HomeMy Public PortalAboutExhibit MSD 18F6 Liberty Mutual - Long-Term DisabilityExhibit MSD 18F6
GROUP DISABILITY INCOME POLICY
Sponsor: Metropolitan St. Louis Sewer District
Policy Number: GF3-890-450911-01
Effective Date: February 1, 2009
Governing Jurisdiction is Missouri and subject to the laws of that State.
Premiums are due and payable monthly on the first day of each month.
Policy Anniversaries shall occur each February 1st beginning in 2010,
Liberty Life Assurance Company of Boston (hereinafter referred to as Liberty) agrees to pay the benefits
provided by this policy in accordance with its provisions. This policy provides Long Term Disability
coverage.
PLEASE READ THIS POLICY CAREFULLY FOR FULL DETAILS.
This policy is a legal contract and is issued in consideration of the Application of the Sponsor, a copy of
which is attached, and of the payment of premiums by the Sponsor.
For purposes of this policy, the Sponsor acts on its own behalf or as the Covered Person's agent. Under
no circumstances will the Sponsor be deemed the agent of Liberty.
This policy is delivered in and governed by the laws of the governing jurisdiction.
The following pages including any amendments, riders or endorsements are a part of this policy.
Signed at Liberty's Home Office, 175 Berkeley Street, Boston, Massachusetts, 02117.
NON -PARTICIPATING
Form ADOP
TABLE OF CONTENTS
SECTION 1 SCHEDULE OF BENEFITS
SECTION 2 DEFINITIONS
SECTION 3 ELIGIBILITY AND EFFECTIVE DATES
SECTION 4 DISABILITY INCOME BENEFITS
SECTION 5 EXCLUSIONS
SECTION 6 TERMINATION PROVISIONS
SECTION 7 GENERAL PROVISIONS
SECTION 8 PREMIUMS
SECTION 9 APPLICATION
Form ADOP-TOC Table of Contents
SECTION 1 - SCHEDULE OF BENEFITS
ELIGIBILITY REQUIREMENTS FOR INSURANCE BENEFITS
Minimum Hourly Requirement:
Employees working a minimum of 20 regularly scheduled hours per week
Long Term Disability Benefits:
Class 1: All full-time Employees
Note: temporary and seasonal Employees and Employees who are not United States citizens or legal
residents working in the United States are not covered under this policy
Eligibility Waiting Period:
1. If the Covered Person is employed by the Sponsor on the policy effective date - none
2. If the Covered Person begins employment for the Sponsor after the policy effective date - 29 days
of continuous, Active Employment
Employee Contributions Required:
No
Name of Associated Companies:
None
Form ADOP-SCH-1 Schedule of Benefits
SECTION 1- SCHEDULE OF BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Elimination Period:
90 days
Amount of Insurance:
60% of Basic Monthly Earnings not to exceed a Maximum Monthly Benefit of $6,000 less Other Income
Benefits and Other Income Earnings as outlined in Section 4.
Maximum Basic Monthly Earnings on which the Benefit is Based:
$10,000
Own Occupation Duration:
36 Month Own Occupation
Form ADOP-SCH-3 Schedule of Benefits
SECTION 1- SCHEDULE OF BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Minimum Monthly Benefit:
The Minimum Monthly Benefit is $100 or 15% of the Covered Person's Gross Monthly Benefit, whichever
is greater.
Maximum Benefit Period:
Age at Disability Maximum Benefit Period
Less than age 60 Age 65 (but not less than 5 years)
60 60 months
61 48 months
62 42 months
63 36 months
64 30 months
65 24 months
66 21 months
67 18 months
68 15 months
69 and over 12 months
Form ADOP-SCH-4 Schedule of Benefits
SECTION 2 - DEFINITIONS
In this section Liberty defines some basic terms needed to understand this policy. The male pronoun
whenever used in this policy includes the female.
"Active Employment" means the Employee must be actively at work for the Sponsor:
1. on a full-time basis and paid regular earnings;
2. for at least the minimum number of hours shown in the Schedule of Benefits; and either perform
such work:
a. at the Sponsor's usual place of business; or
b. at a location to which the Sponsor's business requires the Employee to travel.
An Employee will be considered actively at work if he was actually at work on the day immediately
preceding:
1. a weekend (except where one or both of these days are scheduled work days);
2. holidays (except when the holiday is a scheduled work day);
3. paid vacations;
4. any non-scheduled work day;
5. an excused leave of absence (except medical leave for the Covered Person's own disabling
condition and lay-off); and
6. an emergency leave of absence (except emergency medical leave for the Covered Person's own
disabling condition).
"Administrative Office" means Liberty Life Assurance Company of Boston, 9 Riverside Road, Weston,
MA 02493.
Form ADOP-DEF-1 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Any Occupation" means any occupation that the Covered Person is or becomes reasonably fitted by
training, education, experience, age, physical and mental capacity.
"Application" is the document designated in Section 9; it is attached to and is made a part of this policy.
"Appropriate Available Treatment" means care or services which are:
1. generally acknowledged by Physicians to cure, correct, limit, treat or manage the disabling
condition;
2. accessible within the Covered Person's geographical region;
3. provided by a Physician who is licensed and qualified in a discipline suitable to treat the
disabling Injury or Sickness;
4. in accordance with generally accepted medical standards of practice.
"Basic Monthly Earnings" means the Covered Person's monthly rate of earnings from the Sponsor in
effect immediately prior to the date Disability or Partial Disability begins. However, such earnings will
not include bonuses, commissions, overtime pay and extra compensation.
"Covered Person" means an Employee insured under this policy.
Form ADOP-DEF-2 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Disability" or "Disabled" means:
1. For persons other than pilots, co-pilots, and crewmembers of an aircraft:
i. "Disability" or "Disabled" means that during the Elimination Period and the next 36
months of Disability the Covered Person, as a result of Injury or Sickness, is unable to
perform the Material and Substantial Duties of his Own Occupation; and
ii, thereafter, the Covered Person is unable to perform, with reasonable continuity, the
Material and Substantial Duties of Any Occupation.
2. With respect to Covered Persons employed as pilots, co-pilots and crewmembers of an aircraft:
"Disability" or "Disabled" means as of a result of Injury or Sickness: (a) the Covered Person
cannot perform the material and substantial duties of his own occupation; and (b) after benefits
have been paid for 12 months, the Covered Person is unable to perform the Material and
Substantial Duties of Any Occupation.
