim of a Claimant in
whole or in part shall, in a manner calculated to be understood by
the Claimant:
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(1)
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State the specific reason or
reasons for the Adverse Benefit Determination;
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(2)
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Provide specific reference to
pertinent Plan provisions on which the Adverse Benefit
Determination is based;
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(3)
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In the case of a health or
disability benefit claim and if an internal rule, guideline,
protocol or other similar criterion was relied upon in making the
Adverse Benefit Determination, either provide such criterion or
state that such criterion was relied upon and that a copy of the
criterion will be provided free of charge to the Claimant upon
request;
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(4)
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In the case of a health or
disability benefit claim and if the Adverse Benefit Determination
is based on a medical necessity, experimental treatment or similar
exclusion or limit, either explain the scientific or clinical
judgment for the determination, applying the terms of the Plan to
the Claimant’s medical circumstances, or state that such
explanation will be provided free of charge to the Claimant upon
request;
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(5)
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Describe any additional material or
information necessary for the Claimant to perfect the claim and
explain why such material or information is necessary;
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(6)
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Describe the Plan’s review
procedures and time limits applicable to such procedures, including
a statement of the Claimant’s right to bring a civil action
under section 502(a) of ERISA following an Adverse Benefit
Determination on review; and
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(7)
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If an Urgent Care Claim is
involved, provide a description of the expedited review process
available for Urgent Care Claims (see
Section 5.12).
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5.6 Timing of Adverse Benefit Determination
Notification Regarding Health Benefit Claims
. The Plan Administrator shall
provide a Claimant with notice of an Adverse Benefit Determination
regarding a health benefit claim within the following time
periods:
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(1)
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In the case of an Urgent Care Claim
other than a Concurrent Care Claim, as soon as possible, taking
into account the medical exigencies, but not later than seventy-two
hours after the claim is filed with the Plan Administrator;
provided, however, that if additional information from the Claimant
is necessary to complete the claim, the Claimant will be notified
within twenty-four hours after such claim is filed with the Plan
Administrator and will be given at least forty-eight hours to
provide the specified information, and notice of the Plan
Administrator’s benefit determination will be provided to the
Claimant within forty-eight hours after the earlier of (a) the
Plan Administrator’s receipt of the specified information or
(b) the end of the period afforded the Claimant to provide the
specified information. In addition, such notification may be
provided orally (provided that written or electronic notification
is provided within three days following such oral
notification).
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-12-
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(2)
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In the case of a properly submitted
Urgent Care Claim that is a Concurrent Care Claim, if such claim is
made at least 24 hours prior to the scheduled expiration of
treatment, notice of the disposition of the claim will be furnished
to the Claimant as soon as possible, taking into account the
medical exigencies, but not later than 24 hours after such claim is
filed with the Plan Administrator. If such claim is not made at
least twenty-four hours prior to the scheduled expiration of
treatment, the claim shall be governed by Clause
(1) above.
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(3)
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In the case of a decision to reduce
or terminate a previously approved ongoing course of health benefit
treatment that was to be provided over a period of time or a number
of treatments, the Plan Administrator shall notify the Claimant of
the Adverse Benefit Determination at a time sufficiently in advance
of the reduction or termination to allow the Claimant to appeal and
obtain a determination on review of such Adverse Benefit
Determination before the benefit is reduced or
terminated.
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(4)
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In the case of a Pre-Service Claim
not described in Clauses (1) through (3) above, the Plan
Administrator shall notify the Claimant of the Adverse Benefit
Determination within a reasonable period of time appropriate to the
medical circumstances but not later than fifteen days after receipt
of the claim by the Plan (which period may be extended one time for
up to an additional fifteen days provided that the Plan
Administrator both determines that such extension is necessary due
to matters beyond the control of the Plan and notifies the Claimant
prior to the expiration of the initial fifteen-day period of the
circumstances requiring the extension of time and the date by which
the Plan expects to render a decision).
