HomeMy WebLinkAbout820068.tiff RESOLUTION
RE: AUTHORIZATION FOR HEALTH AND LIFE INSURANCE PLAN
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado Statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Director of Finance and Administration has presented to the
Board of County Commissioners the Health and Life Insurance Plan under the
self-funded program attached hereto and incorporated herein by reference, and
WHEREAS, after reviewing the attached plan, the Board of County
Commissioners deems it advisable and in the best interest of all Weld County
employees to approve said plan, a copy of which is attached hereto and
incorporated herein by reference, and
WHEREAS, the plan costs $85. 76 per month for single coverage, and
$102.48 per month for family coverage, and
WHEREAS, the life insurance is 39Q per $1,000 per month with eligible
employees employed over five years receiving a $12,000 term policy and
eligible employees under five years employment receiving a $7,000 term policy
with Accidental Death and Dismemberment, and
WHEREAS, the Board agrees to pay $71. 71 for single health coverage and
life insurance for eligible employees employeed less than five (5) years, and
$74.44 for single health coverage and life insurance for eligible employees
employed five (5) years or more, and
WHEREAS, the attached plan becomes effective January 1, 1983, and
WHEREAS, the insurance group shall consist of only those employees who
are part of the Weld County personnel/payroll system and employer number(s) ,
and
WHEREAS, Board agrees to self-fund the forty-two retired employees with
$1,000 paid-up life policies and fund the program from the Contingency Fund in
1983, and
WHEREAS, employees can purchase additional life insurance as specified in
the attached plan, and
WHEREAS, effective January 1, 1983, with the self-funded program, only
the above agent/administrator of record (James Company/Masoud Shirazi and
Leonard Amendola) selected through a selective process will be permitted to
provide County endorsed health and life insurance coverage to Weld County
RE txx:o
820068
employees. Solicitation by the above agent/administrator of record or any
other carrier of County employees for additional coverage of any insurance
type is not permitted in County facilities during working hours and not
endorsed by the County. Payroll deductions will only be made for authorized
endorsed insurance coverage for Weld County employees.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County that the attached plan and above recommendation and policies are
hereby approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign the necessary documents to implement the above.
The above and foregoing resolution was, on motion duly made and seconded,
adopted by the following vote on the 15th day of December, A.D. , 1982.
BOARD OF COUNTY COMMISSIONERS
ATTEST WELD COUNTY, COLORADO
U
J
Weld County Clerk and Recorder �i�
and Clerk to the Board /T. Martin,
Johfx�T. Mart Chairman
BY: � 4w�t•�„Le_ husk Carlson, ro Tem
?eputy County Clerk
Approved as to form: Norman Carlson
. Kirby
County Attorney - - /
UGC/
ne K. Stei mark
� r
WELD COUNTY EMPLOYEE BENEFIT FUND
Effective: January 1, 1983
TABLE OF CONTENTS
Page
PARTIES TO THE AGREEMENT
STOP LOSS INSURANCE COMPANY
EFFECTIVE DATE
SUMMARY OF BENEFITS 1
DEFINITIONS 4
SUPPLEMENTAL ACCIDENT BENEFIT 12
MAJOR MEDICAL BENEFIT 13
HOSPITAL CARE BENEFIT 16
ANESTHESIOLOGY BENEFIT 17
SURGICAL BENEFIT 18
GENERAL LIMITATIONS 19
HOW TO FILE A CLAIM 22
COORDINATION OF BENEFITS 23
MISCELLANEOUS DEFINITIONS 25
COMMON LAW SPOUSE 27
FACILITY OF PAYMENT 27
PROCESS IN CASE OF DISPUTED CLAIM 28
CONVERSION PRIVILEGE 29
SIGNATURE PAGE 30
WELD COUNTY EMPLOYEE BENEFIT FUND
Weld County has adopted the Weld County Employee Benefit Fund (the
"Plan" ) , as herein stated. Weld County agrees to provide for its eligible
employees , during continuance of the Plan , the benefits hereinafter described in
the event such employees incur a disability or they and/or their eligible
dependent(s) incur medical expenses covered by the Plan.
The Plan, designed for the exclusive benefit of eligible Weld County
Employees , is subject to all terms, provisions and conditions recited in the
following pages.
In addition to the benefits hereinafter set forth, insurance policies
have been purchased and are part of the Plan to insure against certain hazards
and to provide for certain contingencies as follows:
1. An Aggregate Stop-Loss policy to insure maximum annual claim
liabilities ;
2. A Specific ( Individual ) Stop-Loss policy to insure individual
claims in excess of the amount specified in the insurance
contract.
3. A Health Conversion provision to allow an individual to convert to
an individual Medical Policy upon termination.
Copies of the actual policy or policies are available for review at
the offices of Weld County, or James Benefits , the Contract Administrator, and
will be made available, upon request, at a reasonable charge.
Weld County has caused this Plan to be EFFECTIVE as of 12:01 a.m. ,
January 1, 1983, at Greeley, Colorado.
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SUMMARY OF BENEFITS
FOR EMPLOYEES AND DEPENDENTS
Supplemental Accident Benefit: 100% of the first $500.00 per accident ,
per person , not subject to the $100.00
deductible.
Pre-Admission Testing: Covered at 100% of Usual , Reasonable and
Customary medically necessary expenses.
Birthing Centers: Covered at 100% of Usual , Reasonable and
Customary medically necessary expenses.
Major Medical Benefit:
Maximum Lifetime Benefit: $1,000,000 each Covered Person.
Deductible : $100.00 per person each Calendar Year,
not to exceed $200.00 combined
(aggregate) per family each Calendar
Year.
NOTE: The Family Deductible may be
comprised of any combination of eligible
medical expenses among covered family
members.
Co-Insurance: After the deductible has been met , 80% of
the next $2,000 (80% of $4,000 per
family) , and 100% thereafter of Covered
Expenses will be paid per Covered Person
each Calendar Year, but not to exceed the
maximum lifetime benefit. Room and board
charges shall not exceed the
semiprivate, ICU and CCU room rates. All
charges are subject to the "General
Limitations" of this Plan.
In-Hospital "Well Baby" Hospital Nursery charges and one
Benefit : Physician visit covered as any other
illness subject to the deductible and
coinsurance.
Outpatient Pediatric "Well Pediatric well baby care is available
Baby" Benefit : until the child's second birthday;
limited to a maximum of $90 per dependent
child per Calendar Year. This "well
baby" care includes lab and x-ray ser-
vices. Routine immunizations are
available until the child's second birth-
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day, not limited to the Calendar Year
maximum.
Treatment of Alcoholism, Drug Abuse ,
Nervous and Mental Illness :
In-Hospital : 45 days maximum per Calendar Year.
NOTE: Partial hospitilization - the
lesser of 1) the number of days of
patient hospitilization or 2) 90 days in
any Calendar Year. (Each two partial
days will count as one full hospital
day. )
Out-patient: 50% of each visit , not to exceed usual ,
reasonable and customary, up to a maximum
payment of $1,250.00 per Calendar Year.
The eligible charges for outpatient ser-
vices are the reasonable charges for the
care and treatment of mental , psycho-
neurotic and personality disorders fur-
nished (1) by a hospital (other than
inpatient or partial hospitalization
services) ; (2) by a Physician; (3) under
the direct supervision of a Physician by
a comprehensive health care service cor-
poration , a community mental health
center, or other mental health clinic,
which is licensed or approved to furnish
mental health services by the state where
rendered ; or (4) by a social worker
registered or licensed by the state where
rendered, if furnished under the direct
supervision of a Physician.
Chiropractic: $30.00 maximum consideration per visit.
$500.00 maximum payment per Calendar
Year.
$5,000.00 maximum payment per lifetime
for each Covered Person.
Covered Expenses (Up to Usual ,
Customary and Reasonable) Examples
A. Doctor's services.
B. Prescription drugs.
C. Blood and blood plasma.
D. Ambulance service.
E. Artificial limbs.
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F. Rental of wheel chairs , braces,
crutches , etc.
G. Physical therapy and outpatient oxy-
gen therapy.
H. Intensive care unit room charges.
I. Emergency room services.
J. Hospital room and board.
NOTE: This is a partial listing of
covered major medical expenses. Items
specifically excluded are shown elsewhere
in the Plan.
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DEFINITIONS
Terms as used herein shall be deemed to define terms that may be used in the
wording of the Plan Document. These definitions shall not be construed to pro-
vide coverage under any benefit unless specifically provided.
A. GENERAL DEFINITIONS
f'1. Age Discrimination - Subject to any changes in the Social Security Act,
ITT active employees age 65 and over (up to 70 years of age) are
entitled to the same and/or equal benefits that they had prior to age
65.
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2. Amendment is a formal document changing the provisions of the Plan and
signed by the representatives of Weld County. Amendments apply to all
Covered Persons , including those persons who are covered before the
Amendment becomes effective, unless otherwise specified.