"Disability Benefits under a Retirement Plan" means money which:
1. is payable under a Retirement Plan due to Disability as defined in that plan; and
2. does not reduce the amount of money which would have been paid as retirement benefits at the
normal retirement age under the plan if the Disability had not occurred. (If the payment does
cause such a reduction, it will be deemed a Retirement Benefit as defined in this policy.)
Form ADOP-DEF-3.1 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Eligibility Date" means the date an Employee becomes eligible for insurance under this policy.
Eligibility Requirements are shown in the Schedule of Benefits.
"Eligible Survivor" means the Covered Person's spouse, if living, otherwise the Covered Person's
children under age 25.
"Eligibility Waiting Period" means the continuous length of time an Employee must be in Active
Employment in an eligible class to reach his Eligibility Date.
"Elimination Period" means a period of consecutive days of Disability or Partial Disability for which no
benefit is payable. The Elimination Period is shown in the Schedule of Benefits and begins on the first
day of Disability.
If the Covered Person returns to work for any thirty or fewer days during the Elimination Period and
cannot continue, Liberty will count only those days the Covered Person is Disabled or Partially Disabled
to satisfy the Elimination Period.
"Employee" means a person in Active Employment with the Sponsor.
"Enrollment Form" is the document completed by the Covered Person, if required, when enrolling for
coverage. This form must be satisfactory to Liberty.
Form ADOP-DEF-4.10 ' Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Extended Treatment Plan" means continued care that is consistent with the American Psychiatric
Association's standard principles of Treatment, and is in lieu of confinement in a Hospital or Institution.
It must be approved in writing by a Physician.
"Family and Medical Leave" means a leave of absence for the birth, adoption or foster care of a child, or
for the care of the Covered Person's child, spouse or parent or for the Covered Person's own serious
health condition as those terms are defined by the Federal Family and Medical Leave Act of 1993 (FMLA)
and any amendments, or by applicable state law.
"Gross Monthly Benefit" means the Covered Person's Monthly Benefit before any reduction for Other
Income Benefits and Other Income Earnings.
"Hospital" or "Institution" means a facility licensed to provide Treatment for the condition causing the
Covered Person's Disability.
Form ADOP-DEF-5 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Initial Enrollment Period" means one of the following periods during which an Employee may first
enroll for coverage under this policy:
1. for an Employee who is eligible for insurance on the policy effective date, a period before the
policy effective date set by the Sponsor and Liberty.
2. for an Employee who becomes eligible for insurance after the policy effective date, the period
which ends 31 days after his Eligibility Date.
"Injury" means bodily impairment resulting directly from an accident and independently of all other
causes. For the purpose of determining benefits under this policy:
1. any Disability which begins more than 60 days after an Injury will be considered a Sickness; and
2. any Injury which occurs before the Covered Person is covered under this policy, but which
accounts for a medical condition that arises while the Covered Person is covered under this
policy will be treated as a Sickness.
"Last Monthly Benefit" means the gross Monthly Benefit payable to the Covered Person prior to his
death without any reduction for earnings received from employment.
"Material and Substantial Duties" means responsibilities that are normally required to perform the
Covered Person's Own Occupation, or any other occupation, and cannot be reasonably eliminated or
modified.
Form ADOP-DEF-6 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Mental Illness" means a psychiatric or psychological condition classified as such in the most current
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) regardless of the underlying
cause of the Mental Illness. If the DSM is discontinued, Liberty will use the replacement chosen or
published by the American Psychiatric Association.
"Monthly Benefit" means the monthly amount payable by Liberty to the Disabled or Partially Disabled
Covered Person.
"Non -Verifiable Symptoms" means the Covered Person's subjective complaints to a Physician which
cannot be diagnosed using tests, procedures or clinical examinations typically accepted in the practice of
medicine. Such symptoms may include, but are not limited to, dizziness, fatigue, headache, loss of
energy, numbness, pain, ringing in the ear, and stiffness.
"Own Occupation" means the Covered Person's occupation that he was performing when his Disability
or Partial Disability began. For the purposes of determining Disability under this policy, Liberty will
consider the Covered Person's occupation as it is normally performed in the national economy.
Form ADOP-DEF-7 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Partial Disability" or "Partially Disabled" means the Covered Person, as a result of Injury or Sickness,
is able to:
1. perform one or more, but not all, of the Material and Substantial Duties of his Own Occupation
or Any Occupation on an Active Employment or a part-time basis; or
2. perform all of the Material and Substantial Duties of his Own Occupation or Any Occupation on
a part-time basis; and
3. earn between 20% and 80% of his Basic Monthly Earnings.
"Physician" means a person who:
1. is licensed to practice medicine and is practicing within the terms of his license; or
2. is a licensed practitioner of the healing arts in a category specifically favored under the health
insurance laws of the state where the Treatment is received and is practicing within the terms of
his license.
It does not include a Covered Person, any family member or domestic partner.
Form ADOP-DEF-8 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Proof" means the evidence in support of a claim for benefits and includes, but is not limited to, the
following:
1. a claim form completed and signed (or otherwise formally submitted) by the Covered Person
claiming benefits;
2. an attending Physician's statement completed and signed (or otherwise formally submitted) by
the Covered Person's attending Physician; and
3. the provision by the attending Physician of standard diagnosis, chart notes, lab findings, test
results, x-rays and/or other forms of objective medical evidence in support of a claim for
benefits.
Proof must be submitted in a form or format satisfactory to Liberty.
"Regular Attendance" means the Covered Person's personal visits to a Physician which are medically
necessary according to generally accepted medical standards to effectively manage and treat the Covered
Person's Disability or Partial Disability.
"Retirement Benefit under a Retirement Plan" means money which:
1. is payable under a Retirement Plan either in a lump sum or in the form of periodic payments;
2. does not represent contributions made by an Employee (payments which represent Employee
contributions are deemed to be received over the Employee's expected remaining life regardless
of when such payments are actually received); and
3. is payable upon:
a. early or normal retirement; or
b. Disability, if the payment does reduce the amount of money which would have been paid
under the plan at the normal retirement age.
Form ADOP-DEF-9 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Retirement Plan" means a plan which provides retirement benefits to Employees and which is not
funded wholly by Employee contributions. The term shall not include a profit-sharing plan, informal
salary continuation plan, registered retirement savings plan, stock ownership plan, 401(K) or a non -
qualified plan of deferred compensation.
"Schedule of Benefits" means the section of this policy which shows, among other things, the Eligibility
Requirements, Eligibility Waiting Period, Elimination Period, Amount of Insurance, Minimum Benefit,
and Maximum Benefit Period.
"Sickness" means illness, disease, pregnancy or complications of pregnancy.
"Sponsor" means the entity to whom this policy is issued.
