Long Term Disability Plan

Transcription

1 Long Term Disability Plan Revised January 1, 2017 The Enrollment/Change Form is included at the end of this booklet B SI (11/16)

2 STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon (503) CERTIFICATE AND SUMMARY PLAN DESCRIPTION GROUP LONG TERM DISABILITY INSURANCE Policyholder: Washington State Health Care Authority Policy Number: B Effect ive Dat e: July 1, 1992 and as amended A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you m eet t h e r equ irem en t s set ou t in t h is Cer t ificat e. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All ot h er defined t er m s appear with t h e initial let t er capitalized. Sect ion h eadings, an d r efer en ces t o t h em, appear in boldface type. GC190-LTD

3 Table of Contents COVERAGE OUTLINE... 1 GENERAL POLICY INFORMATION... 1 BECOMING INSURED... 1 SCHEDULE OF INSURANCE... 2 DISABILITY PROVISIONS... 5 EXCLUSIONS AND LIMITATIONS... 5 DEDUCTIBLE INCOME... 5 OTHER PROVISIONS... 5 PREMIUM CONTRIBUTIONS... 6 INSURING CLAUSE... 7 DEFINITION OF DISABILITY... 7 RETURN TO WORK INCENTIVE... 8 TEMPORARY RECOVERY... 8 WHEN LTD BENEFITS END... 9 PREDISABILITY EARNINGS... 9 DEDUCTIBLE INCOME EXCEPTIONS TO DEDUCTIBLE INCOME RULES FOR DEDUCTIBLE INCOME RETIREMENT PLAN OFFSET (RPO) COST OF LIVING ADJUSTMENT BENEFIT HIGHER EDUCATION RETIREMENT CONTRIBUTIONS BENEFIT (PLAN D) SURVIVORS BENEFIT WAIVER OF PREMIUM BENEFITS AFTER INSURANCE ENDS OR IS CHANGED EFFECT OF NEW DISABILITY EXCLUSIONS LIMITATIONS CLAIMS TIME LIMITS ON LEGAL ACTIONS INCONTESTABILITY PROVISIONS CONTINUITY OF COVERAGE WHEN YOUR INSURANCE BECOMES EFFECTIVE ACTIVE WORK PROVISIONS WHEN YOUR INSURANCE ENDS REINSTATEMENT OF INSURANCE DEFINITIONS... 22

4 Index of Defined Terms Active Work, Actively at Work, 20 Allowable Period, 8 Any Occupation Definition of Disability, 7 Any Occupation Income Level, 5 Any Occupation Period, 5 Benefit Waiting Period, 3, 22 COLA Factor, 13 CPI-W, 22 Dedu ct ible Incom e, 10 Disability, 7 Disabled, 7 Dom est ic Par t n er, 23 Eligibility Waiting Period, 22 Em ployer (s), 1 Evidence of Insurability, 22 Exclusion Period, 5 Preexisting Condition, 16 Preexisting Condition Period, 5 Pregnancy, 22 Pr ior Plan, 22 Proof Of Loss, 17 Qualifying Years Of Disability, 2 Return To Work Incentive, 8 Salary Continuation Offset, 5 Sickness, 22 Social Secu r ity Nor m al Ret irem en t Age (SSNRA), 4 Spouse, 22 Tem por ar y Recover y, 8 War, 16 Work Earnings, 8 Group Policy, 22 Group Policy Effective Date, 1 Group Policy Number, 1 Hospital, 16 Indexed Predisability Earnings, 22 Injury, 22 LTD Ben efit, 22 Material Duties, 7 Maximu m Ben efit Per iod, 4, 22 Maximum LTD Benefit, 2 Men t al Disor der, 16 Minimum LTD Benefit, 2 Own Occupation, 7 Own Occupation Definition Of Disability, 7 Own Occupation Income Level, 5 Own Occupation Period, 5 Partial Disability, 7 Physician, 22 Policyholder, 1 Predisability Earnings, 9

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6 COVERAGE OUTLINE This section contains many of the features of your long term disability (LTD) insurance. Ot h er provisions, including exclusions, limitations, and Deductible Income, appear in other sections. Please r efer t o t h e t ext of each sect ion for fu ll det ails. Th e Table of Con t en t s an d t h e Index of Defined Ter m s help locate sections and definitions. GENERAL POLICY INFORMATION Group Policy Number: B Policyholder: Washington State Health Care Authority Employer (s): See Definitions Gr ou p Policy Effect ive Dat e: July 1, 1992 St at e of Issu e: Washington BECOMING INSURED To becom e insu r ed you m u st : (a) Be a Mem ber ; and (b) Meet t h e r equ irem ents in Active Work Provisions and When Your Insurance Becomes Effective. You ar e a m em ber if you ar e an em ployee who m eet s eligibility cr iter ia est ablish ed by t h e Policyh older, consistent with applicable state statutes, regulations and PEBB rules. Your employing agency will det er m ine whet h er you ar e eligible for ben efits u pon em ploym en t or ch an ge in st at u s. You m ay r equ est eligibility information from your personnel, payroll or benefits offices, including the Member definition and any waiting period for your insu r an ce t o becom e effect ive. Evidence of Insurability requirements and decisions to approve or decline satisfactory Evidence of Insurability are made by Standard Insurance Company. Definition of Member for: Plan A (Basic Insurance) and Plan B (Optional Insurance) Plan C (Optional Insurance) Plan D (Optional Insurance) Persons not eligible for any plan St at e agen cy em ployees eligible for PEBB ben efits an d em ployer gr ou p em ployees as descr ibed in t h e em ployer gr ou p s con t r act with the Health Care Authority, with the exception of the following em ployees who ar e eligible for Plan A (Basic Insurance) only: Seasonal employees who work a season of less than nine months Port Commissioners Mem ber s en r olled in Plan B an d n ot eligible t o be cover ed u n der t h e higher education retirement plan. Mem ber s en r olled in Plan B an d eligible t o be cover ed u n der t h e h igh er edu cat ion r et irem en t plan. Persons not eligible for an Employer contribution under the policy established by the Public Employees Ben efits Boar d Pr ogr am. Evidence Of Insurability Requ ired for : a. Late application for Optional insurance (more than 31 days after initial eligibility). b. Reducing a Benefit Waiting Period. This requirement will not apply t o a Mem ber whose employment changes from an Employer paying the entire cost of Optional Insurance to any other Employer, provided the Revised 01/ B