3. Common-Law Marriages - In order for an employee of Weld County to be
eligible for dependent medical coverage, the Common-Law Marriage must be
recognized by the State of Colorado. (See page 27. )
4. Calendar Year is the 12 month period beginning on each January 1st and
ending on the following December 31st.
5. Contract Administrator shall mean the person or firm employed by the
P a� n Administrator who is responsible for the processing of claims and
payment of benefits, administration , accounts, reporting and other ser-
vices contracted for by Weld County.
6. Plan Year is the 12 month period beginning on each January 1st and
eking the following December 31st.
7. Employer shall refer to Weld County.
8. Medicare - Title XVIII (Health Insurance for the Aged) of the United
States Social Security Act as amended.
9. Plan shall refer to the benefits and provisions as described herein for
payment.
10. Plan Administrator - Weld County.
11. Subrogation - The transfer of one's liabilities for another's ; in this
case the temporary assumption of the claimant 's liabilities by the Plan
prior to repayment by the party of primary liability. This Plan con-
tains a subrogation clause and the Claimant is obligated to obtain any
monies available from third parties to reduce the Plan 's claim losses.
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B. MEDICAL DEFINITIONS
1. Expense incurred means only the fees and prices regularly and custo-
mariTcharged for the medical services and supplies generally furnished
for cases of comparable nature and severity in the particular geographi -
cal area concerned. Any agreement as to fees or charges made between
the individual and the Physician shall not bind the Plan Administrator
in determining its liability with respect to expense incurred. Expense
incurred is deemed to be incurred on the date on which the service or
supply is rendered or obtained.
2. Illness shall mean bodily sickness or disease , psychiatric disorders ,
and, in the case of a newborn child, congenital abnormalities.
Illness must be medically diagnosed and be treated by a Physician for
purposes of determining benefits payable.
3. Morbid Obesity shall mean a condition in which the pressure of excess
weight causes physical trauma; or where pulmonary and circulatory insuf-
ficiencies are present; or where complications related to the treatment
of conditions such as arteriosclerosis , diabetes or coronary disease
exist ; and where the person is 100% or 100 pounds overweight, whichever
is greater, according to the Metropolitan Life Table of Desirable
Weights. (Excerpt from The Four Steps to Weight Control . )
4. Injury is a condition which results independently of sickness and all
other causes and is a result of an externally violent force , or acci -
dent.
5. HIAA Prevailing Charge Study is The Health Insurance Association of
America Schedule and shall be the basis for dental claim reimbursement
at "Usual , Reasonable and Customary" levels, applied to the particular
Zip-code area where the procedure is performed.
6. Pregnancy includes (1) all pregnancies except extra-uterine , which are
considered to be genito-urinary conditions , (2) childbirth, (3) mis-
carriage , or (4) any complications arising wholly from these conditions ,
and (5) any pregnancy complications arising from any trauma, and (6)
only those charges related to the pregnancy of a female employee or
spouse of an enrolled employee.
7. Period of Disability for a Covered Employee as it applies to an indivi -
dual , means all periods of disability arising from the same cause,
including any and all complications therefrom except that if the indivi -
dual completely recovers or returns to active full -time employment, any
subsequent period of disability from the same cause shall be considered
a new disability.
For a Covered Dependent , the term "Period of Disability," means all
periods of disability arising from the same cause including any and all
complications therefrom, except that if the dependent re-covers for a
period of three months and throughout such period is capable of resuming
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the normal activities of a person in good health and of the same age and
sex , any subsequent period of disability from the same cause shall be
considered a new period of disability.
8. Total Disability shall mean that the Covered Employee is prevented,
i5-1-Ty because of a non-occupational injury or non-occupational
disease, from engaging in the employee's regular or customary occupation
and is performing no work of any kind for compensation or profit , or if
a Covered Dependent is prevented, solely because of a non-occupational
injury or non-occupational disease, from engaging in all of the normal
activities of a person of like age and sex in good helth.
C. PROVIDER DEFINITIONS
1. Alcoholism Treatment Center - Any public or private place or other
facility which is licensed by the State to provide alcoholism treatment
services as a detoxification facility and/or inpatient rehabilitation
facility.
2. Hospital means only an institution constituted and operated pursuant to
law, engaged in providing on an inpatient basis at the patient 's
expense, diagnostic and therapeutic facilities for the surgical and
medical diagnosis, treatment and care of injured and sick individuals,
by or under the supervision of a licensed Physician ; and providing
24-hour-a-day services by registered nurses. The term "Hospital " shall
not include an institutional part thereof which is other than inciden-
tally a place for rest, a place for the aged, or a place for con-
valescant care. However, an institution specializing in the care and
treatment of mentally ill patients which would qualify under this defi -
nition as a hospital , except solely for the fact that it lacks organized
facilities on its premises for major surgery, shall nevertheless be
deemed a hospital under the Plan.
In-Hospital Convalescent Care Limitations:
a. Convalescent Care benefits are limited to the normal Convalescent
Care received by the Covered Person while the Covered Person is an
in-patient in the hospital for treatment of a specific acute medi -
cal , surgical , or psychiatric condition ; however,
b. Convalescent Care is not a benefit when the Covered Person ' s
admission to the hospital is for Convalescent Care, or when such
inpatient care ceases to be medically necessary.
c. If a Covered Person remains in the hospital after the date that the
Covered Person 's physician or other health care provider determines
that in-patient hospital care is no longer necessary, then the
Covered Person shall be liable for payment of any physician 's or
other health care provider' s charges after that date.
3. Intensive Care Unit is a section , ward, or wing within a hospital which
is operated exclusively for critically ill patients and provides special
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supplies , equipment and constant observation and care by registered grad-
uate nurses or other highly trained personnel , excluding, however, any
hospital facility maintained for the purpose of providing normal post-
operative recovery treatment or service.
4. Nurse shall mean a Registered Graduate Nurse (R.N. ) , a Licensed
Vocational Nurse (L.V. N. ) , or a Licensed Practical Nurse (L.P.N. ).
5. Outpatient is a Covered Person treated at a hospital and confined
less than 15 consecutive hours or treated outside a hospital setting.
6. Physician is a person acting within the scope of his/her license and
holding the degree of Doctor of Medicine (M.D. ) , Doctor of Ostheopathy
(D.O. ) , Doctor of Dental Surgery (D.D.S. ) , Doctor of Medical Dentistry
(D.M. D. ) Doctor of Podiatry (D.P.M. ) , a Board Certified Psychologist
(PhD) , a Doctor of Chiropractic (D.C. ) , Physicians Assistant or Nurse
Practitioner, who is legally entitled to practice medicine in all its
branches under the laws of the State or jurisdiction where the services
are rendered.
7. Semi -Private is a hospital room containing two (2) or more beds , but,
benefits provided therefor do not include any charge made by the hospi -
tal for Intensive Care.
8. Usual , Reasonable and Customary:
a. The usual charge is the most consistent charge by a physician or
provider of service to patients for a given service.
b. The charge is customary when it is within the range of usual charges
for a given service billed by most physicians or providers of ser-
vice with similar training and experience.
c. A charge is reasonable when it meets the usual and customary cri -
teria as determined by the Contract Administrator; or it may be
reasonable if, upon review, it merits special consideration based on
the nature and extent of treatment of the particular case.
9. Medically Necessary: Any service or supply for diagnosis or treatment
that is:
a. consistent with the illness, injury or condition of the Covered
Person ; and
b. ordered by an attending Physician ; and
c. in accordance with approved and generally accepted medical or surgi-
cal practice prevailing in the geographical locality where and at
the time when the service or supply is ordered. Determination of
"generally accepted practice" is the perogative of the Contract
Administrator through consultation with appropriate authoritative
medical or surgical persons.
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10. Diagnostic Charges means the actual cost charged for X-Ray or
Laboratory examinations of the Covered Person which are made or recom-
mended by a Physician for diagnostic purposes.
11. Covered Expense includes only those usual , reasonable, and customary
charges made for medical services and supplies which most physicians
would consider to be necessary for treatment of an injury or illness.
D. PARTICIPATION DEFINITIONS
1. Active Service - An employee will be considered in Active Service with
thehe employer on a day which is one of the employer's scheduled work days
if the employee is performing in the customary manner all of the regular
employment duties with the employer on a full -time basis on that day,
either at one of the employer's business establishments or at some loca-
tion to which the employer's business requires travel . An employee will
be considered in Active Service on a day which is not one of the
employer's scheduled work days only if the employee was performing in
the customary manner all of the regular employment duties on the pre-
ceding scheduled work day.
A Dependent will be considered in Active Service on any day if the
dependent is then engaging in all the normal activities of a person in
good health of the same age and sex, and is not confined in a medical
facility. (This does not apply to a newborn).
2. Contribution shall mean the amount payable by the employer or the amount
payable by the employer/employee jointly for participation in the bene-
fits of the Plan.
3. Covered Dependents shall be those who are eligible as provided herein
and enrolled by a Covered Employee. Covered Dependents shall be the
spouse of the Covered Employee ; and children from birth to age 19, to
age 23, if a registered student at an accredited college, vocational
school , or university on a full -time basis, provided such children are
unmarried , and dependent upon the Covered Employee for support and main-
tenance. The term "children" shall include natural children , adopted
children , foster children , and step children who depend upon the
employee for support and maintenance.