"Sponsor's Retirement Plan" is deemed to include any Retirement Plan:
1. which is part of any Federal, State, Municipal or Association retirement system; or
2. for which the Employee is eligible as a result of employment with the Sponsor.
"Substance Abuse" means alcohol and/or drug abuse, addiction or dependency.
"Treatment" means receiving medical advice, receiving care or services provided by or under the
direction of a Physician including diagnostic measures, being prescribed drugs and/or medicines,
whether the Covered Person chooses to take them or not, and taking drugs and/or medicines.
Form ADOP-DEF-10.1 Definitions
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
Eligibility Requirements for Insurance Benefits
The eligibility requirements for insurance benefits are shown in the Schedule of Benefits.
Eligibility Date for Insurance Benefits
An Employee in an eligible class will qualify for insurance on the later of:
1. this policy's effective date; or
2. the day after the Employee completes the Eligibility Waiting Period shown in the Schedule of
Benefits.
Form ADOP-ELG-1 Eligibility and Effective Dates
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Effective Date of Insurance
Insurance will be effective at 12:01 A.M. Standard Time in the governing jurisdiction on the day
determined as follows, but only if the Employee's application or enrollment for insurance is made with
Liberty through the Sponsor in a form or format satisfactory to Liberty.
An Employee will be insured on his Eligibility Date.
Delayed Effective Date for Insurance
The effective date of any initial, increased or additional insurance will be delayed for an individual if he
is not in Active Employment because of Injury or Sickness. The initial, increased or additional insurance
will begin on the date the individual returns to Active Employment.
Form ADOP-ELG-2 Eligibility and Effective Dates
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Family and Medical Leave
An Employee's coverage may be continued under this policy for an approved family or medical leave of
absence for up to 12 weeks following the date coverage would have terminated, subject to the following:
1. the authorized leave is in writing;
2. the required premium is paid;
3. the Covered Person's benefit level, or the amount of earnings upon which the Covered Person's
benefit may be based, will be that in effect on the date before said leave begins; and
4. continuation of coverage will cease immediately if any one of the following events should occur:
a. the Covered Person returns to work;
b. this group insurance policy terminates;
c. the Covered Person is no longer in an eligible class;
d. nonpayment of premium when due by the Sponsor or the Covered Person;
e. the Covered Person's employment terminates.
Rehire Terms
If a former Employee is re -hired by the Sponsor within 12 months of his termination date, all past periods
of Active Employment with the Sponsor will be used in determining the re -hired Employee's Eligibility
Date. If a former Employee is re -hired by the Sponsor more than 12 months after his termination date, he
is considered to be a new Employee when determining his Eligibility Date.
Family and Medical Leave/Rehire
Form ADOP-ELG-7 Eligibility and Effective Dates
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Leave of Absence
The Sponsor may continue the Covered Person's coverage(s) by paying the required premiums, if the
Covered Person is given a leave of absence.
The Covered Person's coverage will not continue beyond the end of the policy month following the
policy month in which the leave of absence begins. In continuing such coverage under this provision, the
Sponsor agrees to treat all Covered Persons equally.
Lay-off
The Sponsor may continue the Covered Person's coverage(s) by paying the required premiums, if the
Covered Person is temporarily laid off.
The Covered Person's coverage will not continue beyond the end of the policy month in which the lay-off
begins. In continuing such coverage under this provision, the Sponsor agrees to treat all Covered
Persons equally.
Associated Companies
Companies, corporations, firms or individuals that are subsidiary to, or affiliated with, the Sponsor will
be called Associated Companies. The Associated Companies, if any, are listed in the Schedule of
Benefits. Employees of Associated Companies will be considered Employees of the Sponsor for purposes
of this policy.
As they relate to this policy, all actions, agreements and notices between Liberty and the Sponsor will be
binding on the Associated Companies.
If an Associated Company ceases to be an Associated Company for any reason, its Employees will be
deemed to have transferred to a class of Employees not eligible for coverage under this policy.
Leave of Absence/Lay-Off/Associated Companies
Form ADOP-ELG-8 Eligibility and Effective Dates
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Transfer Provision
In order to prevent loss of coverage for an individual because of transfer of insurance carriers, this policy
will provide coverage for certain individuals as follows:
Failure to be In Active Employment Due to Injury or Sickness:
Subject to premium payments, this policy will cover individuals who:
1. at the time of transfer are covered under the prior carrier's policy; and
2. are not in Active Employment due to Injury or Sickness on the effective date of this policy.
Benefits will be determined based on the lesser of:
1. the amount of the Disability benefit that would have been payable under the prior policy and
subject to any applicable policy limitations; or
2. the amount of Disability benefits payable under this policy. If benefits are payable under the
prior policy for the Disability, no benefits are payable under this policy.
Disability Due to a Pre -Existing Condition
If an individual was insured under the prior carrier's policy at the time of transfer and was in Active
Employment and insured under this policy on its effective date, benefits may be payable for a Disability
due to a Pre -Existing Condition.
If the individual can satisfy this policy's Pre -Existing Condition Exclusion, the benefit will be determined
according to this policy.
If the individual cannot satisfy this policy's Pre -Existing Condition Exclusion, then:
1. Liberty will apply the Pre -Existing Condition Exclusion of the prior carrier's policy and;
2. if the individual would have satisfied the prior carrier's pre-existing condition exclusion, giving
consideration towards continuous time coverage under this policy and the prior carrier's policy,
the benefit will be determined according to this policy. However, the Maximum Monthly Benefit
amount payable under this policy shall not exceed the maximum monthly benefit payable under
the prior carrier's policy.
No benefit will be paid if the individual cannot satisfy the Pre -Existing Condition Exclusions of either
policy.
Transfer Provision
Form ADOP-ELG-9 Eligibility and Effective Dates
SECTION 4 - DISABILITY INCOME BENEFITS
LONG TERM DISABILITY COVERAGE
Disability Benefit
When Liberty receives Proof that a Covered Person is Disabled due to Injury or Sickness and requires the
Regular Attendance of a Physician, Liberty will pay the Covered Person a Monthly Benefit after the end
of the Elimination Period, subject to any other provisions of this policy. The benefit will be paid for the
period of Disability if the Covered Person gives to Liberty Proof of continued:
1. Disability;
2. Regular Attendance of a Physician; and
3. Appropriate Available Treatment.
The Proof must be given upon Liberty's request and at the Covered Person's expense. In determining
whether the Covered Person is Disabled, Liberty will not consider employment factors including, but not
limited to, interpersonal conflict in the workplace, recession, job obsolescence, paycuts, job sharing and
loss of a professional or occupational license or certification.