7 Mem ber elect s a Ben efit Waiting Period no shorter than the Optional Insurance Benefit Waiting Period for which the Member was insured immediately preceding employment with the Employer who pays the entire cost of Optional Insurance. c. Reinst at em en t s if r equ ired. SCHEDULE OF INSURANCE Amount of Benefit: Plan A (Basic Insurance): LTD Ben efit: Maximum: Minimum: $50 Plan B (Optional Insurance): LTD Ben efit: Maximum: Minimum: $50 Plan C (Optional Retirement Supplement Ben efit) For a PERS 1 Mem ber with at least 5 years of employment with the Employer and whose disability qualifies under PERS as a duty disability: 60% of the first $400 of your Predisability Earnings, r edu ced by Dedu ct ible Incom e. $240 before reduction by Deductible Income. 60% of the first $10,000 of your Predisability Earnings, reduced by Deductible Income and by any benefits under Plan A. $6,000 before reduction by Deductible Income and by any ben efits u n der Plan A. 1% of the first $10,000 of your Predisability Earnings times the Qualifying Years Of Disability, not to exceed 30% of the first $10,000 of your Predisability Earnings. For an y ot h er Mem ber with at least 5 years of employment with the Em ployer who is cover ed u n der any plan sponsored by the Employer except a h igh er edu cat ion r et irem en t plan : 2% of the first $10,000 of your Predisability Earnings times the Qualifying Years Of Disability, not to exceed 60% of the first $10,000 of your Predisability Earnings. For a Mem ber with less than 5 years of employment with the Employer: None However, n o ben efit will be payable if the monthly benefit amount would be less than $50. Plan C ben efits ar e n ot payable u n t il aft er ser ving t h e Ret irem en t Su pplem en t Defer m en t Period, which is the scheduled Maximum Benefit Period under Plan B when you become Disabled. No Plan C benefit will be payable du r ing an y per iod t h at LTD Ben efits ar e payable. Qualifying Years Of Disability means the number of years, including fractional parts (complete calendar months) of any year, for which benefits were paid under Plan B. Revised 01/ B

8 Aft er t h e Ret irem en t Su pplem en t Defer m en t Per iod h as been ser ved, Plan C ben efits ar e payable for your lifetime. Plan D (Optional Higher Education Retirement Plan Contribution Benefit): The amount payable on your behalf is the sum of: Benefit Waiting Period: Plan A: Plan B: 1. Th e con t r ibu t ion you wer e r equ ired t o m ak e t o you r Employer s mandatory higher education retirement plan as of the date you became disabled, and 2. The contribution made by your Employer to its mandatory higher education retirement plan. In no case will the benefit exceed 15% of the first $10,000 of your monthly Predisability Earnings. The amount payable is in addition to any amount payable under Plan B. No benefit is payable under Plan D if no ben efit is payable u n der Plan B. 90 days, or the period of sick leave (excluding shared leave) for which you ar e eligible u n der t h e Em ployer 's sick leave plan, which ever is lon ger. 30, 60, 90, 120, 180, 240, 300 or 360 days, depending on you r elect ion, or t h e per iod of sick leave (excluding sh ar ed leave) for which you ar e eligible u n der t h e Em ployer 's sick leave plan, which ever is lon ger. Central Washington University Mem ber s who ar e design at ed as facu lty with tenure and tenure track appointments and non-tenure track faculty with full academic year appointments: 90 days. However, if you wer e insu r ed for a Ben efit Waiting Period other than 90 days under Plan B on August 31, 2006, you may retain that Benefit Waiting Period or become insured for a 90 day Benefit Waiting Period, subject to the following: Eastern Washington University Mem ber s who ar e design at ed as pr obat ion ar y, t en u r ed, or Sen ior Lect u r er s, excluding a. Evidence Of Insurability will not be required if you elect t h e 90 day Ben efit Waiting Per iod bet ween April 1, 2006 and April 30, b. You must make premium contributions to remain insu r ed for a Ben efit Waiting Period of less than 90 days under Plan B. If you wer e eligible bu t n ot insu r ed u n der Plan B on August 31, 2006, you may become insured under Plan B on September 1, 2006, subject to the following: a. Evidence Of Insurability will be required if you previously applied for insurance under Plan B and whose Evidence Of Insurability was disapproved. b. Evidence Of Insurability will not be required for an y ot h er Mem ber. Revised 01/ B

9 Lect u r er s, Facu lty in Residen ce and Quarterly Faculty: 120 days. However, if you wer e insu r ed for a Ben efit Waiting Period other than 120 days under Plan B on August 31, 2006, you may retain that Benefit Waiting Per iod or become insured for a 120 day Benefit Waiting Period, subject to the following: a. Evidence Of Insurability will not be required if you elect t h e 120 day Ben efit Waiting Per iod bet ween September 1, 2006 and September 30, b. You must make premium contributions to remain insured for a Benefit Waiting Period of less than 90 days under Plan B. If you wer e eligible bu t n ot insu r ed u n der Plan B on August 31, 2006, you may become insured under Plan B on September 1, 2006, subject to the following: a. Evidence Of Insurability will be required if you previously applied for insurance under Plan B and whose Evidence Of Insurability was disapproved. b. Evidence Of Insurability will not be required for an y ot h er Mem ber. Plan C: The end of the Maximum Benefit Per iod under Plan B. Plan D: You r Ben efit Waiting Period under Plan B. Maximu m Benefit Per iod: Plan A, Plan B, and Plan D: Age Determined by your age when Disability begins, as follows: Maximu m Ben efit Per iod 61 or younger... To age 65, or to SSNRA, or 3 years 6 months, whichever is lon gest To SSNRA, or 3 years 6 months, whichever is longer To SSNRA, or 3 year s, which ever is lon ger To SSNRA, or 2 years 6 months, whichever is longer year s year 9 months year 6 months year 3 months 69 or older... 1 year Social Secu r ity Nor m al Ret irem en t Age (SSNRA) means your normal retirement age under the Feder al Social Secu r ity Act, as am en ded. Plan C: To t h e dat e of you r deat h. Th e Maximu m Ben efit Per iod begins at t h e en d of t h e Ret irem en t Su pplem en t Defer m en t Per iod. Revised 01/ B

10 Own Occupation Period: Any Occupation Period: Partial Disability: Own Occupation Income Level: Any Occupat ion Incom e Level: DISABILITY PROVISIONS The first 24 months for which LTD Benefits are paid. From the end of the Own Occupation Period to the end of t h e Maximu m Ben efit Per iod. Cover ed See Definition of Disability for more information. 80% of your Indexed Predisability Earnings. 60% of your Indexed Predisability Earnings. Preexisting Condition Exclusion: Preexisting Condition Period: Exclusion Period: EXCLUSIONS AND LIMITATIONS Yes, the Group Policy contains a Preexisting Condition exclusion. This exclusion is waived for Members whose Evidence Of Insurability is approved by us. Th e 90 day per iod pr ior t o t h e m ost r ecen t effect ive dat e of your insurance under th e Employer's group long term disability insurance program. The period of time until you have been continuously insured for 12 months. See Exclusions and Limitations for this and other exclusions and limitations. Social Security Offset: Salary Continuation Offset: DEDUCTIBLE INCOME Full offset See Deductible Income for this and other Deductible Income. Sick Pay, shared leave and other salary continuation paid to you by your Employer. OTHER PROVISIONS Survivors Benefit Amount: COLA Ben efit: Continuity of Coverage: Predisability Earnings based on: A lump sum equal to 3 times your monthly LTD Benefit (Plan A and Plan B) without reduction by Deductible Incom e. Th e LTD Ben efit u n der Plan B will be r edu ced by any LTD Benefit under Plan A. Yes, t h e Group Policy contains a cost of living adjustment provision. Yes Earnings in effect on your last full day of Active Work. Revised 01/ B

