Life and AD&D Insurance Benefits

Transcription

1 Life and AD&D Insurance Benefits It is important to know that your family is provided for if you die or suffer a disability. That is why the Major League Baseball Players Benefit Plan offers a Life Insurance Plan (the Life Insurance Plan ) with life insurance and accidental death and dismemberment (AD&D) insurance coverage. Life insurance can help provide some financial security in the event of your death. AD&D insurance pays benefits if you suffer certain serious injuries or die as the result of an accident. Important! For more information about your life and AD&D insurance benefits, refer to Administration. In This Section See Page Overview Eligibility, Enrollment, and More Who Is Eligible Enrolling in the Plan Cost of Coverage Changing Coverage When Coverage Ends Life Insurance Active Members Inactive Members Disabled Members Retired Members Conversion Privilege Accidental Death and Dismemberment (AD&D) Insurance Active Members Inactive Members Disabled Members Retired Members Covered Losses...90 Exclusions Filing Claims Initial Benefit Determination Claims Appeal Process Civil Actions Under ERISA Limits on the Plan s Liability

2 OVERVIEW Your life and AD&D insurance coverage varies depending on your member status and/or your years of credited service. If You Are a(n) Your Life Insurance Benefit Is Your AD&D Insurance Benefit Is Active member $450,000 $1.05 million for accidental death Inactive vested* member (with four or more years of credited service) Inactive vested* member (with at least 60 days of credited service, but less than four years of credited service) Inactive vested* member (with less than 60 days of credited service) Disabled member (receiving disability benefits from the Pension Plan, if disability pension began on or after July 1, 1990) Disabled member (receiving disability benefits from the Pension Plan, if disability pension began before July 1, 1990, and member had at least 60 days of credited service and was an active member when the member became disabled) maximum of $1.05 million $225,000 $225,000 for accidental death maximum of $225,000 $40,000 $40,000 for accidental death None None Amount in force as of date of disability (you may call the Benefit Plan Office to find out the amount of your insurance) (reduces to $40,000 retired member benefit at retirement) $300,000 (reduces to $40,000 retired member benefit at retirement) maximum of $40,000 Full amount of life insurance in force as of date of disability for accidental death covered losses, to a maximum of the full life insurance benefit $300,000 for accidental death maximum of $300,000 84

3 If You Are a(n) Disabled member (receiving disability benefits from the Pension Plan, if disability pension began before July 1, 1990, and member had at least four years of credited service and was an inactive member when the member became disabled) Retired member (receiving retirement benefits from the Pension Plan) Eligible employee of the Players Association Your Life Insurance Benefit Is $150,000 (reduces to $40,000 retired member benefit at retirement) Your AD&D Insurance Benefit Is $150,000 for accidental death maximum of $150,000 $40,000 $40,000 for accidental death Lesser of $450,000 or three times base rate of annual compensation (insurance amount will be adjusted every April 1 to reflect changes in compensation that took effect in the preceding 12 months) maximum of $40,000 Same as life insurance amount for accidental death maximum of the full life insurance benefit * Vested refers to your status under the Pension Plan. To determine whether you have earned enough pension credited service to be vested, see Credited Service in Pension Benefits or in Terms for more information. The life and AD&D insurance benefits are insured, which means that premiums are paid by the Major League Baseball Players Welfare Plan to the insurance company insuring the benefits. The insurer determines the life and AD&D insurance benefits payable under the policy issued by the insurer, and the insurer pays the benefits. The Major League Baseball Players Welfare Plan does not pay any life or AD&D insurance benefits. Effective April 1, 2012 through March 31, 2016, the current insurer is MetLife. ELIGIBILITY, ENROLLMENT, AND MORE This section explains who is eligible to participate in the Life Insurance Plan, how to enroll in the Life Insurance Plan, the cost of coverage, how to change coverage, and when participation ends. Who Is Eligible You are eligible for life insurance and AD&D benefits if you are: an active member; an inactive vested member with 60 or more days of pension credited service; a disabled member; a retired member; a player on a club s 40-man roster at any time during a championship season; or an eligible employee of the Players Association. 85