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(5)
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In the case of a Post-Service Claim
not described in Clauses (1) through (3) above, the Plan
Administrator shall notify the Claimant of the Adverse Benefit
Determination within a reasonable period of time but not later than
thirty days after receipt of the claim (which period may be
extended one time for up to fifteen days provided that the Plan
Administrator both determines that such extension is necessary due
to matters beyond the control of the Plan and notifies the Claimant
prior to the expiration of the initial thirty-day period of the
circumstances requiring the extension of time and the date by which
the Plan expects to render a decision).
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The period of
time within which an Adverse Benefit Determination regarding a
health benefit claim shall be made, as described above, shall begin
at the time a claim is filed in accordance with the reasonable
procedures of the Plan, without regard to whether all the
information necessary to make a benefit determination accompanies
the filing. In the case of claims described in Clauses (4) or
(5) above, in the event an extension of the period of time for
an Adverse Benefit Determination is required because additional
information is necessary to decide the claim, (including
examination by a physician selected by the Plan Administrator or
the performance of an autopsy), the notice of extension will
specifically describe the required information, the Claimant will
be afforded at least forty-five days from receipt of the notice to
provide such specified information, and the period for making the
Adverse Benefit Determination will be tolled from the date on which
the notification of the extension is sent to the Claimant until the
date on which the Claimant responds to the request for additional
information.
-13-
5.7 Timing of Adverse Benefit Determination
Notification Regarding Disability Benefit Claims
. The Plan Administrator shall
notify the Claimant of the Adverse Benefit Determination regarding
a disability benefit claim within a reasonable period of time, but
not later than forty-five days after receipt of the claim. This
period may be extended by the Plan Administrator for up to thirty
days, provided that the Plan Administrator both determines that
such extension is necessary due to matters beyond the control of
the Plan and notifies the Claimant, prior to expiration of the
initial forty-five-day period, of the circumstances requiring the
extension of time and the date by which the Plan expects to render
a decision. If, prior to the end of the first thirty-day extension
period, the Plan Administrator determines that, due to matters
beyond the control of the Plan, a decision cannot be rendered
within that extension period, the period for making the
determination may be extended for up to an additional thirty days,
provided that the Plan Administrator notifies the Claimant prior to
the expiration of the first thirty-day extension period of the
circumstances requiring the extension and the date as of which the
Plan expects to render a decision. Any extension notice provided to
a Claimant shall specifically explain the standards on which
entitlement to the benefit at issue is based, the unresolved issues
that prevent a decision on the claim, and the additional
information needed to resolve those issues, and the Claimant shall
be afforded at least forty-five days in which to provide the
specified information. In the event of such an extension, the
period for making the Adverse Benefit Determination will be tolled
from the date on which the notification of extension is sent to the
Claimant until the date on which the Claimant responds to the
request for additional information. The period of time within which
an Adverse Benefit Determination shall be made, as described above,
shall begin at the time a claim is filed in accordance with the
reasonable procedures of the Plan, without regard to whether all
the information necessary to make a benefit determination
accompanies the filing.
5.8 Timing of Adverse Benefit Determination
Regarding Non-Health and Disability Claims
. In any case of an Adverse Benefit
Determination of a claim for a Plan benefit other than a health or
disability benefit claim, the Plan Administrator shall furnish
written notice to the affected Claimant within a reasonable period
of time but not later than ninety days after receipt of such claim
for Plan benefits (or within 180 days if special circumstances
necessitate an extension of the ninety-day period and the Claimant
is informed of such extension in writing within the ninety-day
period and is provided with an extension notice consisting of an
explanation of the special circumstances requiring the extension of
time and the date by which the benefit determination will be
rendered).
