Employee Assistance Program (EAP)

Transcription

1 Employee Assistance Program (EAP)

2 CONTENTS Introduction... 4 Eligibility and Enrolling... 5 Eligibility... 6 Your Household Members... 6 Dual Coverage for the EAP... 6 Situations Affecting Your Eligibility for Benefits... 7 Family and Medical Leave of Absence... 7 Continuation of Coverage During Military Service... 7 Sickness or Accident... 8 Rescissions of Coverage... 8 Continuing Coverage Under COBRA... 9 Cost of COBRA Coverage Trade Act of When COBRA Coverage Ends Employee Assistance Program (EAP) EAP at a Glance How the EAP Works Receiving EAP Services Covered EAP Services Personal Consultation Services Legal and Financial Consultation Services Work-Life Services What s Not Covered by the EAP Requesting EAP Benefits Claim Denials and Appeals Assigning Benefits Claims and Appeals Procedures Questions About Benefit Determinations Plan Administration When Coverage Ends Certificate of Group Health Plan Coverage Administrative Information Plan Name and Number Claims Administrators and Supplier Partners Trustee Plan Sponsor and Administrator Agent for Service of Legal Process Employer Identification Number Plan Year Right to Amend or Terminate the Plan No Employment Guarantee Employee Assistance Program (EAP) 2 January 1, 2011

3 Your ERISA Rights Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Notice of Privacy Practices How the Plans May Use Your Information Other Permitted Uses and Disclosures Other Uses and Disclosures of Health Information You Rights Regarding Protected Health Information Right to Request Restrictions Right to Request Confidential Communications Complaints About This Notice Contacting Us Employee Assistance Program (EAP) 3 January 1, 2011

4 INTRODUCTION This summary plan description (SPD) describes the Dover Corporation Employee Assistance Program (EAP). The EAP is maintained by Dover Corporation (the Company) on behalf of its employees. Please read this SPD to help you understand your EAP benefits, and keep it for future reference. This SPD is a summary of the key provisions of the EAP provided under the Dover Corporation Health and Wellness Plan (the plan or Dover plan) as of January 1, The SPD also provides a brief description of your rights as a participant under the EAP. Complete details of the EAP are contained in the official plan documents. Every attempt was made to make this SPD as accurate as possible. However, if a discrepancy exists between this SPD and the official plan documents, the plan documents will govern. The Company reserves the right to modify, amend or terminate the EAP at any time for any reason. If you have any questions about your benefit plan, you can contact the claims administrator (see Claims Administrators and Supplier Partners under Plan Administration) or your local HR representative. Ayuda con Idiomas Extranjeros Este folleto incluye un resumen en inglés de sus derechos y beneficios del plan de acuerdo al Programa de Asistencia para los Empleados de Dover Corporation. Si tiene alguna dificultad para entender cualquier parte del folleto, comuníquese con su representante local de RH o con el administrador del plan a Dover Corporation, 3005 Highland Parkway, Suite 200, Downers Grove, IL El horario de oficina es de lunes a viernes de las 8:00 a.m. a las 5:00 p.m, hora del Centro. También puede llamar a la oficina del administrador del plan al para que le ayuden. Employee Assistance Program (EAP) 4 January 1, 2011

5 ELIGIBILITY AND ENROLLING This section includes information on the following: Eligibility for you and your dependents When coverage begins Who pays for your and your dependents benefits Situations that may affect your eligibility for benefits Information on continuing coverage under COBRA Employee Assistance Program (EAP) 5 January 1, 2011

6 Eligibility You and your eligible dependents participate in the EAP on your first day of work. Participation is automatic; you do not need to enroll. Your eligible dependents include all members of your household (such as your spouse) and your unmarried dependent children whether or not they live with you. The Company pays the entire cost of EAP coverage for you and your household members. Your Household Members Members of your household, whether or not they are dependents, are automatically covered by the EAP. Dual Coverage for the EAP You and your dependents may not be covered twice by the Company EAP. For example, this applies to married couples or a parent and child working for the Company. If dual Company benefit coverage applies, there is no coordination of benefits only one plan will pay. Employee Assistance Program (EAP) 6 January 1, 2011