4 Earning Pension Credited Service Pension credited service is used to determine whether inactive members and disabled members are eligible for life insurance and AD&D insurance. See Credited Service in Pension Benefits or in Terms for more information about earning pension credited service. Enrolling in the Plan Beneficiary After a Divorce If you have named your spouse as your beneficiary, be aware that a subsequent divorce, legal separation, or annulment will not automatically cancel that beneficiary designation. You will need to send a new beneficiary designation to the Benefit Plan Office if you do not want your former spouse to be your beneficiary. You are not required to enroll for life insurance benefits under the Plan coverage begins automatically on the date that you become eligible. Naming a Beneficiary When you are eligible for life insurance and AD&D insurance, you must choose a beneficiary. Your beneficiary is the person who receives your insurance benefits if you die. The Benefit Plan Office will send you a beneficiary form. Simply complete the form and sign it. Then return the form to the Benefit Plan Office. You should keep a copy of the form for your records. You can change your beneficiary at any time by completing a new form and returning it to the Benefit Plan Office. You can name multiple beneficiaries to share your benefit, or you can name a primary beneficiary and another to be a contingent beneficiary (who would receive the benefits if the primary beneficiary is not alive when benefits are paid). If you do not name a beneficiary, or if benefits cannot be paid to the person you named as beneficiary, the insurer pays life insurance and accidental death benefits to your estate. If you have named your spouse as your beneficiary, be aware that a subsequent divorce, legal separation, or annulment will not automatically cancel that beneficiary designation. You will need to send a new beneficiary designation to the Benefit Plan Office if you do not want your former spouse to be your beneficiary. Cost of Coverage Major League clubs pay the full cost of coverage for life and AD&D insurance for active, inactive, disabled, and retired players under an agreement with the Players Association. The Players Association pays the full cost of coverage for its eligible employees. Changing Coverage If your employment status changes (for example, from an active member to an inactive member), your life and AD&D insurance coverage will change as well. When your status changes, you do not need to do anything you will receive a notice of a change in your benefits. The status change and the resulting change in coverage will become effective on opening day of the next championship season, except for: inactive, disabled, or retired members who become active members, whose change in coverage will be effective on the first day they are on the active list or on a club s 40-man roster at any time during a championship season; employees of the Players Association, whose change in coverage will be effective immediately; and retired members, whose change in coverage is effective on the date when pension benefits begin. 86

5 When your life insurance coverage is reduced because of a status change, you will have an opportunity to convert to an individual policy all or a portion of the amount of life insurance that you lost due to the change in status. If you die within 31 days of a status change without having exercised that option, the insurer pays your beneficiary the life insurance benefit in effect for you immediately prior to the change. If that benefit is less than the amount of coverage you were eligible for after the status change, the insurer pays the greater amount. When Coverage Ends Coverage ends when you become an inactive member if you have less than 60 days of credited service. For employees of the Players Association, coverage ends upon termination of employment, unless you are entitled to coverage as an inactive or a retired player. Coverage also would end if the Life Insurance Plan were terminated. LIFE INSURANCE If you die while you are insured by the Life Insurance Plan, the insurer will pay benefits to your designated beneficiary. The benefits for which you are eligible depend on your member status. The life insurance benefit is insured, which means that the insurer determines and pays the life insurance benefits payable under the policy issued by the insurer. Active Members If you are an active member at the time of your death, your beneficiary will receive $450,000. For life insurance and AD&D purposes, an active member includes any player on a Major League club s 40-man roster at any time during a championship season. Inactive Members With Four or More Years of Credited Service If you are an inactive vested member with four or more years of credited service at the time of your death, your beneficiary will receive $225,000. With at Least 60 Days but Less Than Four Years of Credited Service If you are an inactive member with at least 60 days but less than four years of credited service at the time of your death, and you are vested under the terms of the Pension Plan, your beneficiary will receive $40,000. (See Vesting in Pension Benefits for more information about vesting under the Pension Plan. See Credited Service in Terms for more information about pension credited service.) Disabled Members If you are receiving disability benefits from the Pension Plan at the time of your death, the insurer pays the benefit amount in force as of the date of your disability. You may call the Benefit Plan Office to find out the amount of your insurance. 87