-14-
5.9 Review of Adverse Benefit Determination
Regarding Health or Disability Benefit Claims
. A Claimant has the right to have
an Adverse Benefit Determination of a health or disability benefit
claim reviewed in accordance with the following claims review
procedure:
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(1)
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To exercise the right to request a
review of an Adverse Benefit Determination, a Claimant must submit
a written request for such review to the Plan Administrator not
later than 180 days following receipt by the Claimant of the
Adverse Benefit Determination notification;
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(2)
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The Claimant shall have the
opportunity to submit written comments, documents, records, and
other information relating to the claim for benefits to the Plan
Administrator or, as applicable, to the Independent
Fiduciary;
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(3)
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The Claimant shall have the right
to have all comments, documents, records, and other information
relating to the claim for benefits that have been submitted by the
Claimant considered on review without regard to whether such
comments, documents, records or information was considered in the
initial benefit determination;
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(4)
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The Claimant shall have reasonable
access to, and copies of, all documents, records, and other
information relevant to the claim for benefits free of charge upon
request, including (a) documents, records or other information
relied upon for the benefit determination, (b) documents, records
or other information submitted, considered or generated without
regard to whether such documents, records or other information were
relied upon in making the benefit determination,
(c) documents, records or other information that demonstrates
compliance with the standard claims procedure in making the benefit
determination on the Claimant’s claim, and
(d) documents, records or other information that constitutes a
statement of policy or guidance with respect to the Plan concerning
the denied treatment option or benefit for the Claimant’s
diagnosis, without regard to whether such statement of policy or
guidance was relied upon in making the benefit
determination;
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(5)
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The review of the Adverse Benefit
Determination shall not give deference to the original
decision;
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(6)
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The review of the Adverse Benefit
Determination shall be conducted solely by an Independent
Fiduciary;
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(7)
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If the initial benefit
determination was based in whole or in part on a medical judgment,
including determinations with regard to whether a particular
treatment, drug or other item is experimental, investigational or
not medically necessary or appropriate, the Independent Fiduciary
conducting the review shall consult with a Health Care Professional
with appropriate training and experience in the applicable field of
medicine who was not consulted, and is not the subordinate of
someone who was consulted, during the initial benefit
determination; and
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(8)
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The Claimant shall have the right
to have identified to him the medical or vocational experts whose
advice was obtained in connection with the Adverse Benefit
Determination (without regard to whether the advice was relied upon
in making such determination).
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-15-
The decision on
review by the Independent Fiduciary Plan Administrator will be
binding and conclusive upon all persons, and the Claimant shall
neither be required nor be permitted to pursue further appeals to
the Plan Administrator. Notwithstanding anything to the contrary in
this Section 5.9, an expedited review process is available for
Urgent Care Claims. A request for expedited review may be submitted
orally or in writing, in which case all necessary information will
be transmitted between the Plan Administrator and the Claimant by
telephone, facsimile or other similarly expeditious
method.
5.10 Review of Adverse Benefit Determination
Regarding Non-Health and Disability Benefit Claims
. A Claimant has the right to have
an Adverse Benefit Determination regarding a claim other than a
health or disability benefit claim reviewed in accordance with the
following claims review procedure:
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(1)
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The Claimant must submit a written
request for such review to the Plan Administrator not later than
60 days following receipt by the Claimant of the Adverse
Benefit Determination notification;
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(2)
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The Claimant shall have the
opportunity to submit written comments, documents, records, and
other information relating to the claim for benefits to the Plan
Administrator;
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(3)
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The Claimant shall have the right
to have all comments, documents, records, and other information
relating to the claim for benefits that have been submitted by the
Claimant considered on review without regard to whether such
comments, documents, records or information was considered in the
initial benefit determination; and
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(4)
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The Claimant shall have reasonable
access to, and copies of, all documents, records, and other
information relevant to the claim for benefits free of charge upon
request, including (a) documents, records or other information
relied upon for the benefit determination, (b) documents,
records or other information submitted, considered or generated
without regard to whether such documents, records or other
information were relied upon in making the benefit determination,
and (c) documents, records or other information that
demonstrates compliance with the standard claims
procedure.
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The decision on
review by the Plan Administrator will be binding and conclusive
upon all persons, and the Claimant shall neither be required nor be
permitted to pursue further appeals to the Plan
Administrator.