No employee will be considered both as a dependent and as an employee.
If an employee and spouse are both eligible employees , only one may have
dependent coverage for eligible children.
Covered Dependent shall also include a dependent child after age 19,
provided the child is (1) incapable of self-sustaining employment by
reason of mental or physical handicap, (2) chiefly dependent upon the
Covered Employee and/or the Covered Employee ' s Spouse for support and
maintenance, and (3) has been continuously covered by the Plan prior to
his/her 19th birthday.
Proof of such incapacity and dependency must be furnished to the
Administrator by the Covered Employee within the thirty one (31) days
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prior to the child 's 19th birthday and at reasonable intervals
thereafter.
Dependents DO NOT include children of a dependent son or daughter.
4. Covered Employee is a permanent full -time employee of the Employer who
is eligible hereunder and who has been enrolled in the Plan. To be con-
sidered a full -time employee, one must work an average of 32 hours per
week. In addition, such an employee will not be covered unless on the
"date of eligibility" the employee is actually working a full day on
that date; otherwise , his/her effective date will be deferred until
return to actual service for a full day's work.
5. Covered Person is a Covered Employee or a Covered Dependent.
6. Eligibility and Effective Dates - Employees who are eligible for health
coverage are those full -time employees of Weld County. Full-time
employees are those employed in a permanent position scheduled to work,
32 or more hours per week. Coverage shall become effective on the first
day of the month following the first full month' s pay period.
All employees shall become covered as they become eligible subject to
the following :
a. All enrollments are subject to making proper application for
coverage under the Plan.
b. Dependents shall be covered simultaneously with employees covering
them as dependents, provided they are not confined in a hospital on
the effective date. Coverage for newborn children will begin from
birth. However, they need to be formally enrolled and appropriate
coverage arranged within thirty-one (31) days from birth for
coverage to be effective thereafter.
c. For dependents (as stated in a and b above) who are not enrolled
within this thirty-one (31) day period, and for whom coverage is
subsequently desired, a health questionnaire showing evidence of
insurability will be required. Coverage will begin on the date of
approval of the Contract Administrator.
d. An open-enrollment period will be scheduled in November of each
year.
7. Pre-existing Conditions
New Employees or Covered Persons becoming eligible after January 1, 1983
will not be entitled to covered medical expenses that are incurred as
the result of an injury or sickness for which the Covered Person has
consulted with a Physician or received any medical care or services
within the three month period immediately preceding the effective date
of coverage, unless incurred after the expiration of a period of:
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a. Three (3) consecutive months ending after the date the benefits are
effective for the Covered Person during which no medical care or
treatment of such injury or illness has been received, or
b. After a period of six (6) consecutive months during which the
Covered Person was continuously at work and a member of the plan.
(This does not pertain to Covered Dependents) ,or
c. After a period of twelve (12) consecutive months during which the
Covered Person has been continuously a member of the Plan.
8. Individual Termination of Coverage:
Coverage for Covered Employees and/or Covered Dependents will terminate
on the earliest of the following dates :
a. The date of termination of the Plan.
b. The date the Covered Person becomes a full -time member of the
Armed Forces of any country.
c. The date the Covered Person ceases to meet eligibility requirements.
d. The end of the month when contributions cease.
9. Late Entrants - Employees or dependents not enrolled within thirty-one
(31) days following their eligibility date , or , in the case of newly
acquired dependents, within thirty-one (31) days of such acquisition,
must provide evidence of good health satisfactory to the Contract
Administrator. Coverage will begin on the date of approval by the
Contract Administrator.
An open enrollment will be conducted each year during the month of
November. Enrollment during this month will not require evidence of
good health.
10. Personal Leave of Absence - Properly enrolled employees of the Employer
may continue, at their expense, health coverage for themselves and/or
their dependents while on an approved Personal Leave of Absence for the
period indicated by the Employer's personnel policy.
11. Medical Leave of Absence - When a Physician requires that a Covered
Person nturn to work, benefits will be continued for a period not
to exceed the length of time accrued under said employee's sick leave
plan, or grants of sick days from the Weld County Sick Leave Bank, plus
31 days , provided the Covered Person makes the required contribution to
the plan which he/she would otherwise be required to contribute. In
order to be covered while on a Medical Leave of Absence, the employee
must be :
a. continuously and totally disabled, and
b. under the care of a licensed Physician, and
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c. provide proof of disability satisfactory to the Employer at reaso-
nable intervals upon request.
12. Dependents of Deceased Employees - Limited coverage for Covered
Dependents T a deceased employee can be continued provided application
for conversion is made in writing to the Plan within thirty-one (31)
days of the date of termination of benefits under this Plan.
E. CONTRIBUTIONS
The employer and employee share in the cost of the benefits under this plan.
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SUPPLEMENTAL ACCIDENT BENEFIT
A. BENEFIT PROVISION
If a Covered Person shall , as a result of accidental bodily injuries
sustained while covered under this Plan, incur expense which is usual ,
reasonable and customary for:
(1) medical treatment or services performed by a legally qualified Phy-
sician ; or
(2) room and board and any other necessary medical services and care pro-
vided by a legally constituted hospital ; or
(3) nursing care provided by a registered graduate nurse ; or
(4) ambulance charges ;
the Plan will pay for such related medical expense incurred during the
ninety day period immediately following the date of the accident , but not to
exceed, in the aggregate , for any one accident, the maximum payment spe-
cified in the "Summary of Benefits. "
B. LIMITATIONS
1. No payment shall be made under this benefit for expenses incurred for or
on account of pregnancy; or
2. for expenses incurred for eye refractions , eye glasses, hearing aids,
prosthetic devices or fitting of same; or
3. for expenses beyond the limitations described under "General
Limitations" ;
4. nor shall payments under the Supplemental Accident Benefit serve to
satisfy the major medical deductible.
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MAJOR MEDICAL BENEFIT
A. BENEFIT PROVISION
Upon receipt of due proof, satisfactory to the Contract Administrator, that
a Covered Person has incurred an expense for treatment of an illness or
injury, the Plan will pay those amounts indicated in the "Summary of
Benefits" of Medically Necessary Usual , Reasonable, and Customary charges.
The benefits payable shall not exceed the "Maximum Lifetime Benefit" and are
subject to the "Deductible" specified herein and are subject to all limita-
tions and conditions of the Plan.
B. DEDUCTIBLE
1. The "Deductible" equals the sum of the cash deductible specified in the
"Summary of Benefits" and any other provision of this Plan. The deduc-
tible amount applies during each Calendar Year.
2. Carry-over Provision: In order that a Deductible will not be applied
late in one Calendar Year and soon again in the following year, any
Covered Expenses incurred during the last three months of a Calendar
Year which apply toward the Deductible (whether or not it is fully
satisfied) for that year, may also be applied toward the Deductible for
the subsequent Calendar Year.
3. Family Deductible: When the covered members of a family have satisfied
the maximum Deductible per family in a Calendar Year , no further cash
Deductible need be satisfied in that Calendar Year. This applies only
to expenses incurred during the Calendar Year; expenses which are
carried over from a prior year under the carry-over provision of this
section will not be recognized.
4. Common Accident : If two or more Covered Persons in the same family are
injured in a common accident , the Deductible amount applicable in the
Calendar Year of the common accident shall be limited to a single cash
Deductible amount for that Calendar Year.
C. MAXIMUM LIFETIME BENEFIT
The Maximum Lifetime Benefit as shown in the "Summary of Benefits", is the
maximum lifetime amount of benefits available for any Covered Person ,
whether or not there has been an interruption in the continuity of coverage.