6 If you began receiving disability benefits on or after July 1, 1990, the life insurance coverage that you had as of your date of disability will remain in effect. If your disability pension began before July 1, 1990, and you had at least 60 days of credited service and were an active member when you became disabled, your life insurance coverage is $300,000. If your disability pension began before July 1, 1990, and you had at least four years of credited service and were an inactive member when you became disabled, your life insurance coverage is $150,000. If you are disabled and you retire, your life insurance coverage is automatically reduced to $40,000 the amount for retired members. Retired Members If you are a retired member (receiving benefits from the Pension Plan) at the time of your death, your beneficiary will receive $40,000. Conversion Privilege If your life insurance benefits are reduced as the result of a status change, you can convert the difference between your old and new benefits into an individual policy. You must apply to convert your coverage and pay the required premium. The Benefit Plan Office will notify you when you can convert your coverage. If you are given notice of the option to convert your coverage within 15 days before or after the date that your life insurance coverage ends or is reduced, the application period for converting your coverage begins on the date that your coverage ends or is reduced and expires 31 days after that date. If you are given notice of the option to convert your coverage more than 15 days after the date that your life insurance coverage ends or is reduced, the application period for converting your coverage begins on the date that your coverage ends or is reduced and expires 15 days after the date of the notice to convert. In no event will the application period to convert your coverage exceed 60 days from the date that your life insurance ends or is reduced. You do not have to provide proof of good health if you convert your coverage to an individual policy during the time period described in this section. You cannot convert more than the amount of coverage you lost as a result of your status change. (See Changing Your Coverage in Understanding Your Benefits for more information about status changes.) ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE The AD&D benefit is insured, which means that the insurer determines and pays the AD&D benefits payable under the policy issued by the insurer. If you have an accidental injury that is the direct and sole cause of death or certain other serious injuries while covered by the Life Insurance Plan, the insurer will pay benefits to you or your beneficiary that are in addition to those paid under the life insurance benefit. The amount of the benefit for which you are eligible depends on your covered loss and your member status. The insurer pays benefits if you suffer a covered loss (as described in Covered Losses on page 90) anytime within 12 months of the accident: as the direct result of injuries received in an accident; and that is unrelated to other causes. 88

7 If you die as a result of the accident, benefits are paid to your beneficiary. All other benefits are paid directly to you. Covered losses are those losses described in the insurance policy issued by the insurer providing AD&D benefits. Covered Losses on page 90 summarizes the covered losses under the insurance policy in effect April 1, 2012 through March 31, This information is subject to change. If you have questions about a covered loss, you should contact the Benefit Plan Office for the most current list of covered losses. Active Members If you die as a result of an accident and you are an active member at the time of the accident, the insurer pays a benefit of $1.05 million to your beneficiary. If you suffer a covered loss (other than accidental death), the insurer generally pays one-half of the accidental death benefit amount, but may pay up to $1.05 million, depending on the type of loss. If you suffer multiple losses, the insurer pays a benefit for each covered loss, up to a total of $1.05 million. The insurer determines the benefits payable under the policy issued by the insurer. In no case will the insurer pay more than the accidental death benefit for which you are eligible. Inactive Members With Four or More Years of Credited Service If you die as a result of an accident and you are an inactive member with four or more years of credited service who is vested in the Pension Plan at the time of the accident, the insurer pays $225,000 to your beneficiary. If you suffer a covered loss (other than accidental death), the insurer generally pays one-half of the accidental death benefit amount, but might pay up to $225,000, depending on the type of loss. If you suffer multiple losses, the insurer pays a benefit for each covered loss, up to a total of $225,000. The insurer determines the benefits payable under the policy issued by the insurer. In no case will the insurer pay more than the accidental death benefit for which you are eligible. With at Least 60 Days but Less Than Four Years of Credited Service If you die as a result of an accident and you are an inactive member with at least 60 days but less than four years of credited service at the time of the accident, and you are vested under the terms of the Pension Plan, the insurance company pays $40,000 to your beneficiary. If you suffer a covered loss (other than accidental death), the insurer generally pays one-half of the accidental death benefit amount, but may pay up to $40,000, depending on the type of loss. If you suffer multiple losses, the insurer pays a benefit for each covered loss, up to a total of $40,000. The insurer determines the benefits payable under the policy issued by the insurer. In no case will the insurer pay more than the accidental death benefit for which you are eligible. 89