For purposes of determining Disability, the Injury must occur and Disability must begin while the
Employee is insured for this coverage.
The Monthly Benefit will not:
1. exceed the Covered Person's Amount of Insurance; or
2. be paid for longer than the Maximum Benefit Period.
The Amount of Insurance and the Maximum Benefit Period are shown in the Schedule of Benefits.
Amount of Disability Monthly Benefit
To figure the amount of Monthly Benefit:
1. Take the lesser of:
a. the Covered Person's Basic Monthly Earnings multiplied by the benefit percentage shown in
the Schedule of Benefits; or
b. the Maximum Monthly Benefit shown in the Schedule of Benefits; and then
2. Deduct Other Income Benefits and Other Income Earnings, (shown in the Other Income Benefits
and Other Income Earnings provision of this policy), from this amount.
The Monthly Benefit payable will not be less than the Minimum Monthly Benefit shown in the Schedule
of Benefits. However, if an overpayment is due to Liberty, the Minimum Monthly Benefit otherwise
payable under this provision will be applied toward satisfying the overpayment.
Long Term Disability
Form ADOP-LTD-1 Standard Integration
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Partial Disability
When Liberty receives Proof that a Covered Person is Partially Disabled and has experienced a loss of
earnings due to Injury or Sickness and requires the Regular Attendance of a Physician, he may be eligible
to receive a Monthly Benefit, subject to any other provisions of this policy. To be eligible to receive
Partial Disability benefits, the Covered Person may be employed in his Own Occupation or another
occupation, must satisfy the Elimination Period and must be earning between 20% and 80% of his Basic
Monthly Earnings.
A Monthly Benefit will be paid for the period of Partial Disability if the Covered Person gives to Liberty
Proof of continued:
1. Partial Disability;
2. Regular Attendance of a Physician; and
3. Appropriate Available Treatment.
The Proof must be given upon Liberty's request and at the Covered Person's expense. In determining
whether the Covered Person is Partially Disabled, Liberty will not consider employment factors
including, but not limited to, interpersonal conflict in the workplace, recession, job obsolescence, paycuts,
job sharing and loss of a professional or occupational license or certification.
For purposes of determining Partial Disability, the Injury must occur and Partial Disability must begin
while the Employee is insured for this coverage.
Loss of Earnings Monthly Calculation with Work Incentive Benefit
For the first 12 months, the work incentive benefit will be an amount equal to the Covered Person's Basic
Monthly Earnings multiplied by the benefit percentage shown in the Schedule of Benefits, without any
reductions from earnings. The work incentive benefit will only be reduced, if the Monthly Benefit
payable plus any earnings exceed 100% of the Covered Person's Basic Monthly Earnings. If the combined
total is more, the Monthly Benefit will be reduced by the excess amount so that the Monthly Benefit plus
the Covered Person's earnings does not exceed 100% of his Basic Monthly Earnings.
Thereafter, the Monthly Benefit will be calculated as follows:
1. The Covered Person's Basic Monthly Earnings minus the Covered Person's earnings received
while he is Partially Disabled. This figure represents the amount of lost earnings.
2. Multiply the amount of lost earnings by 75%; and then
3. deduct Other Income Benefits (shown in the Other Income Benefits and Other Income Earnings
provision of this policy) from this amount.
The Monthly Benefit payable will not be less than the Minimum Monthly Benefit shown in the Schedule
of Benefits. However, if an overpayment is due to Liberty, the Minimum Monthly Benefit otherwise
payable under this provision will be applied toward satisfying the overpayment.
Long Term Partial Disability with Work Incentive
Form ADOP-LTD-4 Loss of Earnings
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Mental Illness, Substance Abuse and/or Non -Verifiable Symptoms Limitation
The benefit for Disability due to Mental Illness, Substance Abuse and/or Non -Verifiable Symptoms will
not exceed a period of 24 months of Monthly Benefit payments while the Covered Person is insured
under this policy.
If the Covered Person is in a Hospital or Institution for Mental Illness and/or Substance Abuse at the end
of the period of 24 months, the Monthly Benefit will be paid during the confinement.
If the Covered Person is not confined in a Hospital or Institution for Mental Illness and/or Substance
Abuse, but is fully participating in an Extended Treatment Plan for the condition that caused Disability,
the Monthly Benefit will be payable to a Covered Person for up to a period of 36 months.
In no event will the Monthly Benefit be payable beyond the Maximum Benefit Period shown in the
Schedule of Benefits.
Long Term Disability
Form ADOP-LTD-7 Mental Illness, Substance Abuse and/or Non -Verifiable Symptoms Limitation
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Rehabilitation Incentive Benefit
Liberty will pay an increased Monthly Benefit while a Covered Person is fully participating in a
Rehabilitation Program. Liberty must first approve the Rehabilitation Program in writing before a
Covered Person can be considered for this benefit. If Liberty does not approve a Rehabilitation Program,
the regular Disability benefit will be payable provided the Covered Person is Disabled under the terms of
this policy. To be eligible for a Rehabilitation Incentive Benefit, the Covered Person must
1. be Disabled and receiving benefits under this policy; and
2. be fully participating in a Rehabilitation Program approved by Liberty.
Increased Monthly Benefit
If the Covered Person is eligible for a Rehabilitation Incentive Benefit, the benefit percentage shown in
the Schedule of Benefits, will be increased to 70%. The increased benefit will begin on the first day of the
month after Liberty receives written Proof of the Covered Person's full participation in the Rehabilitation
Program.
Decreased Monthly Benefit
If the Covered Person, at any time, declines to fully participate in an approved Rehabilitation Program
recommended by Liberty, the benefit percentage shown in the Schedule of Benefits will be reduced to
50% beginning on the first day of the month following the Covered Person's declination to fully
participate in the approved Rehabilitation Program. If Liberty recommends rehabilitation, benefits will
be paid at the reduced amount from the date recommendation is made until Liberty receives the Covered
Person's written agreement to fully participate in the Rehabilitation Program.
Discontinuation of the Rehabilitation Incentive Benefit
The Rehabilitation Incentive Benefit will cease:
1. when the Covered Person is no longer fully participating in a Rehabilitation Program approved
by Liberty;
2. in accordance with the provisions entitled "Discontinuation of the Long Term Disability Benefit";
or
3. when the Rehabilitation Program ends.