11 Plan A (Basic Insurance): PREMIUM CONTRIBUTIONS Contributions from Members for insurance under Plan A ar e n ot r equ ired except while on approved educational leave or USERRA leave (leave for ser vice in t h e u n ifor m ed ser vices as defined in t h e Unifor m ed Ser vices Em ploym en t and Reemployment Rights Act). Plan B, Plan C, and Plan D (Optional Insurance): Contributions from Members for insurance under Plan B, Plan C and Plan D are required and will depend on the Ben efit Waiting Per iod you select. Revised 01/ B

12 INSURING CLAUSE If you becom e Disabled while insu r ed u n der t h e Gr ou p Policy, we will pay LTD Benefits according to the terms of the Group Policy after we receive satisfactory Proof Of Loss. LT.IC.01 DEFINITION OF DISABILITY You ar e Disabled if you meet one of the following definitions: A. Own Occupation Definition Of Disability During the Benefit Waiting Period and the first 24 months for which LTD Benefits are paid (Own Occu pat ion Per iod), you ar e r equ ired t o be Disabled only from your Own Occupation. You ar e Disabled from your Own Occupation if, as a result of Sickness, Injury or Pregnancy, you are unable to perform with reasonable continuity the Material Duties of your Own Occupation. B. Any Occupation Definition Of Disability From the end of the Own Occupation Period to the end of the Maximum Benefit Period (Any Occupation Period), you are required to be Disabled from all occupations. You are Disabled from all occupations if, as a result of Sickness, Injury or Pr egn an cy, you ar e unable to perform with reasonable continuity the Material Duties of any gainful occupation for which you are reasonably able through education, training, and experience C. Partial Disability Definition 1. During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled if you are working in your Own Occupation but, as a result of Sickness, Injury or Pregnancy, you are unable to earn more than the Own Occupation Income Level (80% of Indexed Predisability Earnings). 2. During the Any Occupation Period, you are Partially Disabled if you are working in an occupation but, as a result of Sickness, Injury or Pregnancy, you are unable to earn more than the Any Occupation Income Level (60% of Indexed Predisability Earnings) in that occupation and in all other occupations for which you are reasonably suited under the Any Occupation Definition of Disability. You may work in another occupation while you meet the Own Occupation Definition of Disability. If you are Disabled from your Own Occupation, there is no limit on your Work Earnings in another occupation. You r Wor k Ear n ings m ay be Dedu ct ible Incom e. See Ret u r n To Wor k Incen t ive an d Dedu ct ible Income. Own Occupation means any employment, business, trade, profession, calling or vocation that involves Mat er ial Dut ies of t h e sam e gen er al ch ar act er as you r r egu lar an d or dinar y em ploym en t with you r Employer. Your Own Occupation is not limited to your job with your Employer. Mat er ial Duties means the essential tasks, functions and operations, and the skills, abilities, k n owledge, t r aining an d exper ien ce, gen er ally r equ ired by em ployer s fr om t h ose en gaged in a particular occupation. LT.DD.01X Revised 01/ B

13 A. During The Benefit Waiting Period RETURN TO WORK INCENTIVE You m ay ser ve you r Ben efit Waiting Per iod while wor k ing, if you m eet eith er t h e Own Occu pat ion Definition of Disability or the Partial Disability Definition. B. Aft er Th e Ben efit Waiting Per iod You ar e eligible for t h e Ret u r n t o Wor k Incen t ive on t h e first day you wor k aft er t h e Ben efit Waiting Per iod if LTD Ben efits ar e payable on t h at dat e. Th e Ret u r n To Wor k Incen t ive changes 12 months after that date, as follows: 1. During the first 12 months, your Work Earnings will be Deductible Income as determined below: a. Det er m ine t h e am ou n t of you r LTD Ben efit as if t h er e wer e n o Dedu ct ible Incom e, an d add your Work Earnings to that amount. b. Determine 100% of your Indexed Predisability Earnings. c. If a. is gr eat er t h an b., t h e differ en ce will be Dedu ct ible Incom e. 2. After those first 12 months, one half of your Work Earnings will be Deductible Income. Work Earnings means your gross monthly earnings from work you perform while Disabled, including earnings from your Employer, any other employer, or self-employment. LT.RW.01 TEMPORARY RECOVERY You may temporarily recover from your Disability, and then become Disabled again from the same cause or cau ses, with ou t h aving t o ser ve a n ew Ben efit Waiting Per iod. Tem por ar y Recover y m ean s you cease to be Disabled for no longer than the applicable Allowable Period. A. Allowable Per iods 1. Dur ing t h e Ben efit Waiting Per iod: a t ot al of 5 days of r ecover y for ever y 30 days of t h e Ben efit Waiting Per iod. 2. Dur ing the Maximu m Benefit Per iod: 180 days for each per iod of r ecover y. B. Effect Of Tem por ar y Recover y If you r Tem por ar y Recover y does n ot exceed t h e Allowable Periods, 1 through 5 below will apply. 1. The Predisability Earnings used to determine your LTD Benefit will not change. 2. The period of Temporary Recovery will not count toward your Benefit Waiting Period, your Maximu m Benefit Per iod or you r Own Occupation Period. 3. No LTD Benefits will be payable for the per iod of Tempor ar y Recover y. 4. No LTD Benefits will be payable after benefits become payable to you u nder any other gr ou p long term disability insurance policy under which you become insured during your period of Tempor ar y Recover y. 5. Except as stated above, the provisions of the Gr ou p Policy will be applied as if ther e had been no interruption of your Disability. LT.TR.06 Revised 01/ B

14 WHEN LTD BENEFITS END Your LTD Benefits end automatically on the ear liest of 1 t h r ou gh 4 below. 1. Th e dat e you ar e n o lon ger Disabled. 2. Th e dat e you r Maximu m Ben efit Per iod en ds. 3. Th e dat e you die. 4. Th e dat e ben efits becom e payable u n der an y ot h er gr ou p lon g t er m disability insu r an ce policy under which you become insured during a period of Temporary Recovery. LT.BE.01 PREDISABILITY EARNINGS Your Predisability Earnings will be based on your earnings in effect on your last full day of Active Work u n less a differ en t dat e applies (see t h e Coverage Outline). Any subsequent change in your earnings will not affect your Predisability Earnings. Predisability Earnings means your monthly rate of earnings from your Employer, including: 1. Contributions you make through a salary reduction agreement with your Employer to: a. An Internal Revenue Code (IRC) Section 401(k), 403(b), or 457 deferred compensation arrangement; or b. An execu t ive n on qu alified defer r ed com pen sat ion ar r an gem en t. 2. Amounts contributed to your fringe benefits according to a salar y r edu ct ion agr eem en t u n der an IRC Section 125 plan. 3. Any public funds paid to you as a grant, subsidy or contract for a research project or other work you perform. Predisability Earnings does not include: 1. Bonuses. 2. Shift differential pay. 3. Standby pay. 4. Commissions. 5. Optional stipends. 6. Over t ime pay. 7. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan. 8. Any other extra compensation. If you are paid on an annual contract basis or have an understanding of continued full-t ime employment, your monthly rate of earnings is one-twelfth (1/ 12th) of your annual salary (including position stipends). If you are a full-time hourly paid Member, your monthly rate of earnings is your hourly pay rate multiplied by the number of hours you are regularly scheduled to work per month, but not more than 173 hours. If you are a part-time faculty Member, your monthly rate of earnings is your average monthly earnings during the preceding 12 calendar months (or during the period of your employment as a part-time Member if less than 12 months). Revised 01/ B