7 Situations Affecting Your Eligibility for Benefits Family and Medical Leave of Absence If you are entitled to a leave under the Family and Medical Leave Act (FMLA), you may continue your and your dependents health-related benefits under the plan during your FMLA leave period, up to 12 weeks. No new conditions or waiting periods apply to your benefits when you return to work as a covered employee. Leave under FMLA may be available for the following reasons: Birth of a child and to care for the newborn; Placement of a child with you for adoption or foster care; To care for your seriously ill spouse, child or parent; A serious health condition that makes you unable to perform your job functions; or Any qualifying exigency arising out of the fact that your spouse, son, daughter or parent is on active duty or has been notified of an impending call to active duty status as a member of the Armed Forces, including the National Guard or Reserves, in support of a contingency operation. The Company is responsible for determining your eligibility, rights or length of leave for FMLA for purposes of continuing your benefits under the plan. Military Family Leave You are also eligible for up to 26 weeks of unpaid military family leave in a single 12-month period to care for a member of the Armed Forces (including a member of the National Guard, Reserves or a veteran). He or she must be undergoing medical treatment, recuperation or therapy; is otherwise in outpatient status; or is otherwise on the temporary disability retired list, for a serious injury or illness incurred in the line of duty on active duty or that existed before the covered service member s active duty and was aggravated by service in the line of duty on active duty. This leave may be granted to an eligible employee who is the spouse, child, parent or next-of-kin (i.e., closest blood relative) of a covered service member. If you are eligible to take both FMLA and military family leave, your total leave will be limited to 26 weeks in a 12-month period. Payment for Coverages If you elect to continue coverage during any leave under the FMLA, such coverage is on the same terms as if you were actively employed. During any unpaid leave, you are responsible for paying any premiums when due. If you fail to return to work at the end of an FMLA leave, the Company reserves the right to recover from you: The Company s share of the cost of coverage provided during leave, and Your portion of any contributions that the Company paid during the leave. Continuation of Coverage During Military Service If you are on a military leave of absence covered by the Uniformed Services Employment and Reemployment Rights Act (USERRA), your and your dependents coverage may continue under the plan. Coverage continues until the earlier of the following occurs: The date you fail to return to active employment as required under the USERRA, or The last day of the 24-month period beginning on the date of your military leave of absence. When you have been on unpaid military leave, you must pay any required contributions. Once your coverage ends, you can elect to continue eligible coverage under COBRA. USERRA coverage runs concurrently with COBRA continuation coverage. Employee Assistance Program (EAP) 7 January 1, 2011

8 If you decide to waive coverage under the plan during a military leave qualifying under USERRA and return to work following the leave (within the time specified by USERRA), you are reinstated in the plan. Once you resume coverage, the plan does not cover any expenses you incur relating to any illness or injury incurred in, or aggravated during, the performance of military service. Sickness or Accident If you become sick or experience an accident and you cannot work, the Company may continue your coverage for a certain time. For more information on your coverage status during a sickness or accident, contact your local HR representative. Rescissions of Coverage Once you or any of your dependents are enrolled in the plan, your coverage may not be rescinded (i.e., terminated retroactively) unless: You or your dependent performs an act, practice or omission that constitutes fraud; or You or your dependent makes an intentional misrepresentation of a material fact. Inadvertent omissions or unintentional misrepresentations are not grounds for rescission of coverage. If your coverage is going to be rescinded, you will receive written notice 30 days before coverage is cancelled. Employee Assistance Program (EAP) 8 January 1, 2011

9 Continuing Coverage Under COBRA If you lose your eligibility for group health care coverage (such as medical, dental, vision, Health Care FSA and EAP), the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) gives you a right to continue coverage for a specified period. This section generally explains COBRA continuation coverage, when it may become available to you, your spouse and/or your dependent children, and what you need to do to protect the right to receive it. For additional information regarding COBRA, you should review this SPD or contact the billing department of BCBSIL s COBRA administrator (Health Care Services Corporation) at The Company may extend COBRA-like continuation coverage to your domestic partner and his or her children who experience a qualifying event, as set forth below. Qualified Beneficiary A qualified beneficiary for COBRA coverage includes you, your covered spouse, your covered dependent children, your covered domestic partner and/or the covered children of your covered domestic partner at the time a coverageending event occurs. If you or your spouse or domestic partner gives birth to or adopts a child after the qualifying COBRA event, the child is also a qualified beneficiary if he or she is enrolled in the plan within 30 days of the event. If you marry or begin a domestic partnership while continuing coverage under COBRA, your new spouse or domestic partner is not considered a qualified beneficiary. Any other dependents you add to your family are not qualified beneficiaries. Qualifying Events You and your qualified beneficiaries have a right to choose COBRA coverage if you or your qualified beneficiaries lose group health coverage because of any one of the qualifying events listed in the following chart: Coverage Is Lost Because Your hours are reduced You go on certain leaves of absence Your termination of employment for reasons other than gross misconduct You die You become entitled to benefits under Medicare You divorce, legally separate or your marriage is annulled Dissolution of your domestic partnership Can Continue for You Your spouse or domestic partner Your dependent children or the children of your domestic partner Your spouse or domestic partner Your dependent children or the children of your domestic partner Your ex-spouse or former domestic partner Your dependent children or the children of your former domestic partner For Up To Take Action 18 months You and your qualified beneficiaries are automatically notified of the right to continue coverage. To continue coverage, you and your qualified beneficiaries must complete a COBRA enrollment form and return it to the plan administrator within 36 months 60 days of the later of the COBRA notification or the date regular benefits end. 36 months You or your qualified beneficiaries must notify the plan administrator within 60 days of the event. This notification must be in the form and method approved by the plan administrator. If the plan administrator is not notified within the required time frame, your dependents will lose their right to COBRA continuation coverage. Employee Assistance Program (EAP) 9 January 1, 2011