Long Term Disability
Form ADOP-LTD-8 Rehabilitation
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Rehabilitation Incentive Benefit (Continued)
For the purpose of this provision, "Rehabilitation Program" means a comprehensive individually
tailored, goal oriented program to return a Disabled Covered Person to gainful employment. The
services offered may include, but are not limited to, the following:
1. physical therapy;
2. occupational therapy;
3. work hardening programs;
4. functional capacity evaluations;
5. psychological and vocational counseling;
6. rehabilitative employment; and
7. vocational rehabilitation services.
Long Term Disability
Form ADOP-LTD-9 Rehabilitation
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Three Month Survivor Benefit
Liberty will pay a lump sum benefit to the Eligible Survivor when Proof is received that a Covered
Person died:
1. after Disability had continued for 180 or more consecutive days; and
2. while receiving a Monthly Benefit.
The lump sum benefit will be an amount equal to three times the Covered Person's Last Monthly Benefit.
If the survivor benefit is payable to the Covered Person's children, payment will be made in equal shares
to the children, including step children and legally adopted children. However, if any of said children
are minors or incapacitated, payment will be made on their behalf to the court appointed guardian of the
children's property. This payment will be valid and effective against all claims by others representing or
claiming to represent the children.
If there is no Eligible Survivor, the benefit is payable to the estate.
If an overpayment is due to Liberty at the time of a Covered Person's death, the benefit payable under
this provision will be applied toward satisfying the overpayment.
Long Term Disability
Form ADOP-LTD-10 Three Month Survivor
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Workplace Modification Benefit
If a Covered Person is Disabled or Partially Disabled and receiving a benefit from Liberty, a benefit may
be payable to the Sponsor as part of the Covered Person's benefit for modifications to the workplace to
accommodate the Covered Person's return to work or to assist the Covered Person in remaining at work.
Liberty will reimburse the Sponsor for up to 100% of reasonable costs the Sponsor incurs for the
modification, up to the greater of:
1. $1,000; or
2. the equivalent of two months of the Covered Person's Monthly Benefit.
To qualify for this benefit:
1. the Disability or Partial Disability must prevent the Covered Person from performing some or all
of the Material and Substantial Duties of his occupation; and
2. any proposed modifications must be approved in writing and signed by the Covered Person, the
Sponsor and Liberty; and
3. the Sponsor must agree to make the modifications to the workplace to reasonably accommodate
the Covered Person's return to work or to assist the Covered Person in remaining at work.
The Sponsor's costs for the approved modifications will be reimbursed after:
1. the proposed modifications have been made; and
2. written proof of the expenses incurred by the Sponsor has been provided to Liberty; and
3. Liberty has received proof that the Covered Person has returned to and/or remains at work.
Long Term Disability
Form ADOP-LTD-14 Workplace Modification
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Other Income Benefits and Other Income Earnings
Other Income Benefits means:
1. The amount for which the Covered Person is eligible under:
a. Workers' or Workmen's Compensation Laws;
b. Occupational Disease Law;
c. Title 46, United States Code Section 688 (The Jones Act);
d. any work loss provision in mandatory "No -Fault" auto insurance;
e. Railroad Retirement Act;
f. any governmental compulsory benefit act or law; or
g. any other act or law of like intent.
2. The amount of any Disability benefits which the Covered Person is eligible to receive under:
a. any other group insurance plan of the Sponsor;
b. any governmental retirement system as a result of his employment with the Sponsor; or
c. any individual insurance plan where the premium is wholly or partially paid by the Sponsor.
However, Liberty will only reduce the Monthly Benefit if the Covered Person's Monthly
Benefit under this policy, plus any benefits that the Covered Person is eligible to receive
under such individual insurance plan exceed 100% of the Covered Person's Basic Monthly
Earnings. If this sum exceeds 100% of Basic Monthly Earnings, the Covered Person's
Monthly Benefit under this policy will be reduced by such excess amount.
3. The amount of benefits the Covered Person receives under the Sponsor's Retirement Plan as
follows:
a. the amount of any Disability Benefits under a Retirement Plan, or Retirement Benefits under
a Retirement Plan the Covered Person voluntarily elects to receive as retirement payment
under the Sponsor's Retirement Plan; and
b. the amount the Covered Person receives as retirement payments when he reaches the later of
age 62, or normal retirement age as defined in the Sponsor's plan.
4. The amount of Disability and/or Retirement Benefits under the United States Social Security Act,
the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act, which:
a. the Covered Person receives or is eligible to receive; and
b. his spouse, child or children receives or are eligible to receive because of his Disability; or
c. his spouse, child or children receives or are eligible to receive because of his eligibility for
retirement benefits.
5. Any amount the Covered Person receives from any unemployment benefits.
Long Term Disability Primary and Family Integration
Form ADOP-LTD-22 Other Income Benefits and Other Income Earnings
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Other Income Benefits and Other Income Earnings (Continued)
Other Income Earnings means:
1. any amount the Covered Person receives from any formal or informal sick leave or salary
continuation plan(s).
2. the amount of earnings the Covered Person earns or receives from any form of employment
including severance.
Other Income Benefits, except retirement benefits, must be payable as a result of the same Disability for
which Liberty pays a benefit. The sum of Other Income Benefits and Other Income Earnings will be
deducted in accordance with the provisions of this policy.
Long Term Disability Primary and Family Integration
Form ADOP-LTD-23 Other Income Benefits and Other Income Earnings
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Estimation of Benefits
Liberty will reduce the Covered Person's Disability or Partial Disability benefits by the amount of Other
Income Benefits that we estimate are payable to the Covered Person and his dependents.
The Covered Person's Disability benefit will not be reduced by the estimated amount of Other Income
Benefits if the Covered Person:
1. provides satisfactory proof of application for Other Income Benefits;
2. signs a reimbursement agreement under which, in part, the Covered Person agrees to repay
Liberty for any overpayment resulting from the award or receipt of Other Income Benefits;
3. if applicable, provides satisfactory proof that all appeals for Other Income Benefits have been
made on a timely basis to the highest administrative level unless Liberty determines that further
appeals are not likely to succeed; and
4. if applicable, submits satisfactory proof that Other Income Benefits have been denied at the
highest administrative level unless Liberty determines that further appeals are not likely to
succeed.
Liberty will not estimate or reduce for any benefits under the Sponsor's pension or retirement benefit
plan according to applicable law, until the Covered Person actually receives them.
In the event that Liberty overestimates the amount payable to the Covered Person from any plans
referred to in the Other Income Benefits and Other Income Earnings provision of this policy, Liberty will
reimburse the Covered Person for such amount upon receipt of written proof of the amount of Other
Income Benefits awarded (whether by compromise, settlement, award or judgment) or denied (after
appeal through the highest administrative level).