15 If you are any other salaried part-t ime Mem ber or fu ll-time Member, your monthly rate of earnings is your monthly wage or salary (including position stipends) times the number of months you are regularly scheduled to work per year, divided by 12. If you are any other hourly paid part-time Member or an intermittent Member, your monthly rate of earnings is your current hourly pay rate times the average number of hours per month for which you were compensated by the Employer during the previous 12 months (or during the period of your coverage under the Group Policy if less than 12 months). If you are a commissioner of a P.U.D., your monthly rate of earnings is 1/ 12th of your annual com pen sat ion (including you r per cen t age of P.U.D. r even u e). LT.PD.06X DEDUCTIBLE INCOME Subject to Exceptions To Deductible Income, Dedu ct ible Incom e means: 1. Sick pay, shared leave or other salary continuation as shown in the Coverage Outline. 2. Your Work Earnings, as described in the Return To Work Incentive. 3. An y am ou n t you r eceive or ar e eligible t o r eceive becau se of you r disability u n der an y workers' compensation law or similar law, including amounts for partial or total disability, whether permanent, temporary, or vocational. 4. An y am ou n t you, you r Spou se, or you r ch ildr en u n der age 18 r eceive or ar e eligible t o r eceive becau se of you r disability or r et irem en t u n der : a. Th e Feder al Social Secu r ity Act ; b. The Canada Pension Plan; c. Th e Qu ebec Pen sion Plan ; or d. Any similar plan or act. Bot h t h e pr imar y ben efit (t h e ben efit awar ded t o you ) an d depen den t s ben efits ar e Dedu ct ible Incom e. Ben efits you r Spou se or ch ildr en r eceive or ar e eligible t o r eceive becau se of you r disability are Deductible Income regardless of marital status, custody, or place of residence. 5. An y am ou n t you r eceive or ar e eligible t o r eceive becau se of you r disability u n der an y st at e disability income benefit law or similar law. 6. Amounts you receive or ar e eligible t o r eceive becau se of your disability under any other group disability insu r an ce cover age, as det er m ined below: a. Det er m ine t h e am ou n t of you r LTD Ben efit as if t h er e wer e n o Dedu ct ible Incom e, an d add you r group disability insurance benefits to that amount. b. Determine 60% of the first $10,000 of your total monthly earnings from all employment plus 40% of the remainder of your total monthly earnings from all employment. c. If a. is gr eat er t h an b., t h e differ en ce will be Dedu ct ible Income. 7. You r Dedu ct ible Incom e fr om you r Em ployer 's r et irem en t plan, as descr ibed in t h e Retirement Plan Offset (RPO) section. 8. Any amount you receive by compromise, settlement, or other method as a result of a claim for any of t h e above, whet h er disputed or undisputed. LT.DI.02X Revised 01/ B

16 Dedu ct ible Incom e does n ot include: EXCEPTIONS TO DEDUCTIBLE INCOME 1. Any cost of living increase in any Deductible Income other than Work Earnings, if the increase becom es effect ive while you ar e Disabled an d while you ar e eligible for t h e Dedu ct ible Incom e. 2. Reimbu r sem en t for h ospital, m edical, or su r gical expen se. 3. Reasonable attorneys fees incurred in connection with a claim for Deductible Income. 4. Benefits from any individual disability insurance policy. 5. Ear ly r et irem en t ben efits u n der t h e Federal Social Security Act which are not actually received. 6. Group credit or mortgage disability insurance benefits. 7. Acceler at ed ben efits paid u n der a life insu r an ce policy. 8. Benefits from a through h below: a. Profit sharing plan. b. Thrift or savings plan. c. Defer r ed com pen sat ion plan. d. Plan under IRC Section 401(k) or 457. e. Individual Retirement Account (IRA). f. Tax Sheltered Annuity (TSA) under IRC Section 403(b). g. Stock ownership plan. h. Keogh (HR-10) plan. 9. Vacation pay (annual leave). 10. Military retirement or disability benefits. LT.ED.02X A. Monthly Equivalents RULES FOR DEDUCTIBLE INCOME Each m on t h we will det er m ine you r LTD Ben efit u sing t h e Dedu ct ible In come for the same monthly per iod, even if you act u ally r eceive t h e Dedu ct ible Incom e in an ot h er m on t h. If you are paid Deductible Income in a lump sum or by a method other than monthly, we will det er m ine you r LTD Ben efit u sing a pr or at ed am ou n t. We will u se t h e per iod of t ime t o which t h e Dedu ct ible Incom e applies. If n o per iod of t ime is st at ed, we will u se a r eason able on e. B. Your Duty To Pursue Deductible Income You m u st pu r su e Dedu ct ible Incom e for which you m ay be eligible. We m ay ask for wr itt en documentation of your pursuit of Deductible Income. You must provide it within 60 days after we m ail you ou r r equ est. Ot h er wise, we m ay r edu ce you r LTD Ben efits by t h e am ou n t we est imat e you wou ld be eligible t o r eceive u pon pr oper pu r su it of t h e Dedu ct ible Incom e. C. Pending Deductible Income We will not deduct pending Deductible Income until it becomes payable. You must notify us of the amount of the Deductible Income when it is approved. You must repay us for the resulting overpayment of your claim. Revised 01/ B