10 Coverage Is Lost Because Your dependent child or the child of your domestic partner is no longer eligible for coverage under the plan (for example, your child reaches the age limit) Can Continue for Your dependent child or the child of your domestic partner For Up To 36 months Take Action After receiving notice of the qualifying event, the COBRA administrator notifies your qualified beneficiaries of their right to continue coverage. To continue coverage, you or your qualified beneficiaries must complete a COBRA enrollment form and return it to the plan administrator within 60 days of the later of the COBRA notification or the date regular benefits terminate. Second Qualifying Event An 18-month extension of coverage is available to spouses, domestic partners and dependent children who elect COBRA continuation coverage if a second qualifying event occurs during the first 18 months of COBRA coverage. The maximum amount of COBRA coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death of a covered employee, legal separation, divorce, termination of a domestic partnership or a dependent child s ceasing to be eligible for coverage. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the plan if the first qualifying event had not occurred. You must notify the COBRA administrator in writing within 60 days after a secondary qualifying event occurs if you want to extend your COBRA coverage. In no event will your COBRA coverage last beyond 36 months from the date of the event that originally made a qualified beneficiary eligible to elect coverage. Disability Extension of 18-Month Period of COBRA Continuation Coverage An 11-month extension of coverage may be available if any one of the qualified beneficiaries is determined by the Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA coverage. To qualify for this disability extension, you must notify the COBRA administrator and provide a copy of the SSA determination within 60 days after the date of the SSA disability determination and before the end of the original 18-month COBRA continuation period. Each qualified beneficiary (whether or not disabled) who has elected COBRA continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the qualified beneficiary is later determined by the SSA to no longer be disabled, you must notify the COBRA administrator of that fact within 30 days after the SSA s determination. Cost of COBRA Coverage You automatically receive EAP coverage continuation under COBRA. Your cost for EAP coverage while you are on COBRA is paid in full by the Company. Keep Your Plan Informed of Address Changes To protect your family s rights, you should keep the COBRA administrator (Health Care Services Corporation) informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the plan administrator. Employee Assistance Program (EAP) 10 January 1, 2011

11 Trade Act of 2002 The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance. Under the new tax provisions, eligible individuals can take a tax credit for qualified health insurance, including continuation coverage. If you have questions about these tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at TTD/TTY callers may call toll-free at More information about the Trade Act is also available at Certain individuals who, under limited circumstances, become eligible to take advantage of trade adjustment assistance pursuant to the Trade Act may receive a second 60-day COBRA election period. If you are receiving or are eligible for trade adjustment assistance, please contact the plan administrator for more information. When COBRA Coverage Ends COBRA continuation coverage ends on the date the earliest of the following occurs: The COBRA maximum period of continuation ends; Failure to pay the premium when due or within the 30-day grace period; A qualified beneficiary becomes entitled to coverage under Medicare after electing COBRA coverage; The Company ends all of its health benefit plans; A qualified beneficiary becomes covered, after making the COBRA continuation coverage election, under another group health plan that does not exclude or limit coverage for any pre-existing condition the beneficiary may have; or A qualified beneficiary is on extended coverage for up to 29 months due to disability and a final determination is made that the beneficiary is no longer disabled. COBRA continuation coverage may also be terminated for any reason the plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud). Contact Information If you have questions about COBRA, contact the COBRA administrator, Health Care Service Corporation Continuation Billing department at For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) Employee Assistance Program (EAP) 11 January 1, 2011

12 EMPLOYEE ASSISTANCE PROGRAM (EAP) The Employee Assistance Program (EAP) is designed to provide confidential support services to you and your eligible household members in dealing with whatever life throws your way, including: Stress Family and relationship problems Work-life balance Depression Mental illness Legal or financial issues Substance abuse Caring for children or aging parents You can be assured that your personal information will not be disclosed to anyone without your written approval except to the extent required or permitted by law. Employee Assistance Program (EAP) 12 January 1, 2011

13 EAP at a Glance Feature Enrolling Contributions EAP Benefits Provisions You do not need to enroll in the EAP. Coverage for you and your eligible household members is automatic and starts on your first day of work. The Company pays the total cost for your and your eligible household members EAP coverage. The EAP is designed to provide confidential support services to you and your eligible household members in dealing with whatever life throws your way, including: Managing stress Handling relationship issues Balancing work and home life Quitting tobacco, alcohol or drug use Caring for children or aging parents Exploring career development options Dealing with conflict or violence Working through grief and loss issues Controlling depression and anxiety You and your eligible household members can access the EAP in two ways: Call the EAP at day or night to speak with a trained professional. Explore the on-line resources at MagellanHealth.com/member. As a new user, you will need to enter the 10-digit phone number ( ). Then you can either register (create a username and password) or use the site as a guest. Either way, it s confidential. Your personal information will not be disclosed to anyone without your written approval except to the extent required or permitted by law. Employee Assistance Program (EAP) 13 January 1, 2011

14 How the EAP Works The EAP offers a wealth of practical, solution-focused resources to help you develop answers for problems, including Managing stress Handling relationship issues Balancing work and home life Quitting tobacco, alcohol or drug use Caring for children or aging parents Exploring career development options Dealing with conflict or violence Working through grief and loss issues Controlling depression and anxiety Receiving EAP Services You or your eligible household members can access the EAP in two ways: Call the EAP at day or night to speak with a trained professional. EAP representatives are available 24 hours a day, 7 days a week, to provide referral and emergency crisis intervention services. Spanish-speaking representatives and counselors are also available. Explore the on-line resources at MagellanHealth.com/member. As a new user, you will need to enter the 10-digit phone number ( ). Then you can either register (create a username and password) or use the site as a guest. Either way, it s confidential. Your personal information will not be disclosed to anyone without your written approval, and when allowed except to the extent required or permitted by law. Employee Assistance Program (EAP) 14 January 1, 2011