D. COVERED MEDICAL EXPENSES
Covered Medical Expenses shall include, subject to the "General
Limitations ," only Medically Necessary Usual , Reasonable and Customary
charges for services and supplies which are incurred by a Covered Person due
to:
1. hospital charges by a "hospital " as defined herein for room and board
and other hospital services required for purposes of treatment , but not
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to exceed the average semi-private room rate or intensive care unit room
rate ;
2. charges for anesthetics and their administration ;
3. charges made by a "Physician" or recommended by and directly supervised
by a "Physician" for Medically Necessary services ;
4. charges made for the necessary professional services of a physiothera-
pist ;
5. charges for speech therapy by a qualified speech therapist to restore
speech loss, or correct an impairment, due to (a) a congenital defect
for which corrective surgery has been performed, or (b) an injury or
sickness except for a mental , psychoneurotic or personality disorders ;
6. charges for the following medical services or supplies that are recom-
mended by the Physician:
a. drugs and medicines requiring a Physician 's prescription ;
b. oxygen and/or rental of equipment required for its administration ,
but not to exceed the purchase price of such equipment ;
c. radiotherapy;
d. diagnostic X-ray and laboratory services ;
e. charges for braces, casts, splints, initial artificial limbs or
other original prosthetic appliances to replace lost physical organs
or parts or to aid in their functions when impaired if the loss or
impaired function occurred while covered under this Plan. Covered
charges are for original placement.
f. blood and blood plasma ;
g. ambulance to a local hospital where adequate medical treatment
can be administered;
h. insulin and insulin syringes;
i . head halter or other traction apparatus ;
j. rental of a wheel chair, special hospital bed, iron lung, crutches ,
and other reasonable, Medically Necessary mechanical and therapeutic
equipment but not to exceed their purchase price ;
k. emergency room services;
7. charges for pre and post natal visits ;
8. charges for vasectomies and tubal ligations ;
-14-
9. Charges made by a legally qualified Physician for performing oral
surgery consisting of cutting procedures for removal of tumors , cysts ,
and charges incurred to restore sound natural teeth within six months
after the date of an accident, unless medically indicated that treatment
be delayed, provided that the injury or condition and treatment thereof
occurs while this coverage is in effect. Such charges includes dental
X-rays and general anesthesia , Medically Necessary and prescribed by a
legally qualified Physician ;
10. Chiropractic services rendered by a D.C. will only be covered for the
detection and correction by manual or mechanical means, including X-rays
incidental thereto, the structural imbalance, distortion or subluxation
in the human body for the removal of nerve interference, where such
interference is the result of or related to distortion, misalignment , or
subluxation of or in the vertebral column. Chiropractic care which
exceeds the following guidelines may not be considered as a covered
expense if it is determined to be maintenance, palative, or excessive
care:
a. three visits per week for the first four weeks ;
b. two visits per week for the next eight weeks ;
c. one visit per week for the next four weeks ;
Consideration of treatment programs exceeding these guidelines must be
accompanied by the attending Chiropractor's statement outlining their
Medical Necessity;
The benefits payable under this provision will not exceed the following
maximums :
a. $30.00 maximum consideration per visit;
b. $500.00 maximum payment per Calendar Year per Covered Person ;
c. $5,000.00 maximum payment per lifetime per Covered Person.
11. charges for services of a registered graduate nurse or licensed prac-
tical nurse or nurse practitioner, if authorized by a Physician;
12. charges for allergy testing or injections.
-15-
HOSPITAL CARE BENEFIT
Upon receipt of due proof of eligibility that a Covered Person has incurred
necessary expenses which are recommended and approved by a "Physician" as herein
defined , for hospital care for diagnosis or treatment of an illness or injury,
the Plan will pay Usual , Reasonable and Customary charges not exceeding the
maximum amount specified in the Summary of Benefits for such charges.
A. DEDUCTIBLE
The "Deductible" equals the sum of the Cash Deductible specified in the
"Summary of Benefits" and any other provision of this Plan. The Deductible
amount applies during each Calendar Year.
B. ROOM, BOARD, AND GENERAL NURSING CARE
The Plan will pay the amount charged by the hospital for a Covered Person
who is confined for room, board, and general nursing care , not to exceed the
Semi-Private, Intensive Care Unit , or Coronary Care Unit room rate.
C. OTHER HOSPITAL CHARGES
The Plan will pay the Usual , Reasonable and Customary amounts charged by the
hospital for Medically Necessary services , medicines , and supplies for
diagnosis or treatment of illness or injury during any one period of con-
finement provided:
1. the Covered Person is hospital -confined as an inpatient ; or
2. the Covered Person has surgery performed in the hospital .
D. SUCCESSIVE PERIODS OF HOSPITAL CONFINEMENT
Successive periods of hospital confinement shall be considered as one con-
finement unless :
1. The later confinement commences after complete recovery from the
sickness or injury which caused an earlier confinement ;
2. The later confinement results from causes entirely unrelated to the
causes of an earlier confinement;
3. The confinements are separated by the employee's return to work for two
weeks , or in the case of a dependent , a separation from the previous
confinement of three (3) months duration.
-16-
ANESTHESIOLOGY BENEFIT
A. BENEFIT PROVISION
Benefits are payable when a Covered Person incurs charges for anesthetic
services rendered by a licensed anesthesiologist in connection with a surgi-
cal operation. Under this benefit , the 1974 American Society of
Anesthesiologists Relative Value Guide will be used based on unit value plus
time, but not to exceed the Usual , Customary and Reasonable charge.
B. ANESTHESIOLOGY BENEFIT LIMITATIONS
No amount will be payable under this Section for charges:
1. which are excluded under the General Limitations provisions ;
2. which result from any sickness or bodily injury arising out of or in the
course of an individual 's employment ;
3. cosmetic surgery.
-17-
SURGICAL BENEFIT
A. BENEFIT PROVISION
If a Covered Person incurs necessary expense as a result of an injury or
illness which causes the person to undergo any non-cosmetic surgical proce-
dure, the Plan shall pay the Medically Necessary Usual , Reasonable and
Customary expense incurred for:
1. the services of the principal surgeon ; and/or
2. plastic and reconstructive surgery if the surgery is necessary to
correct deformities causing functional physiological difficulties
arising from illness or injury.
B. MULTIPLE AND/OR BILATERAL PROCEDURES
If two or more surgical procedures are performed at one time through the
same incision or in the same operative field, the maximum amount payable for
surgery will be the procedure for which the highest surgical benefit is pro-
vided.
In the event that two or more separate operations are performed during one
period in the operating room, the amount payable shall be the Surgical
Benefit payable for the operation performed for which the highest Surgical
Benefit is provided; plus not over 50% of the Surgical benefits specified
for the other operation(s).
C. LIMITATIONS
1. No payment shall be made under this benefit for expenses incurred for or
on account of weight control or obesity, other than "Morbid Obesity" ; or
2. for treatment or services described under "General Limitations".
-18-
GENERAL LIMITATIONS
No benefits shall be payable under any part of this Plan with respect to:
1. any charges not Medically Necessary for diagnosis or treatment of an
illness, injury, or pregnancy; or
2. any charges for cosmetic surgery unless due to an accident or injury
occuring while covered; or
3. any charges for rhinoplasty, blepharoplasty or brow lift except charges for
rhinoplasties and blepharoplasties to correct a functional condition or
charges for rhinoplasty to correct a condition as a result of an acci -
dental injury; or
4. vaccinations, innoculations , or any charges for any examination for check-
up purposes not incidental to or necessary to diagnose an injury or
illness (except as otherwise provided for in this Plan) ; or
5. any injury or illness for which the Covered Person on whose behalf claim is
presented is not under the regular care of a Physician ; or
6. any charges for any condition , disability or expense resulting from or
sustained as a result of being engaged in an illegal occupation , commission
of or attempted commission of an assault or a felonious act ; or
7. any charges for any condition , disability or expense resulting from or
sustained as a result of war or act of war , declared or undeclared ; or
8. any charges for any condition or disability which would entitle the Covered
Person to any benefit under a Worker's Compensation Act or similar legisla-
tion or which is due to injury or sickness arising out of or in the course
of any occupation or employment for wage or profit ; or
9. hearing aids , batteries or repairs ; or
10. any charges for professional services performed by a person who ordinarily
resides in the Covered Person 's household or who is related to the Covered
Person as a spouse , parent, child , brother, sister, whether such rela-
tionship is by blood or exists in law; or
11. charges for instruction or activities for weight reduction, weight control ,
or physical fitness even if the services are performed or prescribed by a
Physician ; or
12. any charges for artificial insemination; or reversal of vasectomies , or
reversal of tubal ligation ; or
13. any charges for eye glasses , correction of vision , fitting of glasses or
eye examinations ; or
14. any charges for air conditioners , purifiers , dehumidifiers , corrective
shoes, heating pads , hot water bottles, and other clothing and equipment
which is not solely for medical purposes ; or
-19-
15. any charges for special education , counseling, or care for learning de-
ficiencies or behavioral problems , whether or not associated with a mani -
fest mental disorder or other disturbance ; or
16. any charges for routine health examinations , multiphasic screening tests,
and physician checkups not associated with any disease, injury or condition
requiring professional service or treatment (except as otherwise provided
for in this Plan) ; or
17. travel expenses of a Physician attending a Covered Person , or travel ex-
penses of a Covered Person , although recommended by a Physician ; or
18. any charges for preparing medical reports or itemized bills ; or
19. non-medical expenses such as training, educational instructions or edu-
cational materials, even if they are performed or prescribed by Physician ;
or
20. services or supplies for which there is no legal obligation to pay, or
charges which would not be made but for the availability of benefits under
this Plan; or
21. any expenses which exceed the usual , customary and reasonable expenses for
the medical care rendered; or
22. vitamins and/or nutritional supplements; or
23. acupuncture administered by other than an M. D. or D.O. ; or
24. any charges related to custodial care , sanitarium care , or rest cares ; or
25. treatment not prescribed or recommended by a Physician ; or
26. hospitalization charges for dental treatment. However, the hospital charges
will be covered if the patient has another medical condition which requires
that dental treatment be provided on an inpatient basis and the Medical
Necessity of hospitalization is certified by a Physician ; or
27. obstetrical care for a dependent other than the spouse of an enrolled
employee or the female employee ; or
28. charges for mailing or sales tax ; or
29. medical expenses for equipment , supplies , procedures or treatments which
are experimental in nature or which have not been approved by the Food and
Drug Administration or the appropriate authorizing agency; or
30. treatment of (a) weak, strained, flat, unstable or unbalanced feet, metetar-
salgia or bunions, except open cutting operations , (b) corns , calluses or
toenails, except the removal of nail roots and necessary services in the
treatment of metabolic or peripheral -vascular disease ; or
-20-
31. expenses in connection with drug abuse , drug addiction, alcoholism, or ner-
vous and mental conditions except where specifically noted herein ; or
32. treatment of periodontal or periapical disease or any condition (other than
a malignant tumor) involving teeth, surrounding tissue or structure.
