2014 Self-Funded Short-Term Disability Summary Plan Description

Transcription

1 THE GATES CORPORATION 2014 Self-Funded Shrt-Term Disability Summary Plan Descriptin Unin-Free Active Assciates What Yur Plan Cvers and Hw Benefits are Paid

2 Table f Cntents Preface... 4 Cverage fr Yu... 5 Shrt-Term Disability Cverage... 5 Shrt Term Disability Schedule f Benefits... 5 Cverage fr Yu... 6 Wh Can Be Cvered... 6 Emplyees... 6 Determining if Yu Are in an Eligible Class... 6 Determining When Yu Becme Eligible... 7 Yur Disability Plan... 8 Shrt Term Disability Cverage... 8 Shrt Term Disability Benefit Eligibility... 8 Test f Disability... 9 When Benefits are Payable... 9 Benefits Payable...9 Adjustments t Yur Benefits If Yu Wrk While Disabled When Shrt Term Disability Benefit Eligibility Ends If Yu Becme Disabled Again (Successive Disabilities) Other Incme Benefits Other Incme Benefits That D Nt Reduce Weekly Benefits What Happens When Other Incme Benefits Increase Hw the Plan Applies Other Incme Benefits t Shrt Term Disability Estimate f Other Incme Benefits Required Prf f Other Incme under the Plan Exclusins That Apply t Shrt Term Disability Reprting f Claims Payment f Benefits Claims and Appeals Review Prcess Claim Determinatins Appeals f Adverse Benefit Determinatins

3 Appeal Prcedure When Cverage Ends When Cverage Ends Fr Emplyees Extensin f Benefits Cverage fr Shrt Term Disability Benefits General Prvisins Administrative Ntice Duty t Cperate Legal Actin...19 Plan Administratr s Right t Amend/Change Plan Cnfidentiality Additinal Prvisins Recvery f Overpayments Shrt Term Disability Cverage Glssary... 1 A Active at Wrk; Actively at Wrk; Active Wrk Adverse Benefit Determinatin Appeal B Base Pay C Claims Administratr E Emplyee Emplyer Effective Treatment f Alchlism r Drug Abuse H Hspital I Illness...23 Injury...23 M Material Duties

4 O P Mtr Vehicle Own Occupatin Physician Predisability Earnings Gates Sick Pay Crdinatin with Shrt Term Disability Benefits Cntinuatin f Optinal Emplyee Benefits Cverage During an Apprved Leave f Absence Granted t Cmply With Federal Law Imprtant Infrmatin

5 Preface The Gates Crpratin is pleased t prvide yu with this Summary Plan Descriptin (SPD). Read this SPD carefully. The disability Plan described in this SPD is a summary f The Gates Crpratin Shrt Term Disability Plan (the Plan ). Claims fr these benefits are administered by the Claims Administratr n behalf f The Gates Crpratin. These benefits are nt insured with the Claims Administratr and will be paid frm The Gates Crpratin s general assets via regular payrll prcessing. This SPD des nt replace the fficial dcuments that legally gvern the Plan s terms and peratins. If this SPD differs frm the Plan s fficial dcuments, the fficial Plan dcuments always gvern. Questins regarding yur benefits shuld be addressed t the Plan Administratr. Questins regarding any claim fr benefits shuld be addressed t the Claims Administratr. The SPD describes rights and bligatins under the Plan, what the Plan cvers and hw benefits are paid fr that cverage. It is yur respnsibility t understand the terms and cnditins in this SPD. Yur SPD includes the Schedule f Benefits. If yu becme cvered, this SPD replaces and supersedes all SPDs describing similar cverage that The Gates Crpratin previusly issued t yu. Plan Spnsr: The Gates Crpratin Issue Date: January 1, 2014 SPD Number:

6 Cverage fr Yu Shrt-Term Disability Cverage The Plan pays yu a prtin f yur incme earnings as a weekly benefit fr a perid f shrt-term disability caused by a nn-ccupatinal illness r injury that ccurs while yur cverage is in effect and s lng as yu meet all requirements under the Plan fr receipt f benefits. Only nn-ccupatinal injuries and nn-ccupatinal illnesses are cvered. Please refer t the Shrt Term Disability sectin fr mre details abut yur cverage. Shrt Term Disability Schedule f Benefits PLAN FEATURES Eliminatin Perid Benefits start n the 8th cnsecutive calendar day fr a disability perid due t illness, a disabling pregnancy-related cnditin r injury. Schedule f Shrt Term Disability Incme Benefits Weekly Benefit 66 2/3% f yur predisability earnings calculated n a weekly basis Maximum Weekly Benefit (cmbined ttal with all Other Incme Benefits) Maximum Weekly Benefit Perid Benefits Actually Payable $2, weeks, unless it ends earlier fr ne r mre f the reasns stated in yur SPD Any weekly benefit actually payable t yu will be reduced by Other Incme Benefits. 5

7 Cverage fr Yu Wh Can Be Cvered Emplyees T be cvered by this Plan, the fllwing requirements must be met: Yu will need t be in an eligible class, as defined belw; and Yu will need t meet the eligibility date criteria described belw. Determining if Yu Are in an Eligible Class Yu are in an eligible class if: Yu are a regular US Emplyee, as defined by yur Emplyer. In additin, t be in an eligible class yu must: Be scheduled t wrk n a regular basis at least 30 hurs per week during yur Emplyer s wrk week; Be n US payrll; Nt be a temprary, leased, cntract r seasnal emplyee; and Nt subject t a cllective bargaining agreement. 6