15 Covered EAP Services The EAP provides benefits for personal consultation services, legal and financial consultation services, and work-life services, as follows. Personal Consultation Services You and each of your eligible household members are eligible to participate in up to five in-person sessions per problem each calendar year (as considered clinically necessary by the EAP). If you receive in-person counseling together with another household member such as your spouse, the total number of in-person sessions for which you and the other person are eligible for that problem is still five. The number of sessions does not increase simply because more than one person participates in counseling. There is no lifetime maximum on the number of sessions. In-person services are available only through the network of independent EAP counselors with whom Magellan contracts. You may select an EAP counselor by calling Magellan at or through the on-line EAP self-referral process at MagellanHealth.com/member. In many cases, the problem is resolved within the five in-person sessions available through the EAP. However, if you need more sessions or other health care services, you may be referred to an outside source for assistance. Legal and Financial Consultation Services You and your eligible household members are eligible for a free initial legal and financial consultation, including the following: Wills and inheritance concerns Divorce, custody and adoption matters Consumer issues Real estate questions Criminal matters Debt management Basic financial and retirement planning, savings and investments Insurance Budgeting and family financial issues Identity theft You may access the legal or financial consultation services by calling Magellan at Legal consultation services are available by telephone and in-person; financial consultation services are available only by telephone. For continued legal assistance after the initial consultation, you can choose whether to: Retain the attorney at your expense, Seek alternative counsel, or Adopt an alternative plan of action. If you retain the consulting attorney, you may be entitled to a 25% reduction in fees from the consulting attorney's normal fees. You are fully responsible for payment of these fees. You may also access an on-line library of articles on legal issues, legal forms and other resources for legal and financial guidance at MagellanHealth.com/member. The number of times you may use the legal and financial consultation services is unlimited. However, you may not access legal consultation services on a continuing basis to undertake your own representation. Employee Assistance Program (EAP) 15 January 1, 2011

16 Work-Life Services The EAP also provides telephone consultation, information, education and referral services in connection with: Child care Elder care Parenting issues Children with special needs Schooling and education Teen and young adult issues Adoption assistance A Work-Life consultant discusses your work-life needs by phone and sends you a packet of educational materials. If you are looking for dependent care or educational resources, the Work-Life consultant researches resources in your area. The consultant sends you a list of at least three licensed, certified or registered dependent care providers with confirmed vacancies in your area that match your needs, to the extent available. The telephone consultation, educational materials and referral list are provided to you at no charge. You are financially responsible for the dependent care arrangement that you select. If you choose to obtain elder care or child care, it is up to you to evaluate each dependent care resource to determine the right arrangement for your situation. It is also up to you to monitor the quality and appropriateness of the arrangement. The EAP does not endorse or recommend any of the dependent care resources identified. Magellan makes reasonable efforts to ensure the accuracy of information provided about dependent care resources. However, the information is obtained from those resources and Magellan cannot guarantee the accuracy of the information. The final decision about your dependent care arrangements is yours. An on-line library of articles and tools on work-life issues is also available at MagellanHealth.com/member. Employee Assistance Program (EAP) 16 January 1, 2011

17 What s Not Covered by the EAP The EAP does not include the following services: Acupuncture Aversion therapy Biofeedback and hypnotherapy Charges for completing claim forms Charges for failure to keep a scheduled visit Court-mandated counseling or evaluations required by a state or federal judicial officer or other governmental agency or to be used in legal actions of any kind (e.g., child custody proceedings) Direct treatment for mental retardation, learning disabilities or autism EAP services when you sue, or threaten to sue, the Company Evaluations for fitness for duty or excuses for leaves of absence or time off Exams and diagnostic services in connection with: - Obtaining employment or a particular employment assignment, - Admission to or continuing in school, - Securing any kind of license (including professional licenses), or - Obtaining any kind of insurance coverage Financial advice or instruction as to any course of action. The financial consultants are not responsible for any decisions you make about your financial planning Inpatient treatment Legal assistance for employment issues, commercial enterprise, second opinions or third-party advice, such as: - A relative s legal problem; - Matters considered frivolous or harassing by the consulting attorney; - Matters involving Magellan, the Company, the legal services vendors or its plan attorneys; or - Any matter that would involve a violation of ethical rules Medication, medication management or treatment of any condition for which medication is required, unless you are seeing a doctor who prescribes medication for that condition and oversees your use of the medication More than five in-person EAP sessions per problem each year Psychiatric services or other medical care, including prescription drugs Psychological, psychiatric, neurological, educational or IQ testing Recommendation or endorsement of a specific attorney to represent you; the final decision regarding whether a particular attorney is suitable for your needs can only be made by you Remedial education services such as: - Evaluation or treatment of learning disabilities, and developmental and learning disorders; - Behavioral training; and - Cognitive rehabilitation Services or supplies not needed for treatment or not approved by your EAP counselor Services or supplies rendered by a family member or for which there is no charge Services or supplies required by or paid for under any government law, including workers compensation or other federal, state or local law Services rendered before coverage became effective or after coverage ends Sleep therapy Testimony in legal proceedings or preparation for legal proceedings Treatment by someone other than an EAP counselor for whom a Magellan representative opened a case, or you completed a referral request through Magellan s on-line EAP self-referral process Treatment for any physical illness Treatment for any problem or condition that cannot be resolved in brief counseling (e.g., a psychosis or any other condition that requires inpatient treatment or more than five sessions) Treatments, procedures or devices considered experimental or investigational in nature as determined by the EAP administrator Employee Assistance Program (EAP) 17 January 1, 2011