-16-
5.11 Notification of Benefit Determination on
Review . Notice of
the final benefit determination regarding an Adverse Benefit
Determination will be furnished in writing or electronically to the
Claimant after a full and fair review. Notice of an Adverse Benefit
Determination upon review will be provided at the time described in
Section 5.12, 5.13 or 5.14 below, whichever is applicable with
respect to a claim, and will, in the case of any Adverse Benefit
Determination:
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(1)
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State the specific reason or
reasons for the Adverse Benefit Determination;
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(2)
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Provide specific reference to
pertinent Plan provisions on which the Adverse Benefit
Determination is based;
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(3)
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State that the Claimant is entitled
to receive, upon request and free of charge, reasonable access to
and copies of all documents, records, and other information
relevant to the Claimant’s claim for benefits including
(a) documents, records or other information relied upon for
the benefit determination, (b) documents, records or other
information submitted, considered or generated without regard to
whether such documents, records or other information were relied
upon in making the benefit determination, (c) documents, records or
other information that demonstrates compliance with the standard
claims procedure in making the benefit determination on the
Claimant’s claim, and (d) in the case of claims
regarding health or disability benefits, documents, records or
other information that constitutes a statement of policy or
guidance with respect to the Plan concerning the denied treatment
option or benefit for the Claimant’s diagnosis, without
regard to whether such statement of policy or guidance was relied
upon in making the benefit determination.
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(4)
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Describe the Claimant’s right
to bring an action under section 502(a) of ERISA;
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In the case of
an Adverse Benefit Determination regarding health or disability
benefits, such notice shall also:
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(1)
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If an internal rule, guideline,
protocol or other similar criterion was relied upon in making the
Adverse Benefit Determination, either provide such criterion or
state that such criterion was relied upon and that a copy of the
criterion will be provided free of charge to the Claimant upon
request;
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(2)
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If the Adverse Benefit
Determination is based on a medical necessity, experimental
treatment or similar exclusion or limit, either explain the
scientific or clinical judgment for the determination, applying the
terms of the Plan to the Claimant’s medical circumstances, or
state that such explanation will be provided free of charge to the
Claimant upon request;
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(3)
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Include the following statement:
“You and your plan may have other voluntary alternative
dispute resolution options, such as mediation. One way to find out
what may be available is to contact your local U.S. Department of
Labor Office and your State insurance regulatory
agency.”
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5.12 Timing of Notification Regarding Review
of Health Benefit Claims . For Urgent Care Claims, such notice will be
furnished as soon as possible, taking into account the medical
exigencies, but not later than seventy-two hours following a
request for review. For other claims, such notice will be furnished
(i) within a reasonable period of time appropriate to the
medical circumstances but not later than thirty days following a
request for a review of a Pre-Service Claim, and (ii) within a
reasonable period of time but not later than sixty days following a
request for a review of a Post-Service Claim. The period of time
within which a benefit determination on review will be made begins
at the time an appeal is filed in accordance with the reasonable
procedures of the Plan, without regard to whether all the
information necessary to make a benefit determination on review
accompanies the filing.
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5.13 Timing of Notification Regarding Review
of Disability Benefit Claims . Such notice will be furnished within a
reasonable period of time but not later than forty-five days
following receipt of a request for a review (which period may be
extended for up to forty-five additional days provided that the
Plan Administrator both determines that such an extension is
necessary due to special circumstances and notifies the Claimant
prior to the expiration of the initial forty-five-day period of the
special circumstances requiring an extension and the date by which
the Independent Fiduciary expects to render the determination on
review). The period of time within which a benefit determination on
review will be made begins at the time an appeal is filed in
accordance with the reasonable procedures of the Plan, without
regard to whether all the information necessary to make a benefit
determination on review accompanies the filing. In the event an
extension of time is necessary due to the Claimant’s failure
to submit necessary information, the period for making the Adverse
Benefit Determination will be tolled from the date on which the
notification of the extension is sent to the Claimant until the
date on which the Claimant responds to the request for additional
information.