8 Disabled Members If you die as a result of an accident and you are receiving disability benefits at the time of the accident, the insurer pays your beneficiary an AD&D benefit in an amount equal to the amount of your life insurance coverage. If you became disabled on or after July 1, 1990, your AD&D benefit amount is the same as the amount of life insurance coverage you had as of your date of disability. You may call the Benefit Plan Office to find out the amount of your insurance. If you became disabled before July 1, 1990, and you had at least 60 days of credited service and were an active member when you became disabled, your AD&D coverage is $300,000. If you became disabled before July 1, 1990, and you had at least four years of credited service and were an inactive member when you became disabled, your AD&D coverage is $150,000. If you suffer a covered loss (other than accidental death), the insurer generally pays one-half of the accidental death benefit amount, but may pay up to your full life insurance benefit amount, depending on the type of loss. If you suffer multiple losses, the insurer pays a benefit for each covered loss, up to the amount of the maximum AD&D benefit. The insurer determines the benefits payable under the policy issued by the insurer. In no case will the insurer pay more than the accidental death benefit for which you are eligible. Retired Members If you are a retired member (receiving retirement benefits) at the time of the accident, the insurer pays $40,000 to your beneficiary in the event of your death. If you suffer a covered loss (other than accidental death), the insurer generally pays one-half of the accidental death benefit amount, but may pay up to $40,000, depending on the type of loss. If you suffer multiple losses, the insurer pays a benefit for each covered loss, up to a total of $40,000. The insurer determines the benefits payable under the policy issued by the insurer. In no case will the insurer pay more than the accidental death benefit for which you are eligible. Covered Losses What Is Irrecoverable or Irreversible? Generally, a condition is considered irrecoverable or irreversible if the treating physician determines that the covered loss cannot be recovered or reversed by available treatments. Covered losses are those losses described in the insurance policy issued by the insurer providing benefits (currently MetLife). The covered losses described below summarize the covered losses under the insurance policy in effect April 1, 2012 through March 31, This information is subject to change. If you have questions about a covered loss, you should contact the Benefit Plan Office for the most current list of covered losses. If you die or suffer certain other serious injuries (other than death) as the direct result of an accident while covered by the Life Insurance Plan, the insurer will pay benefits to you or your beneficiary. The chart below shows covered losses and the associated AD&D benefit payments. In the covered losses chart, the following definitions apply: Loss of hearing means entire and irrecoverable loss of hearing in both ears that continues for six consecutive months following the accidental injury. Loss of sight means permanent and uncorrectable loss of sight in the eye. Visual acuity must be 20/20 degrees or worse in the eye or the field of vision must be less than 20 degrees. 90