18 Requesting EAP Benefits You do not have to file EAP claims, and there are no copays, coinsurance or deductibles. You should not make any payment to a provider for EAP services. However, you are responsible to pay for services you obtain without contacting Magellan to open an EAP case with a particular EAP counselor or without completing an electronic referral request through Magellan s on-line EAP self-referral process. If you feel you have a claim, you must file a claim with the claims administrator at: Magellan Behavioral Health Magellan Plaza Drive Maryland Heights, MO TTY: Employee Assistance Program (EAP) 18 January 1, 2011

19 Claim Denials and Appeals Claims for plan benefits are administered by Magellan Behavioral Health. In general, there is no need to file claims for EAP benefits as you do not pay for any EAP services. With limited exceptions, you must exhaust these claim procedures before filing a civil action for benefits under section 502(a) of ERISA. If your claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. Assigning Benefits Rights and benefits cannot be assigned to anyone except when allowed under the plan. Claims and Appeals Procedures You, your covered dependents or your authorized representative may file a claim with the claims administrator. The claims administrator is responsible for claim and appeal procedures. When you file a claim, the claims administrator reviews the claim and makes a decision to approve or deny the claim. The claims administrator has the full discretionary authority to: Interpret the provisions of the plan such interpretation will be final and conclusive on all persons, Determine eligibility for benefits, Provide you with reasonable notification of your benefits available under the plan, and Approve reimbursement requests and authorize the benefit payments. If your claim is denied, in whole or in part, you ll receive written notification from the claims administrator within the time frames noted in the following table. A claim denial is any denial, reduction or termination of a benefit or a failure to provide or make a payment, in whole or in part, for a benefit. A claim denial also includes a rescission (or cancellation) of coverage on a retroactive basis. Timing for Notification of Claim Decision Type of Claim Notice of Claim Decision Extension Post-service claims Within a reasonable time, but not later than 30 days after the plan receives your claim. Initial notification may be extended up to 15 days if necessary due to matters beyond the control of the plan. You are notified before the end of the first 30-day period why the extension is necessary and when the plan expects to make a decision. If you did not submit necessary information, the notice specifies what information is necessary, and you have at least 45 days to provide it. If provided within the 45 days, the claims administrator notifies you of its decision within 15 days after receipt of the information. If not received within 45 days, the claim is denied. Key Terms Post-service claim: Your claim for care or treatment under the EAP is a post-service claim since the claim is filed after medical care has been received. If Your Claim Is Denied If your claim for a benefit under the EAP is denied, in whole or in part, you ll receive a written notice of the denial. Such notice will include all of the following, as applicable: The specific reasons for the denial. The specific plan provisions on which the denial is based. A description of any additional material or information needed to complete the claim and an explanation of why it s necessary. Employee Assistance Program (EAP) 19 January 1, 2011

20 If an internal rule, guideline, protocol or other similar criterion (collectively called criteria) was relied on to determine a claim, you ll receive either a copy of the actual criteria or a statement that the criteria was used and how you can request a copy of it free of charge. If the denial is based on a provision such as medical necessity, experimental treatment or a similar exclusion or limit, you ll receive either an explanation of the scientific or clinical judgment for the determination based on the plan terms and your medical circumstances, or a statement that you can receive the explanation free of charge upon request. A statement of your right to bring a civil action under ERISA section 502(a) following a denial on review. A description of available internal appeals and applicable time limits. First Level Appeal If your claim for benefits is denied, you, your beneficiary or your authorized representative may appeal a claim decision by writing to your claims administrator. You must make your initial request for appeal in writing within 180 days after receipt of the claim denial. As part of the appeal process, you or your authorized representative will be given reasonable access to all documents, records and information relevant to the claim for benefits, and you may request copies free of charge upon request. You can also submit to your claims administrator written comments, documents, records and other information relating to the claim for benefits. Review of your claim will take into account all comments, documents, records and other information that is submitted, without regard to whether such information was submitted or considered in the initial benefit determination. Your request for appeal must include the following: The initial denial letter, The reason you believe the claim should be paid, and Any documentation or other written information to support your request for claim payment. Deciding the First Level Appeal The EAP benefit claim will be reviewed again and a decision made based on all comments, documents, records and other information you ve submitted. In reviewing your claim, the following shall apply: The review on appeal will not afford deference to the initial denial of your claim. A person other than the original reviewer (including a subordinate of such person) will review the claim decision. If the denial was based, in whole or in part, on a medical judgment, the person will consult with a health care professional who has appropriate training and experience in the field involving the medical judgment. This health care professional cannot be the same person who made the initial decision of denial, nor a subordinate of the person. The identity of medical or vocational experts who were consulted in the initial claim denial shall be disclosed to you without regard to whether their advice was relied upon in making the claim determination. Notification of First Level Appeal Decision You will receive the claims administrator s written or electronic notification of the decision within the following time frames after the claims administrator receives your request for review: Type of Claim Post-service claim Timing of Notification A reasonable time, but no later than 30 days after the plan receives the request for review. If your first level appeal is denied, in whole or in part, you ll receive a written notice that contains all of the information listed in If Your Claim Is Denied along with: A statement describing any additional mandatory or voluntary appeal procedures offered by the plan. An explanation of your right to request reasonable access to and copies of all documents, records and other information relevant to your claim without charge. Employee Assistance Program (EAP) 20 January 1, 2011