5.14 Timing of Notification Regarding Review
of Non-Health or Disability Claims . The Plan Administrator shall notify a Claimant
of its determination on review with respect to the Adverse Benefit
Determination of the Claimant within a reasonable period of time
but not later than sixty days after the receipt of the
Claimant’s request for review unless the Plan Administrator
determines that special circumstances require an extension of time
for processing the review of the Adverse Benefit Determination. If
the Plan Administrator determines that such extension of time is
required, written notice of the extension (which shall indicate the
special circumstances requiring the extension and the date by which
the Plan Administrator expects to render the determination on
review) shall be furnished to the Claimant prior to the termination
of the initial sixty-day review period. In no event shall such
extension exceed a period of sixty days from the end of the initial
sixty-day review period. In the event such extension is due to the
Claimant’s failure to submit necessary information, the
period for making the determination on a review will be tolled from
the date on which the notification of the extension is sent to the
Claimant until the date on which the Claimant responds to the
request for additional information.
5.15 Exhaustion of Administrative
Remedies .
Completion of the claims procedures described in this
Article V will be a condition precedent to the commencement of
any legal or equitable action in connection with a claim for
benefits under the Plan by a Claimant or by any other person or
entity claiming rights individually or through a Claimant;
provided, however, that the Plan Administrator may, in its sole
discretion, waive compliance with such claims procedures as a
condition precedent to any such action.
5.16 Payment of Benefits
. If the Benefits Administrator,
Plan Administrator or Independent Fiduciary determines that a
Claimant is entitled to a benefit hereunder, payment of such
benefit will be made to such Claimant (or commence, as applicable)
as soon as administratively practicable after the date the Benefits
Administrator, Plan Administrator or Independent Fiduciary
determines that such Claimant is entitled to such benefit or on
such other date as may be established pursuant to the Plan
provisions or, as applicable, designated by the Claimant, Plan
Administrator or Independent Fiduciary, as applicable.
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5.17 Authorized
Representatives . An
authorized representative may act on behalf of a Claimant in
pursuing a benefit claim or an appeal of an Adverse Benefit
Determination. An individual or entity will only be determined to
be a Claimant’s authorized representative for such purposes
if the Claimant has provided the Plan Administrator with a written
statement identifying such individual or entity as his authorized
representative and describing the scope of the authority of such
authorized representative; provided that, for an Urgent Care Claim,
a Health Care Professional with knowledge of a Claimant’s
medical condition will be permitted to act as the authorized
representative of the Claimant. In the event a Claimant identifies
an individual or entity as his authorized representative in writing
to the Plan Administrator but fails to describe the scope of the
authority of such authorized representative, the Plan Administrator
shall assume that such authorized representative has full powers to
act with respect to all matters pertaining to the Claimant’s
benefit claim under the Plan or appeal of an Adverse Benefit
Determination with respect to such benefit claim.
5.18 Temporary Rules Regarding Health
Benefit Claims .
Health benefit claims made under a Constituent Benefit Program
prior to January 1, 2003 shall be subject to the following
special benefit claims rules: Section 5.8 shall be applied in
place of Section 5.6; Sections 5.5(3) and 5.5(4) shall be
inapplicable; Section 5.10 shall be applied in place of
Section 5.9; the special rules regarding health benefit claims
in Section 5.11 shall be inapplicable; and Section 5.14
shal l be applied in place of Section 5.12.
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6.1 Source of Benefits
. Except with respect to benefits
provided by an Insurer or an HMO or through a trust, the Plan shall
be self-funded and any benefit payable under the Plan shall be paid
from the general assets of the Employer.
6.2
Participant Contributions .
(a) Participants’ contributions, if
any, shall be determined by the Employer and shall be set forth in
each Constituent Benefit Program Document. Upon enrollment of a
Participant in, amendment of coverage under, or enrollment of an
Eligible Dependent in any Constituent Benefit Program, each
Participant shall be advised of any required Participant
contributions with respect to the coverage under such Constituent
Benefit Program. Further, Participants’ contributions shall
be subject to change by and in the sole discretion of the Employer,
and each Participant shall be advised of any such change in the
amount of such contributions as provided in the applicable
Constituent Benefit Program and, in the absence of such provision,
in writing no later than thirty-one days prior to the effective
date of such change.
(b) Participants’ contributions shall
be paid by Participants in the manner and within the time period
set forth in the applicable Constituent Benefit Program
Document.