17 D. Over paym en t Of Claim We will notify you of the amount of any overpayment of your claim under any group disability insurance policy issued by us. You must immediately repay us. You will not receive any LTD Ben efits u n t il we h ave been r epaid in fu ll. In the meantime, any LTD Benefits paid, including the Minimu m LTD Ben efit, will be applied t o r edu ce t h e am ou n t of t h e over paym en t. We m ay ch ar ge you int er est at t h e legal r at e for an y over paym en t which is n ot r epaid with in 30 days aft er we first mail you notice of the amount of the overpayment. E. LTD Benefits Payable Under Both Plan A And Plan B Dedu ct ible Incom e will be dedu ct ed fr om Plan B first if LTD Ben efits ar e payable u n der bot h Plan A and Plan B. The amount to be deducted from Plan A is determined as follows: X = 60% of the first $9,600 of your Predisability Earnings over $400. Y = you r Dedu ct ible Incom e. If Y is greater than X, the amount to be deducted from Plan A is (Y - X) plus $50. If X is greater than Y, the amount to be deducted from Plan A is $50 minus (X - Y). However, if t h e differ en ce bet ween X an d Y is $50 or m or e, t h e am ou n t t o be dedu ct ed fr om Plan A is zer o. LT.RU.01X A. Dedu ct ible Incom e RETIREMENT PLAN OFFSET (RPO) Subject to the RPO Exceptions and in accordance with t h e RPO Ru les below, You r Dedu ct ible Incom e fr om you r Em ployer 's r et irem en t plan will be det er m ined as follows: 1. If you r eceive a ben efit, r efu n d, with dr awal, or dist r ibu t ion fr om you r Em ployer 's r et irem en t plan, your Deductible Income will be the am ou n t you r eceive. 2. If you do not receive a benefit, refund, withdrawal, or distribution from your Employer's r et irem en t plan, you r Dedu ct ible Incom e will be: a. the retirement income benefit option that comes closest to providing you a monthly income for life with no survivor's benefit, which b. you ar e eligible t o r eceive, or wou ld h ave been eligible t o r eceive h ad t imely applicat ion been m ade. Your Employer's retirement plan includes any retirement plan established, maintained or participated in by your Employer and to which you or your Employer make contributions, including a pu blic em ployee r et irem en t syst em, a st at e t each er r et irem en t syst em, an d a plan arranged and maintained by a union or employee association for the benefit of its members. B. RPO Exception s Dedu ctible Income fr om you r Employer 's r etir ement plan does not include the amou nts below. 1. Th e por t ion of an y ser vice r et irem en t ben efit you r eceive which is at t r ibu t able t o you r contributions to the plan. 2. An y ser vice r et irem en t ben efit you ar e eligible t o r eceive befor e age 62 (or n or m al r et irem en t age u n der t h e plan if lat er ), bu t which you do n ot r eceive befor e su ch age. 3. Any lump sum refund, withdrawal or distribution of your contributions and earnings you r eceive becau se you ar e n ot vest ed u n der t h e plan. 4. A lump sum payment or monthly annuity from a state teachers retirement system or public em ployees r et irem en t syst em if you ar e n ot eligible for a m on t h ly pen sion paym en t becau se t h e Revised 01/ B

18 monthly pension payment would be less than the minimum amou n t est ablish ed by t h e Depar t m en t of Ret irem en t Syst em s. 5. PERS II and PERS III disability retirement benefits for which you are eligible but you elect not t o r eceive. C. RPO Rules. 1. You will be considered eligible to receive disability benefits from you r Em ployer 's r et irem en t plan unless you provide satisfactory written proof that you made timely application for such ben efits an d wer e den ied or t h at a t imely applicat ion wou ld h ave been den ied if you h ad applied. 2. If we cannot determine from your Employer 's r et irem en t plan t h e am ou n t of disability ben efit or r et irem en t ben efit you ar e or wou ld h ave been eligible t o r eceive, we will det er m ine you r Deductible Income using a lifetime monthly annuity amount, with no survivor income. The annuity will be based on total plan contributions made by you or on your behalf, including your Employer's contributions and roll-over contributions, plus earnings, and on the life expectancy of a person your age on the following dates: a. With respect to a disability benefit, the date you first become eligible for a disability benefit; b. With r espect t o a r et irem en t ben efit, t h e dat e you first becom e eligible for a r et irem en t ben efit; c. Th e dat e LTD Ben efits becom e payable, if we can n ot det er m ine t h e dat e in a or b. 3. If you receive a lump sum refund, withdrawal or distribution of contributions and earnings fr om you r Em ployer 's r et irem en t plan, we will det er m ine you r Dedu ct ible Incom e u sing a lifetime monthly annuity amount, with no survivor income. The annuity will be based on t h e am ou n t you r eceive, an d on t h e life expect an cy of a per son you r age on t h e lat er of: a. The date the lump sum is paid; and b. Th e dat e LTD Ben efits becom e payable. LT.RO.01X A. Eligibility COST OF LIVING ADJUSTMENT BENEFIT You are eligible for a COLA Ben efit if, on each Mar ch 1, you h ave r eceived LTD Ben efits u n der Plan B for at least 3 of the preceding 12 months. If you h ave n ot r eceived LTD Ben efits u n der Plan B for at least 3 of t h e 12 m on t h s pr eceding March 1, you are eligible for COLA Ben efits on t h e following Mar ch 1, pr ovided you h ave r eceived LTD Benefits under Plan B for at least 3 of the 12 months preceding such March 1. B. COLA Ben efit Ru les 1. You r LTD Ben efits becom ing payable u n der Plan B aft er you ar e eligible for a COLA Ben efit ar e incr eased by t h e COLA Fact or in effect for t h e cu r r en t year. 2. A n ew COLA Fact or is det er m ined each Mar ch Your first COLA Factor is equal to 1.00 plus one-h alf t h e r at e of incr ease in t h e CPI-W for t h e prior calendar year. 4. Each following COLA Factor is equal to 1.00 plus one-h alf t h e r at e of incr ease in t h e CPI-W for t h e pr ior calen dar year, t imes t h e pr eviou s COLA Fact or. 5. The maximum increase that we will use is 6%. 6. The Minimum LTD Benefit is not adjusted by the COLA Factor. Revised 01/ B

19 7. You r COLA Fact or will n ot decr ease, even if t h e CPI-W decr eases. 8. The COLA Benefit does not apply to Plan A, Plan C, or Plan D. LT.CA.01X HIGHER EDUCATION RETIREMENT CONTRIBUTIONS BENEFIT (PLAN D) Plan D provides a monthly retirement contribu t ion s ben efit while LTD Ben efits ar e payable u n der Plan B, subject to the following provisions: A. Payment of Higher Education Retirement Contributions Benefit The Higher Education Retirement Contributions Benefit will be paid to your Employer s higher education retirement plan to which you participate, on your behalf. Th e High er Edu cat ion Ret irem en t Con t r ibu t ion s Ben efit becom es payable on t h e lat er of: 1. Th e dat e LTD Ben efits becom e payable u n der Plan B; or 2. Th e dat e you first wou ld h ave been r equ ired to participate under your Employer s higher edu cat ion r et irem en t plan. B. Amount of Higher Education Retirement Contributions Benefit The Higher Education Retirement Contributions Benefit is shown in the Schedule of Benefits, subject to any limitations on the amount of the contribution imposed by the Internal Revenue Code, ERISA, or an y ot h er feder al or st at e laws. If you return to work for your Employer, the Higher Education Retirement Contributions Benefit will be r edu ced by t h e am ou n t of an y em ployee/ Employer contributions transmitted to any one of your Employer s higher education retirement plans, annuity, savings and deferred compensation plans on your behalf. C. When Higher Education Retirement Contributions Benefits End Th e High er Edu cat ion Ret irement Contributions Benefit Plan ends on the earlier of the following dat es: 1. Th e dat e LTD Ben efits cease t o be payable u n der Plan B. 2. The date the Employer s higher education retirement plan in which you participate terminates or may no longer accept the Higher Education Retirement Contributions Benefits on your behalf. D. Other Provisions 1. We may terminate or change the amount of your Higher Education Retirement Contributions Ben efit at t h e Policyh older s r equ est when n ecessar y t o com ply with t h e Int er n al Reven u e Code, ERISA, or an y ot h er feder al or st at e laws. 2. If t h e High er Edu cat ion Ret irem en t Con t r ibu t ion s Ben efit is n ot accept ed by you r Em ployer s mandatory higher education retirement plan, no further Higher Education Retirement Contributions Benefits will be payable. Any Higher Education Retirement Contributions Ben efits n ot accept ed by you r Em ployer s m an dat or y h igh er edu cat ion r et irem en t plan ar e r equ ired t o be r et u r n ed t o St an dar d Insu r an ce Com pan y. 3. If t h e Mem ber direct s con t r ibu t ion s to more than one retirement fund or account the Member m u st design at e in wr iting on e fu n d or accou n t t o r eceive all ben efits payable u n der t h is provision. In the absence of such written designation, we, at our sole discretion will determine to which fund or account the Higher Education Retirement Contributions Benefit will be payable. Revised 01/ B LT.PC.01X