21 Second Level Appeal If you receive an adverse appeal decision from the claims administrator, you, your beneficiary or your authorized representative may make a second appeal of the claim denial directly to the claims administrator. You must make your request for review in writing within 180 days of receipt of the review denial. In reviewing your claim, the claims administrator shall comply with the standards set forth above under Deciding the First Level Appeal. You will receive the claims administrator s written notification of the decision within the following time frames after the claims administrator receives your request for review: Type of Claim Post-service claim Timing of Notification A reasonable time, but no later than 30 days after the plan receives the request for review. If your claim on appeal is denied, in whole or in part, for a second time, you ll receive a written notice that contains all of the information listed in If Your Claim Is Denied along with: A statement describing any additional mandatory or voluntary appeal procedures offered by the plan. An explanation of your right to request reasonable access to and copies of all documents, records and other information relevant to your claim without charge. Questions About Benefit Determinations If you have questions or concerns about a benefit determination, you may informally contact the claims administrator before requesting a formal appeal. If the claims administrator representative cannot resolve the issue to your satisfaction over the phone, you may submit your questions in writing. Remember, however, that if you are not satisfied with a benefit determination, you may appeal it without first informally contacting the claims administrator. Employee Assistance Program (EAP) 21 January 1, 2011

22 PLAN ADMINISTRATION This section includes information on the following: When your and your household members coverage ends Basic plan information including the claims administrators and supplier partners Your rights under ERISA Notice of Privacy Practices Employee Assistance Program (EAP) 22 January 1, 2011

23 When Coverage Ends Your coverage ends as described below when the first of any of the following occurs: The Company terminates the plan. You are no longer eligible for coverage. The date you terminate employment. You fail to make any required contributions. You die. Your dependents coverage ends when the first of any of the following occurs: The Company terminates the plan. You are no longer eligible for coverage. The date you terminate employment. Your dependent is no longer eligible for coverage. You fail to make any required contributions. You or your dependent dies. Your coverage ends. You may be able to continue your plan coverage through COBRA. See Continuing Coverage Under COBRA for more information. You may also be able to continue coverage if you are on an approved FMLA or military leave. See Situations Affecting Your Eligibility for Benefits for more information. It is your responsibility to notify the Company of any change in your status or the status of any of your covered dependents that affects eligibility for coverage under the plan. Certificate of Group Health Plan Coverage For plan options subject to the Health Insurance Portability and Accountability Act (HIPAA), whenever you or a family member loses group health plan coverage, you receive a certificate from your carrier showing the period you were receiving that health coverage. You may need that certificate if you seek other coverage (e.g., to reduce the time period a pre-existing condition limit may apply for the new coverage). Also, you will receive another certificate when your COBRA continuation period ends, if applicable. You or a family member may request a duplicate certificate at any time up to 24 months after regular or COBRA coverage is lost by contacting the plan administrator. Employee Assistance Program (EAP) 23 January 1, 2011

24 Administrative Information This section provides you with information about how the plan is administered. Plan Name and Number The plan names, types, funding and identification numbers are: Plan Names Plan Type and Funding Plan Identification Number Dover Corporation Health and Wellness Plan; the plan is also known as the Dover Plan or plan and includes the: Employee Assistance Program (EAP) Group health plan subject to the Health Insurance Portability and Accountability Act (HIPAA) The EAP is fully insured Claims Administrators and Supplier Partners The Company has different claims administrators and supplier partners for the plan as shown below: 530 Claims Administrator and/or Supplier Partners Dover Benefits Committee Dover Corporation 3005 Highland Parkway, Suite 200 Downers Grove, IL Magellan Behavioral Health Magellan Plaza Drive Maryland Heights, MO MagellanHealth.com/member For Eligibility appeals Employee Assistance Program (EAP) claims, benefit amounts and terms/provisions of the program Address for Filing Claims Dover Corporation 3005 Highland Parkway, Suite 200 Downers Grove, IL Magellan Behavioral Health Magellan Plaza Drive Maryland Heights, MO TTY: Trustee The trustee for the plan is: The Bank of New York One Wall Street New York, NY Plan Sponsor and Administrator Dover Corporation is the plan sponsor and plan administrator for each plan: Dover Corporation 3005 Highland Parkway, Suite 200 Downers Grove, IL The plan administrator has complete discretionary authority to interpret and construe the terms of the plan and to decide factual and other questions relating to the plan and plan benefits, including, without limit, Employee Assistance Program (EAP) 24 January 1, 2011