8 Determining When Yu Becme Eligible Yu becme eligible fr the Plan n yur eligibility date, which is determined as fllws: On the Effective Date f the Plan: If yu are in an eligible class n the effective date f this Plan, yu are benefits eligible, and yu are actively at wrk, yur cverage eligibility date is the effective date f the Plan After the Effective Date f the Plan: If yu are in an eligible class and yu are either hired after the effective date f this Plan r yu were an active emplyee n the effective date, but did nt satisfy the 30 days f emplyment requirement as f the effective date f the Plan and were nt benefits eligible, and yu are actively at wrk, yur cverage eligibility date is the first day f the mnth fllwing 30 days f emplyment. If yu enter an eligible class after the effective date f this Plan, yur cverage eligibility date is the first day f the mnth fllwing 30 days f emplyment as an emplyee in an eligible class. In ther wrds, emplyment with Gates Crpratin prir t yur becming a member f an eligible class des nt cunt twards the 30 days f emplyment requirement. Ntwithstanding the preceding, yu must be actively at wrk n yur eligibility date in rder t cmmence participatin in the Plan (unless such date falls n a weekend r hliday, in which case yu must have been actively at wrk n the wrk day immediately preceding such weekend r hliday); therwise, yu will cmmence participatin n the first day after yur eligibility date n which yu return t active wrk. 7

9 Yur Disability Plan The disability Plan prvides yu with a surce f incme if yu shuld becme disabled because f a nn-ccupatinal illness, injury, r disabling pregnancy-related cnditin while cvered under this Plan. Shrt Term Disability Cverage Shrt term disability cverage will pay a weekly benefit if yu are disabled and unable t wrk because f: An illness that is a nn-ccupatinal illness; An injury that is a nn-ccupatinal injury; r A disabling pregnancy-related cnditin. Imprtant! As used in this sectin f the SPD, "yu" and "yur" refers t a cvered Emplyee f the Emplyer spnsring this Plan. Shrt term disability cverage will nly cver a disability caused by a nn-ccupatinal illness and injury. A nn-ccupatinal illness r injury is any illness r injury that is nt an ccupatinal illness r ccupatinal injury. An ccupatinal illness r ccupatinal injury means an illness r injury that: Arises ut f (r in the curse f) any activity in cnnectin with emplyment r self-emplyment whether r nt n a full time basis; Hwever, if prf is prvided t the Claims Administratr that a claim has been made under any type f wrkers' cmpensatin law and that n benefit, award, settlement r redemptin has been r will be made under such law fr that illness r injury, then that illness r injury will nt be cnsidered an ccupatinal illness r an ccupatinal injury. Fr the purpses f all disability cverage included in this Plan, the term illness will mean: A pathlgical cnditin f the bdy that presents a grup f clinical signs and symptms and labratry findings peculiar t it and that sets the cnditin apart as an abnrmal cnditin differing frm nrmal cnditins r frm ther pathlgical bdy cnditins. Shrt Term Disability Benefit Eligibility Yu will be cnsidered disabled while cvered under this shrt term disability Plan n the first day that yu are disabled as a direct result f a significant change in yur physical r mental cnditin caused by illness r injury, r because f a pregnancy-related cnditin, and yu meet all f the fllwing requirements: Yu must be actively emplyed and cvered by this Plan at the time yu becme disabled; Yu must be under the regular care f a physician. Yu will be cnsidered under the care f a physician up t 31 days befre yu have been seen and treated in persn by a physician fr the illness, injury r 8

10 pregnancy-related cnditin that caused the disability; and Yu must meet the shrt term disability test f disability (see thetest f Disability sectin). Test f Disability Yu meet the test f disability if yu are nt able perfrm the material duties f yur wn ccupatin because f an illness r injury, r because f a pregnancyrelated cnditin. Yu are nt perfrming the material duties f yur wn ccupatin if: Yu are nly perfrming sme f the material duties f yur wn ccupatin; and Yur incme is 80% r less f yur predisability earnings slely because f an illness, injury r a disabling pregnancy-related cnditin. When Benefits are Payable Imprtant Nte The lss f a prfessinal r ccupatinal license r certificatin that is required by yur wn ccupatin des nt mean yu meet the test f disability. Yu must meet this Plan s test f disability t be cnsidered disabled. Once yu meet the shrt term disability test f disability described abve, yur shrt term disability benefits will be payable after the Eliminatin Perid is ver. The Eliminatin Perid is the amunt f time yu must be disabled befre benefits start. N benefit is payable fr r during the eliminatin perid. Yur shrt term disability benefits will be payable fr as lng as yur disability benefit eligibility cntinues but nt beynd the end f the maximum weekly benefit perid. The Eliminatin Perids and the maximum weekly benefit perid are shwn in the Schedule f Benefits. Benefits Payable The weekly benefit is based n yur predisability earnings, up t the maximum weekly benefit shwn in the Schedule f Benefits. T calculate yur weekly shrt term disability benefit, multiply: Yur predisability earnings; times The weekly benefit percentage shwn in the Schedule f Benefits. The benefit payable will be the lesser f: The weekly benefit; and The maximum weekly benefit. Any Other Incme Benefits yu are eligible fr may affect yur benefits frm this Plan. The amunt f the Other Incme Benefits will be subtracted frm yur weekly shrt term disability benefit fr which yu are eligible. Please refer t the Other Incme Benefits sectin f this SPD fr details as t which Other Incme Benefits may reduce yur weekly benefit. 9