(c) Subject to the terms and conditions set
forth in the Dynegy Inc. Pre-Tax Premium and Benefits Plan,
Participants shall be permitted to elect to make certain
Participant contributions with respect to coverage under certain
Constituent Benefit Programs on a pre-tax basis. If a Participant
makes such an election, the Participant’s Compensation shall
be reduced, and an amount equal to the reduction shall be
contributed by the Employer and applied to such Participant’s
share of any cost of coverage under the applicable Constituent
Benefit Program.
6.3 HMO Premiums . HMO premiums shall be paid by the Plan
Administrator to such HMO from the general assets of the Employer
and/or Participants’ contributions within the time period
required by the applicable Constituent Benefit Program or
applicable contract with such HMO or, if earlier, by
law.
6.4 Insurance Premiums
. Insurance premiums payable with
respect to any Insured Constituent Benefit Program shall be paid to
the applicable Insurer from the general assets of the Employer
and/or Participants’ contributions within the time period
required by the applicable Insured Constituent Benefit Program or
applicable contract with such Insurer or, if earlier, by
law.
6.5 Trust . Benefits under any Constituent Benefit
Program, HMO premiums and/or insurance premiums may be paid from
any trust established for that purpose (including any trust which
is or is intended to be a voluntary employees’ beneficiary
association under section 501 (c)(9) of the Code) as determined by
the Plan Administrator.
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VII.
Administration of Plan
7.1 Plan Administrator
. For purposes of ERISA, the Company
shall be the “administrator” and the “named
fiduciary” with respect to the Plan. The general
administration of the Plan and of the Constituent Benefit Programs
shall be vested in the Plan Administrator or, if there be more than
one, the Plan Administrators. There may be more than one Plan
Administrator with respect to the Plan and/or a Constituent Benefit
Program. Appendix B shall identify and describe the respective
powers, duties and responsibilities of each Plan Administrator. If
no Plan Administrator is designated by the Board for the Plan
and/or a Constituent Benefit Program, the Company shall be the Plan
Administrator as to the Plan and/or Constituent Benefit Program
which is lacking an identified and appointed Plan Administrator.
Each Plan Administrator shall constitute a fiduciary of the Plan
for all purposes of ERISA with respect to the duties and
responsibilities assigned to such Plan Administrator as described
on Appendix B. Each Plan Administrator, upon appointment by
the Board as a Plan Administrator, shall be notified in writing of
such appointment, which written notification shall affirmatively
advise the Plan Administrator of his or her fiduciary status for
purposes of ERISA.
7.2 Discretion to Interpret
Plan . A Plan
Administrator shall have absolute discretion to construe and
interpret any and all provisions of the Plan and/or the Constituent
Benefit Programs which are relevant to the duties and
responsibilities of such Plan Administrator as described on
Appendix B, including, but not limited to, the discretion to
resolve ambiguities, inconsistencies, or omissions conclusively;
provided, however, that all such discretionary interpretations and
decisions shall be applied in a uniform and nondiscriminatory
manner to all Participants, beneficiaries, and Covered Eligible
Dependents who are similarly situated. The decisions of the Plan
Administrator upon all matters within the scope of its authority
shall be binding and conclusive upon all persons.
7.3 Powers and Duties
. In addition to the powers
described in Section 7.2 and all other powers specifically
granted under the Plan, a Plan Administrator shall have all powers
necessary or proper to administer the Plan and/or a Constituent
Benefit Program with respect to the duties and responsibilities of
such Plan Administrator as described on Appendix B and to
discharge its duties and responsibilities under the Plan,
including, but not limited to, the following powers:
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(1)
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To make and enforce such rules,
regulations, and procedures as it may deem necessary or proper for
the orderly and efficient administration of the Plan and/or a
Constituent Benefit Program with respect to the duties and
responsibilities of such Plan Administrator as described on
Appendix B;
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(2)
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With the consent of the Company, to
enter into an Administrative Services Agreement with an individual
or entity;
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(3)
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In its discretion and as applicable
with respect to the duties and responsibilities of such Plan
Administrator as described on Appendix B, to interpret and
decide all matters of fact in granting or denying benefits
und
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