25 eligibility for, entitlement to and payment of benefits, to the extent such authority has not been allocated to a claims administrator. Under the terms of the plan, each claims administrator has been allocated full discretionary authority over benefit determinations. See Claims Administrators and Supplier Partners for the names and addresses of the claims administrators. Benefits under the plan will be paid only if the plan administrator or the claims administrator decides in its discretion that under the terms of the plan the applicant is entitled to the benefit. Agent for Service of Legal Process The name and address of the agent for service of legal process is: General Counsel Dover Corporation 3005 Highland Parkway, Suite 200 Downers Grove, IL Legal process also may be served on the plan administrator or trustee. Employer Identification Number Plan Year January 1 through December 31 Right to Amend or Terminate the Plan The Company expects to continue providing the benefits described in this SPD. However, the Company reserves the right to modify, amend or terminate any of the benefit plans described in this SPD at any time, for any reason. No amendment or modification shall diminish or eliminate any claim for any benefit to which you shall have become entitled before such amendment or modification. If the plan is terminated, you will not be vested in any benefits under the plan and will have no further rights under the plan after the termination date (other than payment of benefits for covered expenses incurred before the termination date). You will be notified of any change in benefits. No Employment Guarantee Being a participant in the plan does not grant any current or future employment rights. Plan participation is not a condition of employment. Employee Assistance Program (EAP) 25 January 1, 2011

26 Your ERISA Rights As a participant in the plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 as amended (ERISA). ERISA provides that all plan participants are entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the plan administrator s office and at other specified locations such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, on written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts, collective bargaining agreements, copies of the latest annual report (Form 5500 series), and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the plan s annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, your spouse or your dependents if there is a loss of coverage under the plan because of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan for the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ends if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties on the people who are responsible for the operation of the plan. The people who operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not Employee Assistance Program (EAP) 26 January 1, 2011

27 sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or federal court after you have exhausted the plan s claims procedures as described in this SPD. In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, if for example, it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory. Or you may contact the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Employee Assistance Program (EAP) 27 January 1, 2011

28 Notice of Privacy Practices This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access to This Information. Please Review It Carefully. (This notice only pertains to the medical, prescription drug, dental, vision, EAP and health care flexible spending account benefits under the plans.) As we work every day to operate your health plans, protecting the confidentiality of your personal medical information has always been an important priority. The plans may create, receive and maintain records that contain your health information as necessary to administer the health plans and provide you with health care benefits. The plans have adopted policies to safeguard the privacy of your medical information and comply with federal law, specifically, the Health Insurance Portability and Accountability Act of 1996 (known as HIPAA), as may be amended from time to time. Note: We or us refers to the Dover Corporation Health and Wellness Plan (including only the medical, dental, vision and prescription drug benefits), the health care component of the Dover Corporation Flexible Spending Accounts and the Dover Corporation Employee Assistance Program (collectively the plans ). You or yours refers to the individual participants in the plans. If you are covered by an insured health option under the plans, you may have or will also receive a separate notice from your insurer or HMO. This notice explains: How your personal medical information may be used, and What rights you have regarding this information. The privacy provisions under HIPAA require us to protect the privacy of your personal medical information (called Protected Health Information, or PHI). PHI includes all health information, including genetic information, that identifies you, relates to your physical or mental health condition or the payment of your health expenses, and that is transmitted or maintained by us, regardless of its form (which can be oral, written or electronic). We are required by law to: Maintain the privacy of your PHI, Give you this notice of our legal duties and privacy practices with respect to your Protected Health Information, and Comply with the terms of the notice that is currently in effect. How the Plans May Use Your Information To manage your health plans effectively, we are permitted by law to use and disclose your PHI in certain ways without your authorization: For Treatment. So that you receive appropriate treatment and care, providers may use your PHI to coordinate or manage your health care services. We may disclose your PHI to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, we may advise an emergency room physician about the types of prescription drugs you currently take. For Payment. To make sure that claims are paid accurately and you receive the correct benefits, we may use and disclose your PHI to determine plan eligibility and responsibility for coverage and benefits. For example, we may use your PHI when we confer with other health plans to resolve a coordination of benefits issue. We may also use your PHI for utilization review activities. Employee Assistance Program (EAP) 28 January 1, 2011

29 For Health Care Operations. To ensure quality and efficient plan operations, we may use your PHI in several ways, including plan administration, quality assessment and improvement and vendor review. Your information could be used, for example, to assist in the evaluation of a vendor who supports us. We also may contact you with appointment reminders or to provide information about treatment alternatives or other health-related benefits and services available under the plans. We may also disclose your PHI to Dover Corporation (the plan sponsor) in connection with these activities. If you are covered under an insured health plan, the insurer also may disclose PHI to the plan sponsor in connection with payment, treatment or health care operations. We are prohibited from using or disclosing genetic information for underwriting purposes, and will not use or disclose any of your PHI that contains genetic information for underwriting purposes under any circumstance. Other Permitted Uses and Disclosures Federal regulations allow us to use and disclose your PHI, without your authorization, for several additional purposes, in accordance with law: Public Health We may disclose PHI about you for public health activities, such as providing information to an authorized public health authority for the purpose of preventing or controlling a disease, injury or disability. Abuse, Neglect or Domestic Violence We may disclose your health information to proper government authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. Health Oversight Activities We may disclose your health information to a health oversight agency for audits, investigations, inspections and licensure necessary for the government to monitor the health care system and government programs, or to ascertain compliance with applicable civil rights laws. Judicial and Administrative Proceedings We may disclose your health information in response to a court or administrative order, subpoena, warrant, discovery request or other lawful process. Law Enforcement We may release your health information if asked to do so by a law enforcement official. For example, we may disclose health information to a police officer if needed to help find or identify a missing person. Research We may use or disclose your health information for research, as long as certain privacyrelated standards are satisfied. Coroner or Medical Examiner We may release your health information to a coroner or medical examiner. This may be necessary, for example, to identify the cause of a person s death. Organ, Eye or Tissue Donation Programs If you are an organ donor, we may disclose your health information to organizations that help procure, locate and transplant organs in order to facilitate an organ, eye or tissue donation and transplant. To Avert a Serious Threat to Health or Safety We may use or disclose your health information when necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person. Specified Government Functions In certain circumstances, federal regulations require us to use or disclose your health information to facilitate specialized government functions related to military and veterans activities, national security and intelligence, federal protective services, medical suitability determinations, correctional institutions and other law enforcement custodial situations. Workers Compensation We may disclose your health information as necessary to comply with applicable workers compensation or similar programs established by law that provide benefits for work-related injuries or illness. Required by Law We may use or disclose your health information for other purposes required by law, provided that the use or disclosure is limited to the relevant requirements of such law. Employee Assistance Program (EAP) 29 January 1, 2011