11 Adjustments t Yur Benefits If Yu Wrk While Disabled Yur shrt term disability weekly benefit may be reduced if, while weekly benefits are payable, yu earn incme frm: Yur Emplyer r any ther Emplyer, emplyment r self-emplyment; r Any ccupatin fr cmpensatin r prfit. This is mre than 20% f yur predisability earnings. The weekly benefit adjustment is calculated as fllws: The weekly benefit will be reduced nly t the extent the sum f the amunt f that incme and the weekly benefit payable, withut any reductin fr Other Incme Benefits, exceeds 100% f yur predisability earnings. Incme means incme yu earn, while disabled and wrking, frm yur Emplyer r any ther Emplyer. Hwever, any incme earned by wrking fr anther Emplyer will be cnsidered incme nly if yu: Becme emplyed after the date yur disability started; r Increase the number f hurs yu wrk, r the number r type f duties yu perfrm fr anther Emplyer after the date f yur disability started. In that event, nly the amunt f the incme increase will be taken int cnsideratin fr the benefit adjustment. When Shrt Term Disability Benefit Eligibility Ends Yu will n lnger be cnsidered disabled r eligible fr weekly benefits when the first f the fllwing ccurs: The date yu n lnger meet the shrt term disability test f disability, as determined by the Claims Administratr. The date yu are n lnger under the regular care f a physician. The date yu fail t prvide prf that yu meet the shrt term disability test f disability. The date yu refuse t be examined by r cperate with an independent physician r a licensed and certified health care practitiner, as requested. The Claims Administratr has the right t examine and evaluate yu at any reasnable time while yur claim is pending r payable. The examinatin r evaluatin will be dne at the expense f the Plan. The date an independent medical exam reprt r functinal capacity evaluatin des nt, in the Claims Administratr's pinin, cnfirm that yu are disabled. The date yu reach the end f yur maximum benefit perid, as shwn in the Schedule f Benefits. The date yu are nt receiving effective treatment fr alchlism r drug abuse, if alchlism and drug abuse are the cause (r part f the cause) f yur disability. 10

12 The date yu refuse t cperate with r accept: Changes t yur wrk site r jb prcess designed t suit identified medical limitatins, r Any adaptive equipment r devices designed t suit yur identified medical limitatins; that wuld allw yu t perfrm yur wn ccupatin. This applies nly if a physician agrees that such changes, adaptive devices r equipment suit yur particular medical limitatins. The date yu refuse any treatment recmmended by yur attending physician that, in the Claims Administratr's pinin, wuld cure, crrect r limit yur disability. The date yur wrk cnditin wuld permit yu t: Wrk; r Increase the hurs yu wrk; r Increase the number r type f duties yu perfrm in yur wn ccupatin; but yu refuse t d s. The date f yur death. The date yu are n lnger emplyed by Gates The day after the Claims Administratr determines that yu can participate in an apprved rehabilitatin prgram and yu refuse t d s. If Yu Becme Disabled Again (Successive Disabilities) Once yu n lnger meet the shrt term disability test f disability any new disability will be treated separately. Hwever, tw r mre disabilities will be cnsidered as the same disability if they are due t the same r related illness, injury, r pregnancy related cnditin; and The disabilities are separated by less than 30 cnsecutive calendar days upn return t wrk. In this case nly ne Eliminatin Perid will apply. The first disability will nt be included if it began while yu were nt cvered. The Claims Administratr has the right t evaluate yu fr participatin in an apprved rehabilitatin prgram. If, in the Claims Administratr's judgment, yu are able t participate, the Claims Administratr may, in its sle discretin require yu t participate in an apprved rehabilitatin prgram. 11

13 Other Incme Benefits Other Incme Benefits can affect the weekly benefit described in the shrt term disability cverage sectin. When calculating the benefit payable, Other Incme Benefits that yu, yur spuse, yur children r yur dependents are eligible fr because f yur disability r retirement are taken int cnsideratin. The Other Incme Benefits cnsidered when calculating yur benefits payable are: Disability, retirement r unemplyment benefits required r prvided fr by gvernment law. This includes (but is nt limited t): Unemplyment cmpensatin benefits. Imprtant Nte Please read this sectin carefully. It explains which Other Incme Benefits reduce yur weekly shrt term disability benefit. It is yur respnsibility t enrll r apply fr benefits frm ther surces when yu are eligible. See the Required Prf f Other Incme Under the Plan sectin fr mre infrmatin. Temprary r permanent, partial r ttal, disability benefits under any wrkers' cmpensatin law r similar law meant t cmpensate a wrker fr: Lss f past and future wages; Impaired earning capacity; A lessened ability t cmpete fr jbs; Any permanent impairment; and Any lss f bdily functin r capacity. Autmbile n-fault wage replacement benefits required by law. Benefits under the Federal Scial Security Act, Railrad Retirement Act, Canada Pensin Plan and Quebec Pensin Plan. Veteran's benefits. atutry r State disability benefits Disability r unemplyment benefits payable by either insured and uninsured plans: As a result f emplyment by r assciatin with yur Emplyer. This includes benefits under individual disability plicies supplied r paid fr in whle r in part by yur Emplyer, except as nted belw; r As a result f yur membership in, r assciatin with, any grup, assciatin, unin r ther rganizatin. Unreduced retirement benefits fr which yu are (r may becme) eligible under a grup pensin plan at age 62 r the plan's nrmal retirement age, whichever cmes later. This applies nly t the amunt f the benefit that was paid by the Emplyer. 12