Social Security Assistance
Liberty may help a Covered Person in applying for Social Security Disability Income Benefits. In order to
be eligible for assistance the Covered Person must be receiving a Monthly Benefit from Liberty. Such
assistance will be provided only if Liberty determines that assistance would be beneficial.
Long Term Disability
Form ADOP-LTD-24 Estimation of Benefits and Social Security Assistance
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Lump Sum Payments
Other Income Benefits from a compromise, settlement, award or judgment which are paid to the Covered
Person in a lump sum and are meant to compensate the Covered Person for any one or more of the
following:
1. loss of past or future wages;
2. impaired earnings capacity;
3. lessened ability to compete in the open labor market;
4. any degree of permanent impairment; and
5. any degree of loss of bodily function or capacity;
will be prorated on a monthly basis as follows:
1. over the period of time such benefits would have been paid if not in a lump sum; or
2. if such period of time cannot be determined, the lesser of:
a. the remainder of the Maximum Benefit Period; or
b. 5 years.
Cost of Living Freeze
After the first deduction for each of the Other Income Benefits, the Monthly Benefit will not be further
reduced due to any cost of living increases payable under the Other Income Benefits and Other Income
Earnings provision of this policy. This provision does not apply to increases received from any form of
employment.
Prorated Benefits
For any period for which a Long Term Disability benefit is payable that does not extend through a full
month, the benefit will be paid on a prorated basis. The rate will be 1/30th for each day for such period
of Disability.
Discontinuation of the Long Term Disability Benefit
The Monthly Benefit will cease on the earliest of:
1. the date the Covered Person fails to provide Proof of continued Disability or Partial Disability
and Regular Attendance of a Physician;
2. the date the Covered Person fails to cooperate in the administration of the claim. Such
cooperation includes, but is not limited to, providing any information or documents needed to
determine whether benefits are payable or the actual benefit amount due;
Form ADOP-LTD-25 Long Term Disability
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Discontinuation of the Long Term Disability Benefit (Continued)
The Monthly Benefit will cease on the earliest of: (Continued)
3. the date the Covered Person refuses to be examined or evaluated at reasonable intervals;
4. the date the Covered Person refuses to receive Appropriate Available Treatment;
5. the date the Covered Person refuses a job with the Sponsor where workplace modifications or
accommodations were made to allow the Covered Person to perform the Material and
Substantial Duties of the job;
6. the date the Covered Person is able to work in his Own Occupation on a part-time basis, but
chooses not to;
7. the date the Covered Person's current Partial Disability earnings exceed 80% of his Basic
Monthly Earnings;
Because the Covered Person's current earnings may fluctuate, Liberty will average earnings
over three consecutive months rather than immediately terminating his benefit once 80% of
Basic Monthly Earnings has been exceeded.
8. the date the Covered Person is no longer Disabled according to this policy;
9. the end of the Maximum Benefit Period; or
10. the date the Covered Person dies.
Form ADOP-LTD-26 Long Term Disability
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Successive Periods of Disability
With respect to this policy, "Successive Periods of Disability" means a Disability which is related or due
to the same cause(s) as a prior Disability for which a Monthly Benefit was payable.
A Successive Period of Disability will be treated as part of the prior Disability if, after receiving Disability
benefits under this policy, a Covered Person:
1. returns to his Own Occupation on an Active Employment basis for less than six continuous
months; and
2. performs all the Material and Substantial Duties of his Own Occupation.
To qualify for a Successive Periods of Disability benefit, the Covered Person must experience more than a
20% loss of Basic Monthly Earnings.
Benefit payments will be subject to the terms of this policy for the prior Disability.
If a Covered Person returns to his Own Occupation on an Active Employment basis for six continuous
months or more, the Successive Period of Disability will be treated as a new period of Disability. The
Covered Person must complete another Elimination Period.
If a Covered Person becomes eligible for coverage under any other group long term disability coverage,
this Successive Period of Disability provision will cease to apply to that Covered Person.
Long Term Disability
Form ADOP-LTD-27 Successive Disability
SECTION 5 - EXCLUSIONS
GENERAL EXCLUSIONS
This policy will not cover any Disability due to:
1. war, declared or undeclared, or any act of war;
2. intentionally self-inflicted injuries, while sane;
3. active Participation in a Riot;
4. the committing of or attempting to commit a felony or misdemeanor;
5. cosmetic surgery unless such surgery is in connection with an Injury or Sickness sustained while
the individual is a Covered Person;
6. a gender change, including, but not limited to, any operation, drug therapy or any other
procedure related to a gender change.
No benefit will be payable during any period of incarceration.
With respect to this provision, Participation shall include promoting, inciting, conspiring to promote or
incite, aiding, abetting, and all forms of taking part in, but shall not include actions taken in defense of
public or private property, or actions taken in defense of the Covered Person, if such actions of defense
are not taken against persons seeking to maintain or restore law and order including, but not limited to
police officers and fire fighters.
With respect to this provision, Riot shall include all forms of public violence, disorder or disturbance of
the public peace, by three or more persons assembled together, whether or not acting with a common
intent and whether or not damage to persons or property or unlawful act or acts is the intent or the
consequence of such disorder.
Form ADOP-EXC-1.2 General Exclusions
SECTION 5 - EXCLUSIONS
(Continued)
LONG TERM DISABILITY COVERAGE
Pre -Existing Condition Exclusion
This policy will not cover any Disability or Partial Disability:
1. which is caused or contributed to by, or results from a Pre -Existing Condition; and
2. which begins in the first 12 months immediately after the Covered Person's effective date of
coverage.
"Pre -Existing Condition" means a condition resulting from an Injury or Sickness for which the Covered
Person is diagnosed or received Treatment within three months prior to the Covered Person's effective
date of coverage.
Long Term Disability
Form ADOP-EXC-5 3/12 Pre -Existing Exclusion
SECTION 6 - TERMINATION PROVISIONS
Termination of a Covered Person's Insurance
A Covered Person will cease to be insured on the earliest of the following dates:
1. the date this policy terminates, but without prejudice to any claim originating prior to the time of
termination;
2. the date the Covered Person is no longer in an eligible class;
3. the date the Covered Person's class is no longer included for insurance;
4. the date employment terminates. Cessation of Active Employment will be deemed termination
of employment, except the insurance will be continued for an Employee absent due to Disability
during:
a. the Elimination Period; and
b. any period during which premium is being waived.
5. the date the Covered Person ceases active work due to a labor dispute, including any strike, work
slowdown, or lockout.
Liberty reserves the right to review and terminate all classes insured under this policy if any class(es)
cease(s) to be covered.