20 SURVIVORS BENEFIT If you die while LTD Benefits are payable, we will pay a Survivors Benefit according to 1 through 4 below. 1. The amount of the Survivors Benefit is shown in the Coverage Outline. 2. The Survivors Benefit will first be applied to reduce any overpayment of your claim. 3. The Survivors Benefit will be paid at our option to any one or more of the following: a. Your surviving Spouse; b. Your surviving children through the last day of the month of turning age 26; c. Your child of any age with a developmental disability or physical handicap who, prior to age 26, becam e: i. Incapable of self-sustaining employment; and ii. Is ch iefly dependent upon you for support and maintenance; or d. Any person providing the care and support of any of them. 4. If you are not survived by a Spouse or an eligible child, no Survivors Benefit will be paid. LT.SB.01X WAIVER OF PREMIUM You r insurance will continue without payment of premiums while: 1. LTD Ben efits ar e payable; an d 2. You ar e com plet ing t h e Ben efit Waiting Per iod, pr ovided you ar e n ot in pay st at u s. LT.WP.01X BENEFITS AFTER INSURANCE ENDS OR IS CHANGED Your right to receive LTD Benefits for a period of Disability which begins while you are insured will not be affect ed by: 1. Ter m inat ion of t h e Gr ou p Policy aft er you becom e Disabled; 2. Termination of your insurance while the Group Policy remains in force; or 3. An y am en dm en t t o t h e Gr ou p Policy appr oved aft er t h e dat e you becom e Disabled. LT.BA.01 EFFECT OF NEW DISABILITY If a period of Disability is extended by a new cause while LTD Benefits are payable, LTD Benefits will continue while you remain Disabled. However, 1 and 2 apply. 1. LTD Benefits will not continue beyond the end of the original Maximum Benefit Period. 2. All provisions of the Group Policy, including the Exclusions and Limitations sections, will apply to t h e n ew cau se of Disability. LT.ND.01 Revised 01/ B

21 EXCLUSIONS A. War You are not covered for a Disability caused or contributed to by War or any act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict bet ween or gan ized for ces of a m ilitar y n at u r e. B. Intentionally Self-Inflicted Injury You are not covered for a Disability caused or contributed to by an intentionally self-inflicted injury, while sane or insane. C. Preexisting Condition 1. Definition Pr eexisting Condition means a mental or physical condition for which you have done any of the following at any time during the Preexisting Condition Period shown in the Coverage Outline: a. Consulted a Physician; b. Received m edical treatment or services; or c. Taken prescribed drugs or medications. 2. Exclusion You are not covered for a Disability caused or contributed to by a Preexisting Condition or medical or surgical treatment of a Preexisting Condition unless, on the dat e you becom e Disabled, you: a. Have been con t inu ou sly insu r ed u n der t h e Gr ou p Policy or Pr ior Plan for t h e en t ire Exclusion Period shown in the Coverage Outline; and b. Have been Act ively At Wor k for at least on e fu ll day aft er t h e en d of t h e Exclusion Per iod. LT.EX.01X A. Care Of A Physician LIMITATIONS You must be under the ongoing care of a Physician during the Benefit Waiting Period. No LTD Benefits will be paid for any period of Disability when you are not under the ongoing care of a Physician. B. Men t al Disor der Payment of LTD Benefits is limited to 24 months for each period of Disability caused or contributed to by a Mental Disorder. However, if you are confined in a Hospital at the end of the 24 months, this limitation will not apply while you are continuously confined. Men t al Disor der means a mental, emotional, behavioral, or stress-r elat ed disor der. Hospital means a legally operated hospital providing full-t ime m edical car e an d t r eatment under the direction of a full-time staff of licensed Physicians. Rest homes, nursing homes, convalescent homes, homes for the aged, and facilities primarily affording custodial, educational, or rehabilitative care are not Hospitals. C. Rehabilitation No LTD Benefits will be paid for any period of Disability when you are not participating in good faith in a plan, program or course of medical treatment or vocational training or education approved by us unless your Disability prevents you from participating. Revised 01/ B

22 LT.LM.01 CLAIMS A. Filing A Claim Claims should be filed on our forms. If you do not receive our forms within 15 days after you ask for them, you may submit your claim in a letter to us. The letter should include the date disability began, and the cause and nature of the disability. B. Time Limits On Filing Proof Of Loss You m u st give u s Pr oof Of Loss with in 90 days aft er t h e en d of t h e Ben efit Waiting Per iod. If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one year after that 90 day period. If Proof Of Loss is filed outside these time limits, your claim will be denied. These limits will not apply while you lack legal capacity to file claims. C. Proof Of Loss Proof Of Loss means satisfactory written proof that you are Disabled and entitled to LTD Benefits. Pr oof Of Loss m u st be pr ovided at you r expen se. D. Documentation At your expense, you must submit completed claims statements, your signed authorization for us to obtain information, and any other items we may reasonably require in support of your claim. If you do not provide the documentation within 60 days after we mail you our request, your claim m ay be den ied. E. Investigation Of Claim We may investigate your claim at any tim e. At ou r expen se, we m ay h ave you exam ined at r eason able int er vals by specialist s of ou r ch oice. We may deny or suspend LTD Benefits if you fail to attend an examination or cooperate with the exam iner. F. Time Of Payment We will pay LTD Benefits within 60 days after you qualify and satisfy Proof Of Loss. LTD Benefits will be paid to you at the end of each month you qualify for them. LTD Benefits remaining unpaid at you r deat h will be paid t o t h e per son (s) r eceiving t h e Su r vivor Ben efit. If n o Su r vivor Ben efit is paid, the unpaid LTD Benefits will be paid to your estate. G. Notice Of Decision On Claim You will receive a written decision on your claim within a reasonable time after we receive your claim. If you do not receive our decision within 90 days aft er we r eceive you r claim, you will h ave an imm ediat e r igh t t o r equ est a r eview as if you r claim h ad been den ied. If we deny any part of your claim, you will receive a written notice of denial containing: 1. The reasons for our decision; 2. Refer en ce to the parts of the Group Policy on which our decision is based; 3. A description of any additional information needed to support your claim; and 4. Information concerning your right to a review of our decision. H. Review Pr ocedu r e You m ay r equ est in writing a review of a denial of all or part of your claim within 60 days after you r eceive n ot ice of t h e den ial. Revised 01/ B