30 In Special Situations We may disclose your PHI to a family member, relative, close personal friend or any other person whom you identify, when that information is directly relevant to the person's involvement with your care or payment related to your care, unless you tell us not to do so. We also may use your PHI to notify a family member, your personal representative, another person responsible for your care or certain disaster relief agencies of your location, general condition or death. If you are incapacitated, there is an emergency or you otherwise do not have the opportunity to agree to or object to this use or disclosure, we will do what in our judgment is in your best interest regarding such disclosure and will disclose only information that is directly relevant to the person's involvement with your health care. Other Uses and Disclosures of Health Information Other uses and disclosures of health information not covered by this notice or by the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose your health information, you may revoke the authorization, in writing, at any time. If you revoke your authorization, we will no longer disclose or use your health information for the reasons covered by your written authorization. However, we will not retract any use or disclosure previously made as a result of your prior authorization. You Rights Regarding Protected Health Information You have the right to: Inspect and copy your Protected Health Information that we maintain. We may charge a fee for the costs of copying and mailing your request; On or after February 17, 2010, request a copy of any electronic health record we use or maintain with respect to your Protected Health Information. A fee may be charged for the labor costs associated with responding to your request; Amend or correct incomplete or inaccurate Protected Health Information maintained by us; however, we may deny your request if the Protected Health Information you want to amend: - Is in fact accurate and complete; - Was not created by us; - Is not part of the health information maintained by us; or - Is not information that you are otherwise permitted to inspect and copy; and Receive a paper copy of this Notice, even if you agreed to receive it electronically, Receive an accounting of certain disclosures of your Protected Health Information made by us; however, you are not entitled to an accounting of several types of disclosures including, but not limited to: - Disclosures made for payment, treatment or health care operations, - Disclosures you authorized in writing, and - Disclosures made for periods of time going back more than six years, or for any period before April 14, 2003; and Receive an accounting of disclosures of your Protected Health Information made by us through an electronic health record to carry out treatment, payment and health care operations during the three years before your request. This right applies to: - For electronic health records acquired by us as of January 1, 2009, disclosures made on or after January 1, 2014; and - For electronic health records acquired by us after January 1, 2009, disclosures made after the later of January 1, 2011 or the date the plans acquire the electronic health record. Right to Request Restrictions You may ask us to restrict how we use and disclose your PHI as we carry out payment, treatment or health care operations. You may also ask us to restrict disclosures to your family members, relatives, friends or other persons you identify who are involved in your care or payment for your care. However, we are not required to agree to these requests. Employee Assistance Program (EAP) 30 January 1, 2011

31 Notwithstanding our right to otherwise not agree to your request to restrict disclosures of your PHI, we will comply with the requested restriction if: Except as otherwise required by law, the disclosure is to a health plan for the purposes of carrying out payment or health care operations (and not for the purposes of carrying out treatment); The Protected Health Information pertains solely to a health care item or service for which the health care provider has been paid out of pocket in full; and The request to restrict the disclosure is made on or after February 17, We will not agree to restrictions on uses or disclosures that are legally required, or that are necessary for the administration of the plans. Right to Request Confidential Communications You may request to receive your Protected Health Information by alternative means or at an alternative location if you reasonably believe that other disclosure could pose a danger to you. For example, you may only want to have information sent by mail or to an address other than your home. We will attempt to honor your reasonable requests for confidential communications. For more information about exercising these rights, contact the office below. Complaints If you believe that your privacy rights have been violated, or that the privacy or security of your PHI has been compromised, you may file a written complaint without fear of reprisal. Direct your complaint to the Privacy Officer at the address listed below under Contacting Us or to the appropriate regional office of the Office of Civil Rights, U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint. About This Notice We reserve the right to change the terms of this notice at any time and to make the new notice provisions effective for all PHI we maintain. If we change this Notice, you will be provided with a copy of the revised notice. A copy of the current notice will be posted in Dover Corporation s Corporate Benefits Department at all times and, upon request, will be provided to you without charge. Contacting Us You may exercise the rights described in this notice by contacting the Dover Corporation official identified below, who will provide you with additional information: Doug Wilson HIPAA Privacy Officer Dover Corporation 3005 Highland Parkway, Suite 300 Downers Grove, IL Employee Assistance Program (EAP) 31 January 1, 2011

32 May 2011