14 Retirement benefits yu elect and receive under any grup pensin plan. This applies nly t the amunt f the benefit that was paid by an emplyer. 0% f any award given under The Jnes Act r The Maritime Dctrine f Maintenance, Wages and Cure Disability payments frm under insured mtrist cverage (UIM), uninsured mtrist cverage (UM), liability insurance r ther surces fr a disability caused by a third party. "Other surces" include (but are nt limited t) damages received thrugh legal actin r thrugh settlement r cmprmise f any claim. Disability benefits under any grup mrtgage r grup credit disability plan. Other Incme Benefits That D Nt Reduce Weekly Benefits Incme frm certain surces will nt reduce yur weekly disability benefits under this Plan. Yur benefits under the shrt term disability plan will nt be reduced by the amunt f benefits yu were receiving frm the fllwing surces, befre yu becme disabled: Military and ther gvernment service pensins; Retirement benefits frm a frmer emplyer; Veteran's benefits fr service-related disabilities; Individual disability incme plicies; and Retirement benefits frm the Federal Scial Security Act. The amunt f incme r ther benefits frm the fllwing surces will nt reduce yur shrt term disability benefits: Prfit sharing plans; Thrift r savings plans; 401(k) plans; Kegh plans; Emplyee stck ptin plans; 403 (b) Tax-sheltered annuity plans; 457 deferred cmpensatin plans; Tax-sheltered annuity plans; Severance pay; Salary cntinuatin r accumulated sick leave plans; Individual disability incme plicies; r Individual retirement accunts (IRAs). 13

15 What Happens When Other Incme Benefits Increase An increase in Other Incme Benefits that yu are eligible fr may affect yur benefit payable under this cverage. If yur Other Incme Benefits increase as the result f ne f the fllwing situatins, the increased amunt will be cnsidered when calculating yur benefits payable: The number f peple in yur family changes; Yur benefit level is adjusted r crrected; r The severity f yur disability changes. This may result in a reductin in benefits payable under this Cverage. A cst f living increase in Other Incme Benefits yu receive frm a gvernmental surce (including, but nt limited, t benefits under the Federal Scial Security Act) will nt reduce yur benefits payable. A cst f living increase in Other Incme Benefits yu receive frm a nn-gvernmental surce will nt affect yur benefits payable t the extent that the increase is based n the annual average increase in the Cnsumer Price Index. Hw the Plan Applies Other Incme Benefits t Shrt Term Disability Any lump sum r peridic payments yu receive frm any ther incme benefit are prrated n a weekly basis ver the perid f time fr which the payment was made. If a perid f time is nt indicated, the Claims Administratr will prrate the payments ver a reasnable perid f time. The Claims Administratr will take int accunt the expected duratin f yur disability payments and ther relevant factrs. The part f a lump sum r peridic payment yu receive fr disability will be cunted as ther incme benefit, even if it nt specifically allcated r identified as such. If there is n prf acceptable t the Claims Administratr as t what that part is, the Claims Administratr will cnsider 50% t be payable fr yur disability. Any f these ther incme payments that date back t a prir date may be allcated n a retractive basis. Estimate f Other Incme Benefits The Claims Administratr will estimate Other Incme Benefits fr which yu appear t be eligible, unless yu sign and return a reimbursement agreement t the Claims Administratr. The reimbursement agreement includes yur prmise t repay the Plan fr any verpayment f benefits made t yu. If Other Incme Benefits are estimated, yur weekly benefit will be adjusted when the Claims Administratr receives prf: Of the exact amunt paid r awarded; r 14

16 That benefits have been denied after review at the highest administrative level. If estimating yur Other Incme Benefits results in an underpayment, the Plan will pay yu the difference between the underpayment and the benefit payable. If there is an verpayment, yu must repay the Plan the verpayment the difference between all verpayments and the benefit payable amunt. If the Plan must take legal actin t recver an verpayment, yu als must pay the Plan's reasnable attrney s fees and curt csts, if the Plan prevails. The Claims Administratr is authrized by the Plan t seek these repayments and recveries fr the Plan. Required Prf f Other Incme under the Plan The Claims Administratr may require prf: That yu, yur spuse, child r dependent has applied fr all Other Incme Benefits that yu r they are r may be eligible t receive because f yur disability and has made a timely appeal f any denial f benefits thrugh the highest administrative level. "Timely appeal" means making the appeal in the time required, but never mre than 60 days after the latest denial. That the persn applying fr Other Incme Benefits has furnished the necessary prf needed t btain Other Incme Benefits, which include, but is nt limited t, wrkers' cmpensatin benefits; That the persn has nt waived (given up his r her right t) any Other Incme Benefits withut the Plan Administratr s written cnsent; That the persn has sent the Plan Administratr r the Claims Administratr cpies f dcuments shwing the effective dates and amunts f Other Incme Benefits. Of incme yu receive frm any wrk fr pay r prfit. This may include tax returns and financial infrmatin fr any crpratin yu wn r perate. Yu d nt have t apply fr: Retirement benefits paid nly n a reduced basis; r Disability benefits under a grup life insurance plan, if the disability benefits wuld reduce the amunt f yur grup life insurance. Hwever, if yu apply fr and receive these benefits, they will be cnsidered as Other Incme Benefits and yu must prvide prf t the Claims Administratr, if requested. If yu d nt prvide the prf that the Claims Administratr may require, the Claims Administratr has the right t suspend r adjust this Plan's benefits by the estimated amunt f the Other Incme Benefits. 15