9 Loss of speech means the entire and irrecoverable loss of speech that continues for six consecutive months following the accidental injury. Loss of the thumb and index finger of same hand means that the thumb and index finger are permanently severed through or above the third joint from the tip of the index finger and the second joint from the tip of the thumb. Paralysis means loss of use of a limb, without severance. A physician must determine the paralysis to be permanent, complete, and irreversible. Brain damage means permanent and irreversible physical damage to the brain causing the complete inability to perform all the substantial and material functions and activities of everyday life. Such damage must manifest itself within 30 days of the accidental injury, require hospitalization for at least five days, and persist for 12 consecutive months after the date of the accidental injury. For the Loss of Life Any combination of hand, foot, or sight of one eye Both arms and both legs (paralysis) Brain damage A hand permanently severed at or above the wrist but below the elbow A foot permanently severed at or above the ankle but below the knee An arm permanently severed at or above the elbow A leg permanently severed at or above the knee Sight in one eye The thumb and index finger of the same hand Speech and loss of hearing Speech or loss of hearing Both legs (paralysis) The arm and leg on either side of the body (paralysis) One arm or leg (paralysis) You Will Receive 100% of the accidental death benefit 50% of the accidental death benefit Exposure and Disappearance Benefit Any loss due to unavoidable exposure to the elements will be covered as if the loss is due to an accidental injury if such exposure was a direct result of an accident. If you are not found within one year after the disappearance, sinking, or wrecking of an aircraft or other vehicle in which you were traveling, you will be presumed to have died as the result of an accidental injury. Coma Benefit If you are in a coma due to an accident, you will receive a monthly coma benefit equal to 1% of your accidental death benefit beginning on the seventh day of the coma for the duration of the coma, for up to 60 months. Being in a coma means being in a state of deep and total unconsciousness from which you cannot be aroused. Your coma must begin within 30 days of the accidental injury and continue for seven consecutive days before benefits are paid. 91

10 Hospital Confinement Benefit If you are confined in a hospital due to an accident, you will receive a monthly hospital confinement benefit for each full month of hospital confinement equal to the lesser of $2,500 or 1% of your accidental death benefit, for up to 12 months of continuous confinement (benefits will be paid for one confinement per accident only). Your hospital confinement also must continue for five consecutive days before benefits begin being paid. EXCLUSIONS Exclusions are those losses for which the insurer does not pay a benefit. The exclusions are described in the insurance policy issued by the insurer providing benefits. The exclusions described below summarize the exclusions under the insurance policy in effect April 1, 2012 through March 31, This information is subject to change. If you have questions about exclusions, you should contact the Benefit Plan Office for the most current list of exclusions. The insurer does not pay benefits for a covered loss caused directly or indirectly by: any incident related to parachuting or other descent from an aircraft, except to save your life any incident related to travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight any incident related to travel in an aircraft as a pilot, crew member, flight student, or while acting in any capacity other than as a passenger any incident related to travel in an aircraft or device used: for testing or experimental purposes, by or for any military authority, or for travel or designed for travel beyond the earth s atmosphere committing or attempting to commit a felony physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity infection, other than infection occurring in an external accidental wound intentionally self-inflicted injury service in the armed forces of any country or international authority, except the United States National Guard suicide or attempted suicide the voluntary intake or use by any means of: alcohol in combination with any drug, medication, or sedative any drug, medication, or sedative, unless it is either taken or used as prescribed by a physician, or an over the counter drug, medication, or sedative taken as directed poison, gas, or fumes war, whether declared or undeclared; or an act of war, insurrection, rebellion, or riot Benefits also are not payable if you are intoxicated at the time of the accident and are the operator of a vehicle or other device involved in the accident. Intoxicated means that your blood alcohol level equals or exceeds the level at which there would be a legal presumption of intoxication in the jurisdiction in which the accident occurred. 92