However, this exclusion does not apply to the benefits for dental treatment
described under the "Supplemental Accident Expenses" Section; or
33. Chiropractic Maintenance , Palative or Excessive Care; or
34. any expenses resulting from intentional self-inflicted injury or attempted
intentional self-destruction while sane or insane.
35. any expenses related to treatment of temporomandibular joint disfunction.
-21-
HOW TO FILE A CLAIM
Claim forms can be obtained from the Personnel Office, or by calling or writing
James Benefits , 3895 Upham Street , #100, Wheat Ridge, Colorado 80034-0987, (303)
423-2400. The Employee Statement on the top of the claim form must be completed
in FULL and signed by the employee. Itemized bills (hospital , doctor anesthe-
sioTTgist , laboratory, prescriptions , etc. ) should he attached to the claim
form, and the Attending Physician Statement on the bottom of the claim form
should be completed by the appropriate Physician unless ALL necessary infor-
mation is included on the Physician 's own form. The completed claim form and
the attached bills should be sent to:
Weld County
c/o James Benefits
P.O. Box 987
Wheat Ridge, Colorado 80034-0987
Identification cards and claim forms are available for Plan participants from
the Personnel Office of Weld County.
_P2-
COORDINATION OF BENEFITS
A. APPLICATION
If any individual covered under this Plan is also covered under other plans ,
the benefits payable under this Plan will be coordinated with benefits
payable under all other plans. Coordination will apply in determining the
benefits payable with respect to an individual for any Claim Determination
Period if, for the Allowable Expenses incurred during that period, the sum
of the following would exceed those Allowable Expenses:
1. the benefits that would be payable under this Plan in the absence of
coordination , and
2. the benefits that would be payable under all other plans in the absence
of provisions for coordination in those plans.
Except as provided in the following paragraph, when Coordination of Benefits
applies to the benefits payable with respect to an individual for Claim
Determination Period, the benefits that would he payable for Allowable
Expenses incurred during that period under this Plan in the absence of
Coordination of Benefits will be reduced to the extent necessary so the sum
of those reduced benefits and all the benefits payable for those Allowable
Expenses under all other plans will not exceed the total of those Allowable
Expenses. Benefits payable under all other plans include the benefits that
would have been payable had claim been properly made for them.
If, in coordinating the benefits of this Plan with those of another plan,
the rules set forth in the following paragraph would require this Plan to
determine its benefits before the other plan and the other plan which con-
tains a provision coordinating its benefits with those of this Plan would,
according to its rules , determine its benefits after the benefits of this
Plan have been determined, then the benefits of that other plan will be
ignored for the purposes of determining the benefits of this Plan.
B. ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination are:
1. The benefits of a plan which covers the individual for whom claim is
made other than as a Dependent will be determined before the benefits of
a plan which covers that individual as a Dependent.
2. The benefits of a plan which covers the individual for whom claim is
made as a Dependent of a male will be determined before the benefits of
a plan which covers that individual as a Dependent of a female.
However, for a dependent child of a divorced couple , the coverage of the
parent who has custody of the child will be determined before the bene-
fits of the other parent are determined (unless stipulated otherwise by
a court decree).
-23-
3. When Rules 1 and 2 do not establish an order of benefit determination ,
the benefits of a plan which has covered the individual for whom claim
is made for the longer period of time will be determined before the
benefits of a plan which has covered the individual the shorter period
of time.
When Coordination of Benefits operates to reduce the total amount of benefits
otherwise payable during any Claim Determination Period with respect to an
individual covered under this Plan, each benefit that would be payable in the
absence of Coordination of Benefits , will be reduced proportionately, and the
reduced amount will be charged against any applicable benefit limit of this
Plan.
C. DEFINITIONS APPLICABLE TO THIS PROVISION
1. Plan
The term "Plan" includes the following plans under which a person is
entitled to receive or received benefits or services for or by reason of
medics-or dental treatment.
a. Group Plans , insured or self-funded; group, blanket , or franchise
insurance coverage; group hospital or medical service plans , and
other group pre-payment coverage ; any coverage under labor manage-
ment trusted plans , union welfare plans , employer organization
plans , or employee benefit organization plans.
b. The "Medicare" program, including Part A and Part B, established by
Title XVIII of the Social Security Act. A person shall be con-
sidered to be entitled to all of the coverage provided by Medicare
on and after the earliest date the person would have become so
entitled if the person had promptly submitted all applications and
proofs required for such coverage. A person who is entitled to the
coverage provided by Medicare will be considered entitled to receive
benefits, whether or not application for such coverage or benefits
has been made. It shall be deemed that any disabled person eli -
gible for Medicare benefits or any individual age 65 or over shall
be entitled to Medicare.
NOTE: Medicare benefits will be considered as secondary payments
for any eligible individual between the ages of 65 through age 69
wishing to be covered by this plan.
c. Any coverage required or provided by any statute , including any no-
fault automobile insurance provided or required by statute and/or
any automobile medical insurance.
2. Allowable Expense
Means any Usual , Reasonable and Customary item of expanse at least a
portion of which is covered under at least one of the plans covering the
individual for whom claim is made. When a plan provides benefits in the
-24-
form of services rather than cash payments, the reasonable cash value of
each service rendered will be considered to be both an Allowable Expense
and a benefit paid.
3. Claim Determination Period
The term "Claim Determination Period" means a period commencing with any
January 1 and ending at twelve o'clock (12:00) midnight on the next suc-
ceeding December 31, or that portion of such period during which the
person on whose expenses claim is based has been covered under this
plan.
D. RELEASE OF INFORMATION
For the purposes of determining the applicability of and implementing the
terms of the above provisions of this Plan or any similar provision of
another plan, the Contract Administrator may, without consent of or notice to
any individual , release to or obtain from any other insurance company or
other organization or individual any information , concerning any individual ,
which the Contract Administrator considers to be necessary for those pur-
poses. Any individual claiming benefits under this Plan will furnish to the
Contract Administrator the information that may be necessary to implement
the above provisions.
E. PAYMENTS
Whenever payments which should have been made under this Plan in accordance
with the above provisions have been made under any other plans , the Contract
Administrator will have the right , exercisable alone and in its sole discre-
tion to pay to any organization making those payments any amounts it deter-
mines to be warranted in order to satisfy the intent of the Coordination of
Benefits Provisions. Amounts paid in this manner will be considered to be
benefits paid under this Plan ; and to the extent of these payments, the
Employer will be fully discharged from liability under this Plan.
F. CLAIMS PAYMENTS MADE IN ERROR
If payments in excess of the correct amount due are made, the Plan may
recover all excess amounts paid. Recovery will be made by reducing or
suspending future plan payments, or by requiring the Covered Person to pay
back the overpayment in full , or in installments, until the overpayment is
recovered.
G. RECOVERY AND SUBROGATION
Whenever payments have been made by the Contract Administrator in excess of
the maximum amount of payment necessary to satisfy the intent of the
Coordination of Benefit provisions , the Contract Administrator will have the
right to recover excess payment from any individuals, insurance companies or
other organizations.
-25-
In the event of payment in part or in full by this Plan of any expense
incurred for hospital , surgical , medical , or dental services , and medical
supplies for the benefit of an Eligible Participant or an Eligible
Participant 's dependent , this Plan shall be subrogated to the extent of the
amount of such payment to all the rights , powers, privileges and remedies ,
of the Eligible Participant or the Eligible Participant ' s dependent against
any person , firm, corporation , organization, plan or other entity regarding
the payment of such expense.
H. LEGAL ACTIONS
No action at law or in equity shall be brought to recover on the policy
prior to the expiration of 60 days after written proof of loss has been fur-
nished in accordance with the requirements of the Plan. No such action
shall be brought after the expiration of three years after the time written
proof of loss is required to be furnished.
I. PROOFS OF LOSS/TIMELY SUBMISSION OF CLAIMS
Written proof of loss must be furnished to James Benefits , in case of claim
for loss for which the policy provides any payment , within 90 days after the
date of such loss. Failure to furnish such proof within the time required
shall not invalidate nor reduce any claim if it was not reasonably possible
to give proof within such time , provided such proof is furnished as soon as
reasonably possible ; and in no event, except in the absence of legal capa-
city of the claimant , later than one year from the time proof is otherwise
required. Under no circumstances will a claim be honored for payment beyond
90 days following the date coverage terminates.