17 Exclusins That Apply t Shrt Term Disability Shrt term disability cverage des nt cver any disability n any day that yu are cnfined in a penal r crrectinal institutin fr cnvictin f a criminal act r ther public ffense. Yu will nt be cnsidered t be disabled, and n benefits will be payable. Shrt term disability cverage als des nt cver any disability that: Is due t an ccupatinal illness r ccupatinal injury except in the case f sle prprietrs r partners wh cannt be cvered by wrkers cmpensatin. Is due t insurrectin, rebellin, r taking part in a rit r civil cmmtin. Is due t intentinally self-inflicted injury (while sane r insane). Is due t war r any act f war (declared r nt declared). Results frm yur cmmissin f, r attempting t cmmit a criminal act. Results frm a mtr vehicle accident caused by perating the vehicle while yu are under the influence f alchl. A mtr vehicle accident will be deemed t be caused by the use f alchl if it is determined that at the time f the accident yu were: Operating the mtr vehicle while under the influence f alchl at a level which meets r exceeds the level at which intxicatin wuld be presumed under the laws f the state where the accident ccurred. If the accident ccurs utside f the United States, intxicatin will be presumed if the persn's bld alchl level meets r exceeds.08 grams per deciliter. Reprting f Claims Yu are required t submit a claim t the Claims Administratr. Yu may cntact The Claims Administratr by telephne t file a claim at the tll free number, (866) Yu may als file a claim using the Internet at: Yur claim must give prf f the nature and extent f the lss. Yu must furnish true and crrect infrmatin as the Claims Administratr may reasnably request. At any time, the Claims Administratr may require cpies f dcuments t supprt yur claim, including data abut emplyment. Yu must als prvide the Claims Administratr with authrizatins t allw it t investigate yur claim and yur eligibility fr and the amunt f wrk earnings and Other Incme Benefits. In additin t the abve, if yu must be ut f wrk because yu are disabled, a claim fr a shrt term disability benefit shuld be made right away. D nt wait until yu g back t wrk. This may delay payment f benefits. At any time, the Claims Administratr may require cpies f dcuments t supprt yur claim, including data abut emplyment and any Other Incme Benefits. The deadline fr filing a shrt term disability claim is 5 days after the end f the Eliminatin Perid, if any. 16

18 Payment f Benefits Benefits will be paid as sn as the necessary prf t supprt the claim is received. Shrt term disability benefits will be prcessed weekly. They will be paid at each bi-weekly Gates pay date during the perid fr which benefits are payable. Weekly benefits fr a perid less than a week will be prrated. This will be dne n the basis f the rati t five (5) days f the days f eligibility fr benefits during the week. Claims and Appeals Review Prcess Claim Determinatins The Claims Administratr will make ntificatin f a claim determinatin as sn as pssible but nt later than 45 calendar days after the claim is made. The Claims Administratr may determine that due t matters beynd its cntrl an extensin f this 45 calendar days claim determinatin perid is required. Such an extensin, f n lnger than 30 additinal calendar days, will be allwed if the Claims Administratr ntifies yu within the first 45 calendar day s perid. If prir t the end f the first 30 calendar days extensin perid, the Claims Administratr again determines that due t matters beynd its cntrl a decisin cannt be made within that extensin perid, the claim determinatin perid may be extended fr an additinal 30 calendar days. The Claims Administratr must ntify yu, prir t the end f the first extensin perid, f the circumstance requiring the extensin and the date by which a decisin can be expected. The ntice f any extensin, by the Claims Administratr shall specifically explain: The standards n which entitlement t a benefit is based; The unreslved issues that prevent a decisin n the claim; and The additinal infrmatin needed t reslve thse issues. The claimant will have 7 calendar days, frm the date f the ntice, t prvide the Claims Administratr with the required infrmatin. Appeals f Adverse Benefit Determinatins Yu may submit an appeal if the Claims Administratr gives ntice f an adverse benefit determinatin. Yu have 14 calendar days fllwing the receipt f ntice f an adverse benefit determinatin t request yur appeal. Yur appeal must be submitted in writing and shuld include: Yur name; Yur reasns fr making the appeal; and Any ther infrmatin yu wuld like t have cnsidered. 17

19 Yu may submit written cmments, dcuments, recrds, and ther infrmatin relating t yur claim, whether r nt the cmments, dcuments, recrds, r infrmatin were submitted in cnnectin with the initial claim. Yu may als request that the Plan prvide yu, free f charge, cpies f all dcuments, recrds, and ther infrmatin relevant t the claim. Send in yur appeal t the address shwn n the ntice f adverse benefit determinatin. Yu may als chse t have anther persn (an authrized representative) make the appeal n yur behalf by prviding written cnsent t the Claims Administratr. Appeal Prcedure The Claims Administratr shall issue a decisin within 45 calendar days f receipt f the request fr an appeal. If The Claims Administratr determines that due t special circumstances an extensin f time fr claim prcessing is required, such an extensin, f n lnger than 45 additinal calendar days, will be allwed if the Claims Administratr ntifies yu within the first 45 calendar day perid. The extensin ntice shall indicate the special circumstances requiring an extensin f time and the date by which a decisin can be expected. When Cverage Ends Cverage under yur Plan can end fr a variety f reasns. In this sectin, yu will find details n hw and why cverage ends, and hw yu may still be able t cntinue cverage. When Cverage Ends Fr Emplyees Yur cverage under the Plan will end if: The Plan is discntinued; The date yur emplyment ends; Yu are n lnger eligible fr cverage; Yur emplyment stps fr any reasn, including jb eliminatin r being placed n severance. This will be the date yu stp active wrk, hwever, yur cverage may cntinue until stpped by yur Emplyer as described belw: If yu are nt actively at wrk due t illness r injury, r n apprved leave f absence, yur cverage may cntinue, until stpped by yur Emplyer, but nt beynd 12 mnths frm the start f the absence. If yu are nt actively at wrk due t temprary lay-ff r leave f absence, yur cverage will stp n the day f the lay-ff r leave f absence. It is the Plan Administratr s respnsibility t let the Claims Administratr knw when yur emplyment ends. 18