23 Wh en you r equ est a r eview, you m ay sen d u s wr itt en com m en t s or ot h er item s t o su ppor t you r claim. You may review any non-privileged information t h at r elat es t o you r r equ est for r eview. We will r eview you r claim pr om pt ly aft er we r eceive you r r equ est. We will sen d you a n ot ice of ou r decision within 60 days after we receive your request, or within 120 days if special circumstances r equ ire an ext en sion. We will st at e t h e r eason s for ou r decision an d r efer you t o t h e r elevan t par t s of the Group Policy. I. Assignment The rights and benefits under the Group Policy are not assignable. LT.CL.01X TIME LIMITS ON LEGAL ACTIONS No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No su ch act ion m ay be br ou gh t m or e t h an t h r ee year s aft er t h e ear lier of: 1. Th e dat e we r eceive Pr oof Of Loss; an d 2. The end of the period within which Pr oof Of Loss is r equ ired t o be given. LT.TL.01 A. Incontestability Of Member's Insurance INCONTESTABILITY PROVISIONS Any statement you make to obtain insurance is a representation and not a warranty. No m isr epr esen t at ion by you will be used to reduce or deny your claim or contest the validity of your insurance unless: 1. Your insurance would not have been approved if we had known the truth; and 2. We have given you a copy of a written instrument signed by you which contains your misr epresentation. After you r insu r ance has been in effect for two year s, we will not u se a misr epresentation by you to r edu ce or deny you r claim, u nless it was a fr au du lent misr epresentation. B. Incontestability Of Group Policy Any st at em en t made by the Policyholder or Employer to obtain the Group Policy is a representation and not a warranty. No m isr epr esen t at ion by the Policyholder or Employer will be used to deny a claim or to deny the validity of the Group Policy unless: 1. Th e Gr ou p Policy wou ld n ot h ave been issu ed if we had known the truth; and 2. We have given the Policyholder or Employer a copy of a written instrument signed by the Policyholder or Employer which contains the misrepresentation. The validity of the Group Policy will not be contested after it has been in for ce for t wo year s, except for nonpayment of premiums or fraudulent misrepresentations. LT.IN.01 Revised 01/ B

24 CONTINUITY OF COVERAGE If you wer e insu r ed u n der t h e Pr ior Plan on t h e day befor e t h e effect ive dat e of you r Em ployer 's cover age u n der t h e Gr ou p Policy, you can becom e insu r ed on t h e effect ive dat e of you r Em ployer 's cover age with ou t m eet ing t h e Act ive Wor k Requ irem en t. See Act ive Wor k Pr ovision s. Th e LTD Ben efit payable for a per iod of con t inu ou s Disability beginn ing befor e you m eet t h e Act ive Wor k Requ irem en t will be: 1. The monthly benefit which would have been payable under the terms of the Prior Plan if it had r em ained in for ce; r edu ced by 2. An y ben efits payable u n der t h e Pr ior Plan. LT.CC.10X WHEN YOUR INSURANCE BECOMES EFFECTIVE The Coverage Outline states whether your insurance is Optional or Basic. A. Basic Insurance (Plan A) You r Basic Insu r an ce becom es effect ive on t h e first day of t h e m on t h following t h e dat e you becom e newly eligible for the employer contribution toward insuran ce cover age. If you becom e eligible on the first working day of the month, your Basic Insurance will begin on that date (except that eligibility for employees of participating Employer Groups will be determined based on the Employer Group s contract with t h e HCA). B. Optional Insurance (Plans B, C and D) You must apply in writing for Optional insurance and agree to pay premiums. Subject to the Active Work Provisions, your insurance becomes effective on the first day of the calendar month following: 1. t h e date you apply, if you apply within 31 days after you become eligible; 2. the date you are eligible, if you apply prior to becoming eligible; or 3. the date we approve your Evidence of Insurability, if you apply more than 31 days after you become eligible (late application). C. Changes in Benefit Waiting Period under Plan B You must apply in writing for a change in your Benefit Waiting Period under Plan B. The change becomes effective on the first day of the calendar month following: 1. the date you apply, if you apply for a longer Benefit Waiting Period; or 2. t h e dat e we appr ove you r Eviden ce of Insu r ability, if you apply for a sh or t er Ben efit Waiting Per iod. D. Insurance Subject To Evidence Of Insurability Insurance subject to Evidence of Insurability becomes effect ive on t h e first day of t h e calen dar month following the date we approve Evidence of Insurability. E. Takeover Provisions 1. If you wer e insu r ed u n der t h e Pr ior Plan on t h e day befor e t h e effect ive dat e of you r Em ployer 's cover age u n der t h e Gr ou p Policy, your Eligibility Waiting Period is waived on the effective date of your Employer's coverage under the Group Policy. 2. You must submit satisfactory Evidence of Insurability to become insured for Contributory insurance if you were eligible for insurance under the Prior Plan for more than 31 days but wer e n ot insu r ed. Revised 01/ B

25 LT.EF.10X ACTIVE WORK PROVISIONS A. Act ive Wor k Requ irem en t If you ar e incapable of Act ive Wor k becau se of Sick n ess, Injur y or Pr egn an cy on t h e day befor e t h e sch edu led effect ive dat e of your Optional Insurance, your Optional Insurance will not become effect ive u n t il t h e day aft er you com plet e on e fu ll day of Act ive Wor k as an eligible Mem ber. Active Work and Actively at Work mean performing the material duties of your own occupation at your Employer's usual place of business. B. Changes In Insurance Th is Act ive Wor k Requ irem en t also applies t o an y incr ease in you r insu r an ce. However, if you return to Active Work during a period of Disability or Temporar y Recover y (see Tem por ar y Recovery), you will not qualify for any change in insurance caused by a change in: 1. Th e r at e of ear n ings u sed t o det er m ine you r Pr edisability Ear n ings; or 2. Th e t er m s of t h e Gr ou p Policy. C. Except ion Th e Act ive Wor k Requ irem ent will not apply to you if: 1. You wer e absen t fr om Act ive Wor k becau se of a r egu lar ly sch edu led day off, h oliday, or vacat ion day; 2. You wer e Act ively at Wor k on you r last sch edu led wor k day befor e t h e dat e of you r absen ce; and 3. You wer e capable of Act ive Wor k on t h e day befor e t h e sch edu led effect ive dat e of you r insurance. LT.AW.01X WHEN YOUR INSURANCE ENDS Your insurance ends automatically on the earliest of: 1. The date the last period ends for which you made a premium contribution, if your insurance is Optional. 2. Th e dat e t h e Gr ou p Policy t er m inat es. 3. Th e dat e you r em ploym en t t er m inat es. 4. The date the last period ends for which your Employer made a required premium contribution on your behalf, if you are on a leave of absence without pay, on reduction in force status, or on reversion status. 5. Th e dat e you becom e a fu ll t ime m em ber of t h e ar m ed for ces of an y cou n t r y, u n less t h e insu r er is required to offer you continuation of your insurance by the Uniformed Service Employment and Reemployment Rights Act (USERRA). 6. Th e dat e you cease t o be a Mem ber. However, if you cease t o be a Mem ber becau se you ar e n ot meeting the minimum work requirement, your insurance will be continued during the following periods, unless it ends under 1 through 5 above. a. While your Employer is paying you at least the same Predisability Earnings paid to you imm ediat ely befor e you ceased t o be a Mem ber. Revised 01/ B