-26-
COMMON LAW SPOUSE
Coverage is provided for a common-law spouse, as defined by the courts, in
accordance with the laws of the State of Colorado. The requirements which must
be met for a relationship to gain recognition as a Common-Law Marriage are coha-
bitation and general reputation as married. Both factors must be present. Mere
cohabitation is not sufficient. General reputation as to marital relation has
been defined by the courts to mean "the understanding among neighbors and
acquaintances with whom the parties associate in their daily lives that they are
living together as husband and wife , and not in meretricious intercourse".
(Citations omitted) To establish the presumption of marriage by cohabitation
and repute there must be presented clear, consistent , convincing and positive
evidence. The sorts of things the courts in Colorado have relied upon are:
1. What the parties call themselves in introductions , "my wife, Betty
rather than "my girlfriend, Betty Maiden name" :
2. How each fill out forms such as credit or employment applications , i .e.
checking the block marked married or the one marked single, and the name used
by the woman. ;
3. Whether they rent their apartment or home as Mr. and Mrs. Smith;
4. Presence of joint bank accounts in a married name (joint bank account where
woman uses her family name was held to go against the presumption of
marriage relationship).
If such evidence is present and the couple are holding themselves out as husband
and wife , they are entitled to the benefits and privileges of any other married
couple.
FACILITY OF PAYMENT
If, in the opinion of the Contract Administrator, a valid release cannot be ren-
dered for the payment of any benefit payable under this Plan, the Contract
Administrator may, at its option , make such payment to the individual or indivi-
duals as have , in their opinion , assumed the care and principal support of the
Covered Person and are , therefore, equitably entitled thereto. In the event of
the death of the Covered Person prior to such time as all benefit payments due
him/her have been made , the Plan Administrator may, at its sole discretion and
option , honor benefit assignments, if any, made prior to the death of such
Covered Person.
Any payment made by the Plan in accordance with the above provision shall fully
discharge the Plan to the extent of such payment.
-27-
PROCESS IN CASE OF DISPUTED CLAIM
If a Covered Employee has reason to believe a claim has not been settled pro-
perly, or a claim has been improperly denied, the following process applies :
1. Contact the Contract Administrator in writing to ask for a second review.
The claim will be reviewed by the Contract Administrator and the Plan
Administrator's consultant servicing the account. If the result of this
review is not satisfactory, then:
2. Request a review in writing from the Director of Personnel of Weld County
stating in clear and concise terms the reason for disagreement with the
handling of the claim. This request must be made within sixty (60) days
after receipt of a declination letter from the Contract Administrator
(James Benefits). Upon receipt of the request, the file will be reviewed
and the results of the review will be furnished to the Covered Employee,
along with copies of pertinent Plan Documents upon which this declination
is based. If the Covered Employee still finds the claim is improperly
denied per the Plan Documents , he/she has a legal right to take what
appropriate action he/she believes is necessary.
-28-
CONVERSION PRIVILEGE
Any Covered Person , within thirty-one days after the date health benefits ter-
minate because of termination of employment or because of membership in a class
or classes eligible for such coverage, shall be entitled to have issued to
him/her, without evidence of insurability, an individual policy of health
insurance provided written application therefor and payment of the first premium
thereon is made to the insurance company within said thirty-one days. Any such
individual policy issued shall cover:
a. the Person , if the health benefits under this Plan covered the Person
only; or
b. the Person and his/her Dependents, if the health benefits under this
Plan covered both the Person and the Person 's dependents ;
and shall become effective on the day immediately following the date of ter-
mination of coverage under this Plan. The form of this individual policy,
the coverage thereunder and all other terms and conditions thereof shall be such
as is then provided by the insuring company with respect to insurance issued
pursuant to an application made in accordance with these provisions.
* If a Covered Person 's health coverage under this Plan with respect to a
Dependent spouse is terminated because of the death of the Person , such spouse
shall be entitled to have issued to him/her an individual policy of health
insurance in the same manner and subject to the same conditions as provided for
the Covered Person.
If a Covered Person ' s health coverage under this Plan with respect to a
Dependent child is terminated because of the child 's marriage or attainment of
the maximum age specified in this Plan for Dependent children , such child shall
be entitled to an individual policy of health insurance in the same manner and
subject to the same conditions as provided for the Covered Person.
THE PROVISIONS OF THIS SECTION SHALL NOT BE APPLICABLE TO ANY INDIVIDUAL ON AND
AFTER THE DATE THE COVERED PERSON BECOMES AN ELIGIBLE INDIVIDUAL UNDER TITLE
XVIII OF THE SOCIAL SECURITY ACT AS AMENDED (MEDICARE) , OR WOULD HAVE BECOME AN
ELIGIBLE INDIVIDUAL UNDER SUCH LAW HAD TIMELY APPLICATION BEEN MADE.
* The Conversion Privilege described herein shall also be applicable to a
spouse who ceases to be a Dependent due to legal separation or legal dissolu-
tion of marriage.
-29-
The effective date of this Plan Document is January 1, 1983.
IT IS AGREED BY WELD COUNTY that the provisions contained in this Plan
Document are acceptable and will be the basis for the administration of said
Employer's Employee Benefit Program described herein.
SIGNED AT Greeley, Colorado This 15th day of
December , 1982.
WITNESS:
o l a^,g.Az ?u-ice/ BY
chairman, Board of County Commissioners
1
✓� Title
By
Title
-30-
.' ' -v ..� • . F[:.. C.. . 1,t l.,
FRED. S. JAMES & CO. •
P.O. Box 987, 3895 Upham Street, 4100, Wheat Ridge, (Denver), Colorado 80033(303)423-2400
December 10, 1982
Mr. Richard Barrett
Personnel Director
Weld County - Colorado
915 10th Street
Greeley, Colorado 80631
Re: Group Life & Health Plans
Dear Dick:
Attached are the applications/agreements requiring signature for the
new Life/AD&D/Supplemental Life, Individual Excess Risk, Aggregate
Excess Risk and Administration/Consulting Contracts to be effective
January 1 , 1983.
The following items are attached:
Premium Deposit
1 . Hartford Life Insurance Application ( .36/.03/.33) $3,816.00
2. Hartford Individual Stop-loss Application ($50,000
deductible - 12 mo. accum/12 mo. benefit) (2.32/ee/mo) $1 ,654.16
3. Georgetown (Fiduciary General ) Aggregate
(Stop-loss Application (2.26/ee/mo. ) $1 ,611 .38
4. James Benefits Administration/Consulting Contract $2,000.00 - Set up Fee
Please have the appropriate person sign all forms, make a copy for your
records, and return all originals to my attention. You will note there
are two originals of the Consulting/Administration Contract, you should
have both signed, and return one for your records.
Also, please include drafts for the deposit amounts and parties indicated,
or notify us if you prefer us to withdraw the money from your fund
bank account. The estimated deposits assume 713 employees, $6,400,00
Basic Life/AD&D, and $4,000,000 of Supplemental Life. Proper credits will
be made on the February statements for actual amounts based on final
enrollment.
Mr. Richard Barrett
December 10, 1982
Page 2
Dick, we appreciate your assistance and look forward to serving you and
your employees. Should you have any questions, please contact me.
Sinc ,
Richard W. Johnson
Consultant
RWJ:tmd
cc: Masoud Shirazi
Leonard Amendola
Enclosures
Group Icr>urance- Application
. • THE HARTFORD
Application d to the Hartford Life and Accident Insurance Company on the basis of the information contained in this application,
attaccis hereby mae
and available experience data. The application in its entirety, and any required additional information,
hedd risk specifications, the enrollment data, P
is subject to Home Office approval before insurance can become effective.
II
If any coverage requires employee contributions, at least 75% of the eligible employees must enroll before coverage can become effective. Rates are
subject to change based on final enrollment data and any proposal qualifications.
January 1 , 1983
Subject to enrollment, the following effective date is desired: (Month, Day, Year)
Group None ,
Period: NeOriginal
li ibilit Waiting eperiod
Eligibility following one full month' s pay
New Employees First of month
Indicate name(s) and addresses) of Subsidiary or Affiliated Companies to be insured on the Special Provisions page, along with the Effective Date(s)
of Coverage, and respective number of employees.
Is any other Life Insurance to be written concurrently with this plan? No ❑ Yes — provide details in Special Provisions.
Weld County - Colorado
• ame of Entity --1
By % // li+:T/r Date (Month, Day, Year)
Signature eture
Printed Name and Title of Authorized Signer
To be completed by Sales Representative:
Attachments — Required: ❑ Gen'I Data A
❑ Gen'l Data B
Deposit Premium incl. ISL) Enrollment Cards
(1 month est. premium required)
Group Risk Specifications Forms::-
1
® Life, ADM), 4' $Na�il�ty ❑ Major Medical Expense El Special Provisions
El Long Term Disability El Dental Expense Benefit (85% participation required for dental
❑ Basic Health Coverages
El Survivors Income only plans)
Kristine L. Thompson 333-48-0980
Sales Representative
Social Security No.