20 Extensin f Benefits Cverage fr Shrt Term Disability Benefits If yur shrt term disability cverage ends during a perid f disability which began while yu were cvered, any shrt term disability benefits will be cntinued until yur benefit eligibility ends. General Prvisins Administrative Ntice The Plan Administratr f the Plan has delegated t the Claims Administratr the discretinary authrity t interpret the terms f the Plan and t decide factual and ther questins relatin t the Plan and Plan benefits, including withut limitatin, questins relating t eligibility fr, entitlement t, and payment f benefits. Duty t Cperate Yu have a duty at all times while yur claim is under cnsideratin t cperate with the Claims Administratr in its investigatin and evaluatin f yur claim. The Claims Administratr may require yu t supply signed authrizatins t allw it t btain medical and ther infrmatin. The Claims Administratr may require yu and yur physicians t supply dcuments, prvide infrmatin, and fill ut frms that are needed, in the Claims Administratr's judgment, t assist it in evaluating yur claim. Failure t cperate with the Claims Administratr's reasnable requests fr dcuments and infrmatin may result in a denial f yur claim. The Claims Administratr will have the right and pprtunity t have a physician r apprpriate medical prfessinal f its chice examine any persn wh is requesting certificatin r benefits fr new and nging claims. Multiple exams, evaluatins and functinal capacity exams may be required during yur disability fr an nging claim. This will be dne at all reasnable times while certificatin r a claim fr benefits is pending r under review. This will be dne at n cst t yu. Legal Actin Yu must use and exhaust this Plan s administrative claims and appeals prcedures befre bringing a lawsuit. Any legal actin brught t recver payment f any benefit under this Plan must be initiated befre the earlier t ccur f the fllwing: Tw years after the date f the final decisin n the final appeal f the denial f yur claim; Three years frm the date yur claim fr benefits was first denied. Plan Administratr s Right t Amend/Change Plan The Plan Administratr retains the right t add t, change, amend r suspend the Plan at any time, withut advance ntice, within the parameters f any federal, state r lcal law that may apply. 19

21 Cnfidentiality Infrmatin cntained in yur medical recrds and infrmatin received frm any prvider incident t the prvider patient relatinship shall be kept cnfidential in accrdance with applicable law. Infrmatin may be used r disclsed by the Claims Administratr when necessary fr the peratin f the Plan, payment and administratin f claims fr benefits under the Plan, r ther activities, as permitted by applicable law. Additinal Prvisins The fllwing additinal prvisins apply t yur cverage. Yu cannt receive multiple cverage under the Plan because yu are cnnected with mre than ne emplyer. In the event f a misstatement f any fact affecting yur cverage under the Plan, the true facts will be used t determine the cverage in frce. This SPD describes the main features f the Plan. Additinal prvisins may be described in the Plan. If yu have any questins abut the terms f the Plan r abut the prper payment f benefits, cntact yur Emplyer r the Claims Administratr. Recvery f Overpayments Shrt Term Disability Cverage If payments are made in amunts greater than the benefits that yu are entitled t receive, the Claims Administratr has the right t d any ne r all f the fllwing n behalf f the Plan: Require yu t return the verpayment n request; Stp payment f benefits until the verpayment is recvered; Take any legal actin needed t recver the verpayment; and Place a lien, if nt prhibited by law, in the amunt f the verpayment n the prceeds f any ther incme, whether n a peridic r lump sum basis. If the verpayment: Occurs as a result f yur receipt f Other Incme Benefit fr the same perid fr which yu have received a benefit under this Plan; and T btain such Other Incme Benefits advcate r legal fees were incurred; This Plan will exclude frm the amunt t be recvered, such advcate r legal fees; prvided yu return the verpayment t the Plan within 30 days f the Claims Administratr s written request fr the verpayment. If yu d nt return the Plan verpayment t the Claims Administratr within such 30 days, such fees will nt be excluded; yu will remain respnsible fr repayment f the ttal verpaid amunt. Please cnsult the sectin Other Incme Benefits. 20