Form ADOP-TER-1 Termination Provisions
SECTION 6 - TERMINATION PROVISIONS
(Continued)
Policy Termination
1. Termination of this policy under any conditions will not prejudice any claim which occurs while this
policy is in force.
2. If the Sponsor fails to pay any premium within the grace period, this policy will terminate at 12:00
midnight Standard Time on the last day of the grace period. The Sponsor may terminate this policy
by advance written notice delivered to Liberty at least 31 days prior to the termination date. This
policy will not terminate during any period for which premium has been paid. The Sponsor will be
liable to Liberty for all premiums due and unpaid for the full period for which this policy is in force.
3. Liberty may terminate this policy on any premium due date by giving written notice to the Sponsor
at least 31 days in advance if:
a. the number of Employees insured is fewer than 10; or
b. less than 100% of the Employees eligible for any non-contributory insurance are insured for it; or
c. the Sponsor fails:
i. to furnish promptly any information which Liberty may reasonably require; or
ii. to perform any other obligations pertaining to this policy.
4. Liberty may terminate this policy or any coverage(s) afforded hereunder and for any class of covered
Employees on any premium due date after it has been in force for 12 months. Liberty will provide
written notice of such termination to the Sponsor at least 31 days before the termination is effective.
5. Termination may take effect on an earlier date if agreed to by the Sponsor and Liberty.
Form ADOP-TER-2 Termination Provisions
SECTION 7 - GENERAL PROVISIONS
Assignment
No assignment of any present or future right or benefit under this policy will be allowed.
Complete Contract - Policy Changes
1. This policy is the entire contract. It consists of:
a. all of the pages; and
b. the attached signed Application of the Sponsor.
2. This policy may be changed in whole or in part. Only an officer of Liberty can approve a change.
The approval must be in writing and endorsed on or attached to this policy.
3. No other person, including an agent, may change this policy or waive any part of it.
Conformity with State Statutes
Any provision of this policy which, on its effective date, is in conflict with the statutes of the governing
jurisdiction of this policy is hereby amended to conform to the minimum requirements of such statute.
Employee's Certificate
Liberty will provide a Certificate to the Sponsor for delivery to Covered Persons. It will state:
1. the name of the insurance company and the policy number;
2. a description of the insurance provided;
3. the method used to determine the amount of benefits;
4. to whom benefits are payable;
5. limitations or reductions that may apply;
6. the circumstances under which insurance terminates; and
7. the rights of the Covered Person upon termination of this policy.
If the terms of a Certificate and this policy differ, this policy will govern.
Examination
Liberty, at its own expense, may have the right and opportunity to have a Covered Person, whose Injury
or Sickness is the basis of a claim, examined or evaluated at reasonable intervals deemed necessary by
Liberty. This right may be used as often as reasonably required.
Form ADOP-GNP-1 General Provisions
SECTION 7 - GENERAL PROVISIONS
(Continued)
Furnishing of Information - Access to Records
1. The Sponsor will furnish at regular intervals to Liberty:
a. information relative to Employees:
i. who qualify to become insured;
ii. whose amounts of insurance change; and/or
iii. whose insurance terminates.
b. any other information about this policy that may be reasonably required.
The Sponsor's records which, in the opinion of Liberty, have a bearing on the insurance will be
opened for inspection at any reasonable time.
2. Clerical error or omission will not:
a. deprive an Employee of insurance;
b. affect an Employee's Amount of Insurance; or
c. effect or continue an Employee's insurance which otherwise would not be in force.
Interpretation of the Policy
Liberty shall possess the discretionary authority to construe the terms of this policy and to determine
benefit eligibility hereunder.
Incontestability
The validity of this policy shall not be contested, except for non-payment of premiums, after it has been
in force for two years from the date of issue. The validity of this policy shall not be contested on the basis
of a statement made relating to insurability by any person covered under this policy after such insurance
has been in force for two years during such person's lifetime, and shall not be contested unless the
statement is contained in a written instrument signed by the person making such statement.
Legal Proceedings
A claimant or the claimant's authorized representative cannot start any legal action:
1. until 60 days after Proof of claim has been given; or
2. more than three years after the time Proof of claim is required.
Form ADOP-GNP-2.11 General Provisions
SECTION 7 - GENERAL PROVISIONS
(Continued)
Misstatement of Age
If a Covered Person's age has been misstated, an equitable adjustment will be made in the premium. If
the amount of the benefit is dependent upon an Employee's age, the amount of the benefit will be the
amount an Employee would have been entitled to if his correct age were known.
A refund of premium will not be made for a period more than 12 months before the date Liberty is
advised of the error.
Notice and Proof of Claim
1. Notice
a. Notice of claim must be given to Liberty within 20 days of the date of the loss on which the claim
is based, if that is possible. If that is not possible, Liberty must be notified as soon as it is
reasonably possible to do so. Such notice of claim must be received in a form or format
satisfactory to Liberty.
b. When written notice of claim is applicable and has been received by Liberty, the Covered Person
will be sent claim forms. If the forms are not received within 15 days after written notice of claim
is sent, the Covered Person can send to Liberty written Proof of claim without waiting for the
forms.
2. Proof
a. Proof of loss must be given to Liberty no later than 90 days after the end of the Elimination
Period.
b. Failure to furnish such Proof within such time shall not invalidate or reduce any claim if it was
not reasonably possible to furnish such Proof within such time. Such Proof must be furnished as
soon as reasonably possible, and in no event, except in the absence of legal capacity of the
claimant, later than one year from the time Proof is otherwise required.
c. Proof of continued loss, continued Disability or Partial Disability, when applicable, and Regular
Attendance of a Physician must be given to Liberty within 90 days of the request for such Proof.
Liberty reserves the right to determine if the Covered Person's Proof of loss is satisfactory.
Payment of Claims
The benefit is payable to the Covered Person. But, if a benefit is payable to a Covered Person's estate, a
Covered Person who is a minor, or who is not competent, Liberty has the right to pay up to $2,000 to any
of the Covered Person's relatives or any other person whom Liberty considers entitled thereto by reason
of having incurred expense for the maintenance, medical attendance or burial of the Covered Person. If
Liberty in good faith pays the benefit in such a manner, any such payment shall fulfill Liberty's
responsibility for the amount paid.
Form ADOP-GNP-3.12 General Provisions
SECTION 7 - GENERAL PROVISIONS
(Continued)
Right of Recovery
Liberty has the right to recover any overpayment of benefits caused by, but not limited to, the following:
1. fraud;
2. any error made by Liberty in processing a claim; or
3. the Covered Person's receipt of any Other Income Benefits.