Denver Denver
Area Office Regional Office
Policy/Employer Number Underwriting Approval
Signature
RECEIPT
Weld County - Colorado
Received of
Name of Applicant
$ 3,816.00 to be applied as a credit toward the payment of the first premium on the proposed Group Insurance Policy, or
Policies, for which application is made. In-case application is not accepted by The Hartford, the payment evidenced by this receipt shall be returned
upon surrender thereof. \
Date (Month. Day. Year) Agent or Representative of the Hartford Life and Accident Insurance Company
HARTFORD Life Application Attachment
I. Basic Benefits
Basic Life less than 5 years service $7,000
more than 5 years service $12,000
Basic AD&D less than 5 years service $7,000
more than 5 years service $12,000
Amounts reduce by 35% at age 65, and an additional 35% at age 70,
rounded to next higher $500. All benefits terminate at retirement.
Quoted Rate: Life - .33
AD&D - .06
II . Supplemental Benefits
$10,000; or $20,000; or $30,000; or $40,000; or $50,000
Amount stated cannot exceed 2 x gross annual salary.
Quoted Rate: Life - .33
AD&D - Not available
Same reduction schedule as Basic Plan.
Request for _ A THE HARTFORD
Stop Loss Insurance ..� .
Request is hereby made to the HARTFORD ACCIDENT AND INDEMNITY COMPANY on the basis of the information contained in this Request,
attached risk specifications, the enrollment data, and available experience data. The Request for Stop Loss Insurance in its entirety and any required
additional information are subject to Home Office approval before insurance can become effective.
Indicate name(s) and address(es) of the Subsidiary or Affiliated Companies to be insured on the Special Provisions page along with the Effective
Date(s) of Coverage, and respective number of employees.
Weld County - Colorado
Legal Name of Entity (Requestor)
Desired Effective Date January 1, 1983
Month, Day, Year
I understand that Stop Loss Insurance will become effective on the desired effective date indicated above provided the written Agreement effecting
such Stop Loss Insurance is signed by Hartford Accident and Indemnity and the Requestor within 90 days after the Desired Effective Date. If the
written Agreement is not signed by both parties within such 90 day period, the only obligation of the Hartford Accident and Indemnity Company will be
to return funds tendered in connection with this Rysti.7st for Stop Loss Insurance.
By °S"ignature Date (Month, Day, Year)
)L JOHN T Mi72 77A/
Printed Name and Title of Authorized Signer
To be completed by Sales Representative:
Attachments— Required a Plan Document $50,000 Individual Stop-Loss -
12 mo. accumulation/12 mo. benefit
a Deposit Premium period - rate $1 .51/ee/mo.
(1 month est. premium required)
Group Risk Specifications Forms: )5� Special Provisions
Sales Representative Kris tine L. Thompson Social Security No. 333-48-0980
Area Office Denver Regional Office Denver
Contract Number Underwriting Approval
Signature
Weld County - Colorado
Received of
Name of Requestor
$ 1 ,076.63 to be applied as a credit toward the payment of the first premium on the proposed Stop Loss Insurance Contract for which
request is made. In case the Request for Stop Loss Insurance is not accepted by The Hartford, the payment evidenced by this receipt shall be
returned upon surrender thereof.
p/I-D ),:pcie)
Date (Month, Day, Year) Agent o Representative of a Harffo and Indeompany
Form GR-110060 Printed in U.S.A.
ADMINISTRATION AND CONSULTING CONTRACT •
THIS ADMINISTRATION LAND CONSULTING (,ONTRACT, made and executed the 13th
day of D b , 19_ u _, by and between Weld County
Col nradn hereinafter referred to as"Plan Sponsor", and
JAMES BENEFITS, a division of Fred. S. James & Co., hereinafter referred to as the "Contract Ad-
ministrator and Consultant."
RECITALS
The Contract Administrator and Consultant is engaged in the business of performing services as
Employee Benefit Consultants and Administrators.
The Plan Sponsor hereby engages the services of the Contract Administrator and Consultant to pro-
vide administration services for Weld County Employee Benefit Fund
hereinafter referred to as"Plan."
For and in consideration of the mutual covenants and the monetary consideration herein recited, it
is mutually agreed as follows:
1. Services to be Performed The Contract Administrator and Consultant shall perform for the Plan
Sponsor administrative and consulting services in conjunction with the administration and operation
of the Plan.The administrative services to be performed by the Contract Administrator and Consultant
are set forth in Exhibit "A", attached hereto and by reference made a part hereof for all purposes. The
consulting services to be performed by the Contract Administrator and Consultant are set forth in Ex-
hibit "B", attached hereto and by reference made a part hereof for all purposes.
(a) As a part of the services to be performed by the Contract Administrator and Consultant, the Con-
tract Administrator and Consultant shall maintain and operate an administrative office for such pur-
poses and to pay all normal costs and expenses for such maintenance and operation (except as
herein set forth).
(b) The Contract Administrator and Consultant shall employ a sufficient staff of employees or others
to provide the administrative and consulting services to be performed by the Contract Administrator
and Consultant hereunder. However, the Contract administrator and Consultant will not provide or
be responsible for the expense and cost of legal counsel, actuaries, consulting physicians or den-
tists, certified public accountants, investment counselors, investment analysts or similar type ser-
vices performed for the Plan Sponsor; the Contract Administrator and Consultant shall not be
authorized to engage such services or incur any expense or cost therefore without the written con-
sent of the Plan Sponsor. In the event that such services are engaged by the Contract Administrator
at the request of the Plan Sponsor, the Plan Sponsor shall be responsible for such services and the
cost and expense thereof.
(c) The services to be performed by the Contract Adminstrator and Consultant shall be ministerial in
nature and shall be performed within the framework of policies, interpretations, rules, practices and
procedures made or established by the Plan Sponsor. The Contract Administrator and Consultant
shall not have discretionary authority or discretionary controls respecting management of any trust
fund and shall not have authority to nor exercise any control respecting management or disposition
of the assets of any trust fund and shall not render investment advice with respect to any money or
other property of any trust fund.
2. Service Fee The Plan Sponsor agrees to pay to the Contract Administrator and Consultant for the
services to be performed hereunder the following fees:
(a) An initial one-time fee of$ 2,000 payable on or before December 15, 1982
(b) Monthly fee of $4.25 per covered employee per month
The Contract Administrator and Consultant shall provide a statement of the above fees and deduct
the amount from the Plan account on or before the 10th of each month; based on enrollment the first of
the month. In the event that sufficient funds are not available in the account, or if the Plan Sponsor
does not submit to the Contract Administrator and Consultant the information to deduct the fees, in-
terest will be charged on the fees due the Contract Administrator and Consultant at the rate of one and
one-half percent (11/2 per month or the maximum rate allowed by law, whichever is less.
3. Term The term of this Administration and Consulting Contract would be for the period of one
year, beginning January 1 , 1983 and ending December 31 , 1983 . At the end of the contract
year, if neither party requests a change the contract shall be automatically renewed. The fees stated in
paragraph two(2)are subject to negotiation on the anniversary date of the contract,or on any monthly due
date afterthe initial oneyear period providing theContract Administrator and Consultant has given timely/
JaMES BEnEfits JB Admin & Cons.SF-120-1 4/82
FRED. S. JAMES & CO.
Consultants.Administrators&Act oar les
•
/ notice of intent to adjust the fees.The new fees,and contract would tnen be in force for one year from th\
effective date
Either party shall have the right to terminate or re-negotiate the contract after the initial one year
period by giving to the other party written notice of such termination or re-negotiation of the terms of the
contract at least thirty (30) days in advance. In the event timely notice of intent to re-negotiate the terms
of the contract is given by either party the contract shall continue until such re-negotiated terms are
agreed to in writing. In the event that such re-negotiated terms are not agreed to in writing by both par-
ties within thirty (30) days following the expiration date of the then current contract year, this contract
shall terminate upon thirty(30) days notice. The Contract Administrator and Consultant will have no fur-
ther responsibility or obligation hereunder upon termination of this contract.
In the event of termination of this contract, if claims are to be processed after the termination date,the
fees for services shall be either the specified percentage of claims or dollars per claim, or based on the
average of fees during the last two months of the contract, as follows:
100% of the average fees during the first month after termination, 75% the second
month,50% the third month, and 25% thereafter until no further claims are process-
ed, or services required.