22 Plan Nt a Substitute fr Wrkers Cmpensatin Insurance The Plan is nt in lieu f and des nt affect wrkers' cmpensatin benefits. Hwever, any wrkers' cmpensatin benefits are cnsidered Other Incme Benefits. Glssary A Active at Wrk; Actively at Wrk; Active Wrk In this sectin, yu will find definitins fr the wrds and phrases that appear in bld type thrughut the text f this SPD. Yu will be cnsidered t be active at wrk, actively at wrk r perfrming active wrk n any f yur Emplyer s scheduled wrk days if, n that day, yu are perfrming the regular duties f yur jb n a full time basis fr the hurs yu are nrmally scheduled t wrk. In additin, yu will be cnsidered t be actively at wrk n the fllwing days: Any day which is nt ne f yur Emplyer s scheduled wrk days if yu were actively at wrk n the preceding scheduled wrk day; r A nrmal vacatin day. Adverse Benefit Determinatin A denial, terminatin f, r failure t prvide r make payment (in whle r in part) fr a benefit. Appeal A written request t the Claims Administratr t recnsider an adverse benefit determinatin. B Base Pay This means the eligible Emplyee s basic wages, whether calculated n an hurly r salary basis. Base Pay des nt include cmmissins, vertime, bnuses, r any ther frms f additinal cmpensatin. Fr determining benefits t be paid n a weekly basis, Base Pay will be determined by dividing annual Base Pay by fifty-tw (52). If benefits are paid n a daily r hurly basis, Base Pay is the weekly amunt prrated by the number f days r hurs in the emplyee s nrmal wrkweek r wrkday, as applicable. C Claims Administratr This means Aetna, the cmpany authrized by The Gates Crpratin t administer claims fr benefits under the shrt-term disability Plan. 21

23 E Emplyee This means a persn wh is an active regular unin-free emplyee f the Emplyer n US payrll regularly scheduled t wrk at least 30 hurs per week. Emplyer This means the persn r cmpany emplying yu and prviding yur cverage under the Plan. Effective Treatment f Alchlism r Drug Abuse This means a prgram f alchlism r substance abuse therapy that is prescribed and supervised by a physician and either: Has a fllw-up therapy prgram directed by a physician n at least a mnthly basis; r Includes meetings at least twice a mnth with rganizatins devted t the treatment f alchlism r drug abuse. Detxificatin and maintenance care are nt Effective Treatment f Alchlism r Drug Abuse. H Hspital An institutin that: Is primarily engaged in prviding, n its premises, inpatient medical, surgical and diagnstic services; Is supervised by a staff f physicians; Prvides twenty-fur (24) hur-a-day R.N. service, Charges patients fr its services; Is perating in accrdance with the laws f the jurisdictin in which it is lcated; and Des nt meet all f the requirements abve, but des meet the requirements f the jurisdictin in which it perates fr licensing as a hspital and is accredited as a hspital by the Jint Cmmissin n the Accreditatin f Healthcare Organizatins. In n event des hspital include a cnvalescent nursing hme r any institutin r part f ne which is used principally as a cnvalescent facility, rest facility, nursing facility, facility fr the aged, extended care facility, intermediate care facility, skilled nursing facility, hspice, rehabilitative hspital r facility primarily fr rehabilitative r custdial services. 22

24 I Illness A pathlgical cnditin f the bdy that presents a grup f clinical signs and symptms and labratry findings peculiar t it and that sets the cnditin apart as an abnrmal cnditin differing frm ther nrmal cnditins r frm ther pathlgical cnditins. Injury An accidental bdily injury that is the sle and direct result f: An unexpected r reasnably unfreseen ccurrence r event; r The reasnable unfreseeable cnsequences f a vluntary act by the persn. The act r event must be definite as t time and place. An injury is nt the direct result f illness. M Material Duties Duties that: Are nrmally required fr the perfrmance f yur wn ccupatin; and Cannt be reasnably mitted r mdified. Hwever, t be at wrk in excess f 40 hurs per week is nt a material duty. Mtr Vehicle This is a vehicle that is a registered and licensed vehicle and is: O A passenger land r water vehicle f pleasure design which includes auts, vans, fur-wheel drive vehicles, and self-prpelled mtr hmes; r A truck f cmmercial design. Own Occupatin The ccupatin that yu are rutinely perfrming when yur perid f disability begins. Yur ccupatin will be viewed as it is nrmally perfrmed in the natinal ecnmy instead f hw it is perfrmed: Fr yur specific Emplyer; r At yur lcatin r wrk site; and Withut regard t yur specific reprting relatinship 23

25 P Physician A duly licensed member f a medical prfessin wh: Has an M.D. r D.O. degree; Is prperly licensed r certified t prvide medical care under the laws f the jurisdictin where the individual practices; and Prvides medical services which are within the scpe f his r her license r certificate. This als includes a health prfessinal wh: Is prperly licensed r certified t prvide medical care under the laws f the jurisdictin where he r she practices; Prvides medical services, including evaluatins and examinatins, which are within the scpe f his r her license r certificate; and Under applicable insurance law is cnsidered a "physician" fr purpses f this cverage. Fr the purpses f Shrt Term Disability cverage, regular care f a physician means yu are attended by a physician wh: Is nt yu, and is nt yur immediate family member r anyne related t yu by marriage r adptin; Has the medical training and clinical expertise suitable t treat yur disabling cnditin; Specializes in psychiatry, if yur disability is caused, t any extent, by a mental health r psychiatric cnditin; and Whse treatment is: Cnsistent with the diagnsis f the disabling cnditin; Accrding t guidelines established by medical, research and rehabilitative rganizatins; and Administered as ften as needed. Predisability Earnings The amunt f salary r wages yu were receiving frm an Emplyer participating in this Plan n the day befre a perid f disability started, calculated n a weekly basis Yur predisability earnings will be figured frm the rule belw that applies t yu. If yu are paid n an annual cntract basis, yur weekly salary is based n yur annual cntract divided by 52. If yu are paid n an hurly basis, the calculatin f yur weekly wages is based n yur hurly pay rate multiplied by the number f hurs yu are regularly scheduled t wrk per mnth; but nt mre than 40 hurs per week. Field sales and Drivers Only: Prir year s grss wages. 24