11 FILING CLAIMS The Benefit Plan Office has the forms that you or your beneficiary will need for claiming life insurance and AD&D benefits. The Benefit Plan Office also will provide necessary information and instructions for filing a claim. You or your beneficiary must request the forms, fill them out completely, and return them to the Benefit Plan Office. You must exhaust the Life Insurance Plan s appeal procedures, which include the insurer s appeal procedures, before you can bring a lawsuit under ERISA regarding a claim for benefits under the Life Insurance Plan. Claims for life insurance should be submitted as soon as possible after your death. Claims for AD&D benefits must be submitted within 90 days after the loss on which the claim is based. However, if it is not possible to make the claim within that time (for example, if you are in a coma), you or your beneficiary should submit a claim as soon as reasonably possible. Once the forms have been received and approved, death benefits are paid to your beneficiary. If you have not named a beneficiary, they are paid to your estate. Benefits for any other losses (other than death) are paid directly to you. Initial Benefit Determination The insurer makes all benefit determinations for life insurance and AD&D benefits. For life and AD&D benefit claims, the insurer has up to 90 days to evaluate and respond to claims for benefits. The 90-day period begins on the date the claim is first filed. This period may be extended by up to 90 additional days if the insurer: determines that an extension is necessary because of special circumstances; and notifies you or your beneficiary within the initial 90-day period of the circumstances requiring the extension and the date by which the insurer expects to make a decision. If you or your beneficiary is not furnished with a notice within these time periods, you will be considered to have exhausted your administrative remedies and may pursue your legal remedies. If the insurer denies a claim for life insurance or AD&D benefits, you or your beneficiary will receive a written notice describing the specific reasons for the denial, referring to the insurance policy provisions on which the denial is based. The notice will explain your or your beneficiaries right to appeal. If the insurer denies the claim because you or your beneficiary provided insufficient information to support the claim, the notice will specify what information is needed and when the information must be supplied. Claims Appeal Process You or your beneficiary (or an authorized representative) will have 60 days after receiving written notice of a claim denial to file an appeal. To file an appeal, you should: submit a request for review, in writing, to the insurer; and submit written comments, documents, records, and other information relating to the claim to the insurer. The insurer will make a full and fair review of the claim and all new information submitted, whether or not presented or available at the initial determination, and may require additional documents as it deems necessary or desirable to perform the review. A final decision on the review will be made within 60 days following receipt of the written request for review. 93

12 If special circumstances require an extension of time for processing, you or your beneficiary will be notified of the reasons for the extension and the date by which the insurer expects to make a decision. If an extension is required due to your or your beneficiary s failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the necessary information and the date by which you or your beneficiary needs to provide it. The 60-day extension of the appeal review period will begin after you or your beneficiary has provided that information. The insurer will provide you or your beneficiary with written notification of the determination on appeal. If your or your beneficiaries claim is denied on appeal, the notification will specify the reasons that the claim was denied and the specific insurance policy provisions on which the denial was based. A denial will also contain a statement of your or your beneficiaries right to file a lawsuit under ERISA. (See Your Rights Under ERISA in Administration for more information.) Civil Actions Under ERISA The administrative appeal process described in Claims Appeal Process on page 93 must be completed before any legal action regarding your claim may be brought. Legal action based on the insurer s denial of a claim must be filed no later than three years after the date that you or your beneficiary were first required to provide the claim and proof of loss. Limits on the Plan s Liability Life insurance and AD&D benefits are provided only through the insurance policies that the Life Insurance Plan maintains for this coverage. The premiums for that insurance are paid out of the trust fund that holds the Welfare Plan s assets, but the trust fund is not otherwise responsible for the payment of life insurance or AD&D benefits. Accordingly, your rights and the rights of your beneficiaries to life insurance or AD&D benefits are defined and limited by the insurance policy that is in effect at the time of any covered loss. The terms of the insurance policy may change from time to time. If the information in this Benefits Handbook is different from the terms of the policy, it is the terms of the policy that will govern your benefit rights. To obtain a copy of the insurance policies, contact the Benefit Plan Office. You are entitled to enforce your rights under the insurance policy directly against the insurer after following all administrative remedies described in Filing Claims on page 93. The Pension Committee, as plan administrator and holder of the insurance policy, also retains the right to enforce the policy of insurance on behalf of members and their beneficiaries. 94