4. Records and Files The Contract Administrator and Consultant shall maintain all records in conjunc-
tion with the administrative services to be performed hereunder.The confidentiality of such records shall
be maintained by the Contract Administrator and Consultant and the information therein shall not be
divulged or disclosed or made available to persons other than the Plan Sponsor without the prior written
approval of the Plan Sponsor or a court of competent jurisdiction. In the event of the termination of this
contract, the Contract Administrator and Consultant shall deliver to the Plan Sponsor, upon written re-
quest,at a time period mutually agreeable, but not to exceed six months from date of termination, the in-
formation on all claim histories for the past two years. If the claim history is requested, the Plan Sponsor
will pay all costs incurred by the Contract Administrator and Consultant in providing the history, including
the cost of programming, computer charges, mailing cost, etc. This information will be provided on a
magnetic tape with industry standard labels,and will be in the standard format of the James Benefits data
base. If additional information is requested by the Plan Sponsor subsequent to the termination of this
Contract, the Plan Sponsor will pay all costs incurred by the Contract Administrator and Consultant in
providing such information, including the cost of programming, computer charges, mailing costs, etc.
The Contract Administrator and Consultant shall be entitled to retain copies of any such records at his
own expense.
5. Liabilities and Obligations The Contract Administrator and Consultant shall have no responsibility,
risk, liability or obligation for the funding of the Plan. The responsibility and obligation for funding the
Plan shall be solely and totally the responsibility of the persons or entities so provided in the Plan.
(a) It is further understood and agreed that the Contract Administrator and Consultant shall have no
responsibility or obligation to take action, legal or otherwise, against any employer or employees or
other person to enforce provisions of the Plan. In the event that the Plan Sponsor desires to engage the
services of the Contract Administrator and Consultant for such purposes,such services shall be engag-
ed and rendered only pursuant to a separate written agreement between the parties.
(b) It is further understood and agreed that the Contract Administrator and Consultant shall not be
responsible or obligated for the investment of any assets or funds of the Plan. However, the Contract
Administrator and Consultant agrees to prepare and maintain records of the investment of the assets of
funds of the Plan if the Plan Sponsor requests the Contract Administrator and Consultant to do so and
provide the information and documents necessary to prepare and maintain such record.
(c) The Contract Administrator and Consultant will process and pay benefits in accordance with the
plan or policy adopted by the Plan Sponsor. It is agreed that the Contract Administrator and Consultant
will incorporate sound business practices and be responsible for reasonable internal audits.Where an
error exists the Contract Administrator and Consultant shall use reasonable efforts for recovery of any
loss resulting therefrom, but will not be required to initiate legal process for any such recovery.
6. Independent Contractor It is understood and agreed that the Contract Administrator and Consultant
is engaged to perform services under this Agreement as an independent contractor. The Contract Ad-
ministrator and Consultant shall use its best efforts to implement such written instructions, if any, as to
policy and procedures which may be given by the Plan Sponsor provided that such instructions are consis-
tent and compatible with the description of services to be performed by the Contract Administrator and
Consultant and are not in violation of or contrary to any laws or regulations, including but not limited to
the Employee Retirement Income Security Act of 1974, as amended.
7. Plan Sponsor The term"Plan Sponsor"shall be defined to include the employer or corporation spon-
soring the Plan or Trustees of the Trust sponsoring the Plan who serve at the time of execution of this Con-
tract and shall also include trustees serving from time to time during the term of the Contract. The Con-
tract Administration and Consultant shall be entitled to rely upon the actions, notice or instructions taken
or given by the Plan Sponsor.
IK.S BEnEflts JB Admin &Cons.SF-120-2 4/82
FRED. S. JAMES & CO.
Consultants,Adrnm,stralors 8 Acluaries
8. Assignment This Contract shall not be assigned by the Contract Administrator and Consultant or
its duties, obligations or responsibilities hereunder delegated to any other person or entity without the
prior written approval of the Plan Sponsor.
9. Indemnification The Contract Administrator and Consultant agrees to be responsible for any acts
or omissions wherein it is finally adjudged or willfully acknowledges it is guilty of gross negligence,
willful misconduct or lack of good faith or want of reasonable and ordinary care.
The Plan Sponsor agrees to indemnify and hold harmless the Contract Administrator and Consultant
for any acts or omissions not caused by gross negligence, willful misconduct, lack of good faith or want
of reasonable and ordinary care.
10. Additional Services Any changes in the Plan, found to be compatible with existing systems and
procedures and approved by the Contract Administrator and Consultant which require additional pro-
gramming, reports or services will be at the expense of the Plan Sponsor. The Plan Sponsor agrees to
make changes in benefits only at the beginning of the plan year allowing sixty (60) days prior notice to
the Contract Administrator and Consultant. Exceptions must be agreed upon the by Contract Ad-
ministrator and Consultant.
11. Other Applicable Agreements The Following James Benefits' agreements are by this reference
incorporated in this agreement:
Form Number Plan Sponsor's Initials Title of Agreement Date
SF-120-4 4/82 Administrative Services December 13, 1982
SF-122-3 4/82 Consulting Services December 13, 1982
By \ .,.2 i /////,�I/-Li
. "Plan Sponsor" Date
By
"Contract Administrator Date
and Consultant"
JAMES BEnefits J8 Admin & Cons. SF-120-3 4/82
FRED. S. JAMES & CO.
r....�.n. ..w Administrators S Actuaries
EXHIBIT A
ADMINISTRATIVE SERVICES
1. Answer all telephone and mail inquiries from participants as to benefits provided for them and their
dependents.
2. Provide information concerning the plan benefits and eligibility of participants to all providers and
participants based on eligibility information provided by the Plan Sponsor.
3. Receive claims and claim documents from the participants of the plan and verify the eligibility of the
claimants for benefits based on eligibility information provided by the Plan Sponsor.
4. Review all claims thoroughly and coordinate them with doctors, hospitals, and other providers of
services, to determine that the charges made are necessary, reasonable and customary.
•
5. Correspond with claimants if additional information is needed for payment of their claims.
6. Coordinate benefits with other benefit plans, insurance plans, and health maintenance organiza-
tions.
7. Handle all claims expeditiously.
8. Process, issue and distribute the claims, checks or drafts to the participants, hospitals, doctors, or
others as applicable and provide documents to support these disbursements.
9. Furnish standard Administrator's internal forms and coordinate with the Plan Sponsor the design
and printing of claim forms, ID cards, and other supplies designed specifically for the Plan Sponsor.
10. Notify claimants in writing of ineligible claims filed, indicating the reason for the declination of
same.
11. Provide the following claims report:
A. Explanation of benefits
B. Claim analysis by line of coverage and total
C. Claim list by participant
D. Coordination of benefits savings
E. Incurred claim lag study
F. Claims pending reports
a Cash transaction register
H. Report to IRS regarding payment to health providers
12. Provide the necessary data to the Plan Sponsor for preparation of ERISA reports and filings.
13. Attend meetings with Plan Sponsor(trust or corporate)as necessary for proper administration of the
Plan.
14. Provide the Plan Sponsor or participating groups of the plan instruction for reporting their
employees' eligibility to the Contract Administrator.
15. Provide a monthly financial report to the Plan Sponsor showing the financial status of the plan as of
the end of the preceding month to include the following:
A. Contributions and Income
B. Claims paid and expenses
.Jav neS Benefits JB Admin & Cons. SF-120-4 4/82
FRED. S. JAMES & CO.
cnns,etants.Admmistralors&Actuatles
EXHIBIT B
CONSULTING SERVICES
1. Counsel, advise and suggest to the Plan Sponsor a specific set of benefits which will accomplish the
aims of the Plan.
2. When a specific set of benefits has been agreed upon, perform the marketing function of negotiating
with appropriate insurance carriers.
3. Prepare a detailed written report concerning the companies that have been considered. This report
will contain basically the following material.
A. Plan Provisions
B. Service Facilities
C. Net Cost
D. Claim Reserves
E. Dividends
F. Retentions
4. Provide the consulting, underwriting, and planning to initiate a self-funded plan where applicable.
5. Provide the consulting as to contribution levels for present benefits.
6. Provide evaluation and underwriting data for contract changes and provisions such as benefit in-
creases and decreases.
7. Keep the Plan Sponsor advised of the innovations and developments in the field of health and
welfare which would be helpful or of interest.
8. Counsel with the Plan Sponsor concerning the financial future of the Plan to assure the accumula-
tion of proper reserves.
9. Provide medical cost data and medical cost trends in the area involved which would aid in designing
the benefits.
10. Coordinate with legal counsel and others in regard to ERISA requirements and information.
11.Assist in the preparation of a Plan Document outlining all benefits and provisions of the Plan.
12. Assist in preparing the announcement material and Summary Plan Description which will be design-
ed to advise the Participant of the benefits available and the eligibility requirements.
13. Assist the Plan Sponsor in obtaining proper enrollment data.
14. Consult and assist in design of the required administrative forms; enrollment cards, claim forms,
claim explanation of benefits, drafts.
15. Provide a review of marginal or questionable claims.
16. After the Plan has been implemented, remain at the service of the Plan Sponsor for advice or counsel
on any problems that may arise in relation to the Plan.
17. Act as "Agent of Record" on the following coverages:
Hartford
( Pnrgetnwn d L rd Am ndolal
This service includes competive bidding of various insured plans as requested.
Jam E5 Benefits JB Cons. SF-122-3 0/82
FRED. S. JAMES & CO.
r ncuv ants Adm,n,strators 8 Actuaries
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