26 Included in salary r wages are: Fr Field Sales and Drivers Only: Cmmissins included in prir year s grss wages. Cntributins yu make thrugh a salary reductin agreement with yur Emplyer t any f the fllwing: An Internal Revenue Cde (IRC) Sectin 125 plan fr yur fringe benefits. An IRC 401(k), 403(b), r 457 deferred cmpensatin arrangement. An executive nnqualified deferred cmpensatin agreement. Salary r wages d nt include: Awards and bnuses. Fringe benefits Overtime pay r shift differential Cntributins made by yur Emplyer t any deferred cmpensatin arrangement r pensin plan. Extra cmpensatin such as payments fr revenue sharing, husing allwances, stipends, relcatin incentives r buyuts f unused vacatins, prfessinal fees, nn-qualified incme. A retractive change in yur rate f earnings will nt result in a retractive change in cverage. 25

27 Gates Sick Pay Crdinatin with Shrt Term Disability Benefits The infrmatin utlined belw is a summary f The Gates Crpratin s sick pay plicy as it relates t an emplyee s nn-ccupatinal illness r injury. Shuld yu have questins regarding the sick pay plicy, please cntact Human Resurces. 1. Beginning n the date f hire, all regular active unin-free benefits eligible emplyees begin accruing sick pay fr their wn persnal illness. 2. Temprary emplyees are nt eligible fr sick pay. 3. Benefits eligible emplyees accrue sick pay at a rate f 5.33 hurs per mnth up t a maximum f 64 hurs. If yu are n an apprved leave f absence fr a maximum f 12 weeks r less, yu will cntinue t accrue regular sick pay. If yur apprved leave f absence extends beynd twelve (12) weeks, yu will nt accrue sick pay until yu return t wrk as an active emplyee. Aetna will nt be respnsible fr the accrual calculatin r administratin f sick pay. 4. In general, sick pay is paid at 100% f base pay up t a maximum f 40 hurs per week based n the emplyee s regularly scheduled wrk week. 5. Emplyees hired befre January 1, 2011 must exhaust all sick pay which was accrued prir t December 31, 2010 (Sick Bank #1) befre using regular sick pay (Sick Bank #2) as utlined in this plicy. 6. The Gates Crpratin reserves the right t require emplyees t prvide a dctr s nte verifying an absence was caused by a medical situatin. 7. In rder t use up t 40 hurs f cnsecutive sick pay, the emplyee must be n an apprved Shrt Term Disability claim r leave f absence, as determined by the third party disability administratr. Sick pay frm Sick Bank #1 (when available) is t be used first t bridge the Shrt Term Disability waiting perid. Once Sick Bank #1 is exhausted (r if unavailable), sick pay frm Sick Bank #2 is used t bridge the waiting perid befre Shrt Term Disability benefits cmmence. 8. If the Shrt Term Disability claim is apprved, Shrt Term Disability payment at 100% pay is deducted frm Sick Bank #1 until exhausted. Thereafter, the Shrt Term Disability benefit will be 66 2/3% f the emplyee s regularly scheduled wrk week base pay. 9. The emplyee has the ptin t supplement the 66 2/3% f Shrt Term Disability benefit with accrued vacatin r sick pay (33.1/3%) fr a cmbined maximum nt t exceed 100% f base pay r 40 hurs per week. 10. Cmmissined emplyees such as Field Sales and Transprt Drivers benefit will be based n the prir year s grss wages. 11. A release t return t wrk frm the emplyee s physician will be required befre the emplyee may return t wrk and prvided t Human Resurces and the emplyee s supervisr. 26

28 Cntinuatin f Optinal Emplyee Benefits Cverage During an Apprved Leave f Absence Granted t Cmply With Federal Law This cntinuatin f cverage sectin applies nly fr the perid f any apprved family r medical leave (apprved FMLA leave) required by Family and Medical Leave Act f 1993 (FMLA) and Gates apprved unpaid Leaves. If yur Emplyer grants yu an apprved FMLA leave in accrdance with FMLA r any ther apprved unpaid leave, yur Emplyer may allw yu t cntinue ptinal benefit cverage fr which yu are cvered under the grup cntract n the day befre the apprved leave starts. At the time yu request the leave, yu must agree t make any cntributins required by yur Emplyer t cntinue ptinal benefit cverage. Yur Emplyer must cntinue t make premium payments. Optinal benefits cverage will nt be cntinued beynd the first t ccur f: The date yu are required t make any cntributin and yu fail t d s. The date yur Emplyer determines yur apprved leave is terminated. The date the cverage invlved discntinues as t yur eligible class. 27

29 Imprtant Infrmatin Claim Administratin Under the Plan Plan Name The claim administratin f the Plan is handled by the Claims Administratr. The name f the Plan is The Gates Crpratin Shrt Term Disability Plan. Plan Number The number assigned t the Plan by Aetna is Plan Year Service f Prcess Claims Administratr Plan Administratr and Plan Spnsr Funding The Plan and its recrds are kept n a plan year basis, which is the calendar year. The Plan is classified as a welfare plan prviding shrt term disability benefits. The agent fr service f prcess n the Plan is the Plan Administratr, at the belw address. Aetna The Gates Crpratin Glbal Benefits Department 1551 Wewatta Street Denver, Clrad The Plan is self-funded by The Gates Crpratin, with all benefits payable hereunder t be paid frm Gates Crpratin s general assets. 28