26 b. Dur ing t h e Ben efit Waiting Per iod an d while LTD Ben efits ar e payable. c. During the first 29 months of an agency approved educational leave of absence, if your status as a Mem ber t er m inat es becau se of t h e leave of absen ce, su bject t o t h e following: i. You r Em ployer m u st appr ove t h e leave of absen ce in wr iting. ii. If your rate of pay during the leave is less than 50% of your Predisability Earnings in effect pr ior t o t h e leave, you m u st pay t h e en t ire cost of you r insu r an ce. Insu r an ce en ds automatically on the date the last period ends for which you made a premium contribution. If you becom e Disabled during the leave, the Benefit Waiting Period will not begin until your sch edu led dat e of r et u r n t o wor k. iii. If your rate of pay during the leave is 50% or more of your Predisability Earnings in effect prior to the leave, the Employer will pay the cost of your insurance under Plan A. If you becom e Disabled du r ing t h e leave, t h e Ben efit Waiting Per iod will begin on t h e dat e you becom e Disabled. iv. Predisability Earnings will be your Predisability Earnings in effect immediately prior to the leave of absen ce. d. During the first 29 months of appr oved USERRA leave of absen ce. e. During a leave of absence if continuation of your insurance under the Group Policy is required by the state-mandated family or medical leave act or law. f. During the first 30 days of any other unpaid leave, provided you take the unpaid leave immediately following the end of your annual paid leave, subject to the following: i. If you become Disabled during the leave, the Benefit Waiting Period will not begin until the sch edu led dat e of r et u r n t o wor k. ii. Your Predisability Earnings will be based on your earnings in effect immediately prior to the leave of absen ce. LT.EN.01X REINSTATEMENT OF INSURANCE If your insurance ends you may become insured again as a n ew Mem ber. However, 1 t h r ou gh 5 below will apply. 1. If your insurance ends because you fail to make a required premium contribution, you must provide Evidence of Insurability to become insured again. 2. If you return to pay status after a period of non-pay status which is a result of termination of employment, the Preexisting Condition Period and Exclusion Period will be based on the date you becom e insu r ed again. 3. If you return to pay status immediately after a period of non-pay status of 12 months or less which is not a result of termination of employment, the Preexisting Condition Period and Exclusion Period will be based on t h e dat e you becam e insu r ed pr ior t o t h e beginn ing of t h e per iod of n on -pay status. 4. If your insurance ends because you are on a state-m an dat ed fam ily or m edical leave of absen ce, and you become a Member again immediately following the period allowed, your insurance will be reinstated pursuant to the state-mandated family or medical leave act or law. 5. If your insurance en ds du e t o you r act ive m ilitar y ser vice, an d you becom e a Mem ber again immediately following the period allowed, your insurance will be reinstated pursuant to the Uniformed Services Employment and Reemployment Rights Act (USERRA) LT.RE.01X Revised 01/ B

27 DEFINITIONS Basic m ean s t h e level of insu r an ce cover age for which t h e en t ire pr em ium is paid by t h e Em ployer, except for appr oved edu cat ion al or USERRA leave. Benefit Waiting Period means the period you must be continuously Disabled befor e LTD Ben efits becom e payable. No LTD Ben efits ar e payable for t h e Ben efit Waiting Per iod. See Coverage Outline. CPI-W m ean s t h e Con su m er Pr ice Index for Ur ban Wage Ear n er s an d Cler ical Wor k er s pu blish ed by t h e United St at es Depar tment of Labor. If the CPI-W is discontinued or changed, we may use a com par able index. Wh er e r equ ired, we will obt ain pr ior st at e appr oval of t h e n ew index. Eligibility Waiting Period m ean s t h e per iod you m u st be a Mem ber befor e you becom e eligible for insu r an ce. See Coverage Outline. Employer means the State of Washington and any governmental subdivision approved in writing by the Policyholder. Providing Evidence Of Insurability means you must: 1. Complete and sign our medical history statement; 2. Sign our form authorizing us to obtain information about your health; 3. Undergo a physical examination, if required by us, which may include blood testing; and 4. Provide any additional information about your insurability that we may reasonably require. Providing Evidence Of Insurability does not mean your application for coverage will be approved. Group Policy means the group LTD insurance policy issued by us to the Policyholder and identified by t h e Gr ou p Policy Nu m ber. Indexed Predisability Earnings means your Predisability Earnings adjusted by the rate of increase in t h e CPI-W. During your first year of Disability, your Indexed Predisability Earnings are the same as you r Pr edisability Ear n ings. Th er eaft er, you r Indexed Pr edisability Ear n ings ar e det er m ined on each anniversary of your Disability by increasing the previous year's Indexed Predisability Earnings by the r at e of incr ease in the CPI-W for the prior calendar year. The maximum adjustment in any year is 10%. You r Indexed Pr edisability Ear n ings will n ot decr ease, even if t h e CPI-W decr eases. Injury means harm, hurt or damage to your body. LTD Ben efit means the monthly benefit payable to you under the terms of the Group Policy. Maximu m Ben efit Per iod m ean s t h e lon gest per iod for which LTD Ben efits ar e payable for an y on e period of continuous Disability, whether from one or m or e cau ses. It begins at t h e en d of t h e Ben efit Waiting Per iod. No LTD Ben efits ar e payable aft er t h e en d of t h e Maximu m Ben efit Per iod, even if you ar e st ill Disabled. See Cover age Ou t line. Optional means the level of insurance coverage for which you pay all of the premium. Physician means a licensed medical professional, other than yourself, acting within the scope of the licen se. Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy. Pr ior Plan means your Employer's group long term disability insurance plan in effect on the day before t h e effect ive dat e of you r Em ployer 's cover age u n der t h e Gr ou p Policy an d which is r eplaced by t h e Group Policy. Sickness means your sickness, illness, or disease. Spouse means: 1. A person to whom you are legally married; or Revised 01/ B

28 2. Your Domestic Partner. Your Domestic Partner means an individual recognized as such under applicable law. LT.DF.01X Revised 01/ B

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