Liberty may recover an overpayment by, but not limited to, the following:
1. requesting a lump sum payment of the overpaid amount;
2. reducing any benefits payable under this policy;
3. taking any appropriate collection activity available including any legal action needed; and
4. placing a lien, if not prohibited by law, in the amount of the overpayment on the proceeds of any
Other Income Benefits, whether on a periodic or lump sum basis.
It is required that full reimbursement be made to Liberty.
Statements
In the absence of fraud, all statements made in any application are considered representations and not
warranties (absolute guarantees). No representation by:
1. the Sponsor in applying for this policy will make it void unless the representation is contained in
the signed Application; or
2. any Employee in enrolling for insurance under this policy will be used to reduce or deny a claim
unless a copy of the Enrollment Form, signed by the Employee if required, is or has been given to
the Employee.
Form ADOP-GNP-4.3 General Provisions
SECTION 7 - GENERAL PROVISIONS
(Continued)
Workers' Compensation
This policy and the coverages provided are not in lieu of, nor will they affect any requirements for
coverage under any Workers' Compensation Law or other similar law.
Form ADOP-GNP-5 General Provisions
SECTION 8 - PREMIUMS
Premium Rates
Liberty has set the premiums that apply to the coverage(s) provided under this policy. Those premiums
are shown in a notice given to the Sponsor with or prior to delivery of this policy.
A change in the initial premium rate(s) will not take effect within the first 36 months, except that Liberty
may change premium rates at any time for reasons which affect the risk assumed, including those
reasons shown below:
1. a change occurs in the policy design;
2. a division, subsidiary or Associated Company is added to or deleted from this policy;
3. when the number of Covered Persons changes by 15% or more from the number insured on this
policy's effective date; or
4. a change in existing law which affects this policy.
No premium may be changed unless Liberty notifies the Sponsor at least 31 days in advance. Premium
changes may take effect on an earlier date when both Liberty and the Sponsor agree.
Payment of Premiums
1. All premiums due under this policy, including adjustments, if any, are payable by the Sponsor on or
before their due dates at Liberty's Administrative Office, or to Liberty's agent. The due dates are
specified on the first page of this policy.
2. All payments made to or by Liberty shall be in United States dollars.
3. If premiums are payable on a monthly basis, premiums for additional or increased insurance
becoming effective during a policy month will be charged from the next premium due date.
4. The premium charge for insurance terminated during a policy month will cease at the end of the
policy month in which such insurance terminates. This manner of charging premium is for
accounting purposes only. It will not extend insurance coverage beyond a date it would have
otherwise terminated as shown in the "Termination of a Covered Person's Insurance" provision of
this policy.
5. If premiums are payable on other than a monthly basis, premiums for additional, increased, reduced
or terminated insurance will cause a prorated adjustment on the next premium due date.
6. Except for fraud and premium adjustments, refunds of premiums or charges will be made only for:
a. the current policy year; and
b. the immediately preceding policy year.
Form ADOP-PRE-1 Premiums
SECTION 8 - PREMIUMS
(Continued)
Grace Period
This is the 31 days following a premium due date, other than the first, during which premium payment
may be made. During the grace period this policy shall continue in force, unless the Sponsor has given
Liberty written notice 31 days in advance of discontinuance of this policy.
Waiver of Premium
Premium payments for a Covered Person are waived during any period for which benefits are payable.
If coverage is to be continued, premium payments must be resumed following a period during which
they were waived.
Form ADOP-PRE-2 Premiums
AMENDMENT NO. X
It is agreed the following changes are hereby made to this policy: GF3-890-450911-01
CHANGE(S)
ADDITIONS
DELETIONS
The effective date of this change is January 1, 200x.
The changes will only apply to Disabilities or Partial Disabilities which start on or after the effective date
of this change.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 3rd day of January, 20xx.
Issued to and Accepted by:
Metropolitan St. Louis Sewer District
Sponsor
V
By t 0,A,*(0iihL ( e041.uAtfl
Signature and Title of Offiter
Liberty Life Assurance Company of Boston
Form ADOP-AMENDMENT Delete/Add Policy Pages
J
/a)
The Metropolitan St . L ouis
Sewer Distric
Gr oup L ong Term Dis ability Insurance
Program
Liber ty
Mutual®
Liberty Life Assurance C ompa ny
of Boston
Liberty
Mutual®
7/09
CER TIFICATE OF COVERAGE
Liberty Life Assurance C ompany of Bost on welc omes your empl oyer
as a cli ent.
Sponsor: Metrop olitan St. Louis Sewer District
P olicy Number: GF3-890450911-01
Effective Date: February 1, 2009
When this plan refers to "you" or "y our" it means the Employee
insured under this pl an . This is y our Disability Income certificat e of
coverage as l ong as y ou are eligible for ins urance and remain insured.
A few w ords ab out this certificate of c over age ...
It is written in plain English . A few terms and provisions are written
as required by insurance law . PLEASE READ IT CAREFULLY .
If you h ave any questions abo ut any terms and pr ovisi ons, please
c ontact the Insurance Administrat or at y our work l oc atio n or write
to Liberty. Liberty will assist y ou in any way we c an to help y ou
u nderstand your ben efits.
Also, if the terms of your certificate of c over age and the policy differ,
the p olicy will g overn . Your coverage m ay be terminated or m odified
in whole or in part under the terms and provisions of the policy .
C••••.,"\_
E xecutiv e Vice President
ADOC-1
SECTI ON 1- SCHED ULE OF BENEFITS
ELIGIBILITY REQUI REMENTS FO R INSURANCE BENEFI TS
What is the Minimum Hourly Requirement?
TABLE OF CONTENTS
SECTION 1 SCHEDULE OF BENEFITS
SECTION 2 DEFINITIONS
SECTION 3 ELIGIBILITY AND EFFECTIVE
DATES
SECTION 4 DISA BILITY INCOME BENEFITS
SECTION 5 EXCLUSIONS
SECTION 6 TERMINATION PROVISIONS
SECTION 7 GENERAL PR OV ISIONS
ADOC-TOC
Employees working a minimum of 20 regularly sched uled hours per
week
Who is Eligible f or Long Term Disability Benefits?
Class 1: All full-time Empl oyees
Note: temporary and seas onal Empl oyees and Empl oyees who
are not United States citize ns or legal residents w orki ng in
the United States are not c overed under this pl an
Wh at is the Eligibility Waiting Period?
1. If you are employed by th e Spons or on the plan effective date
- n one
2. If you begin empl oyment f or the Sp ons or after the plan
effecti ve date - 29 d ays of c onti nuous, Active Employment
Are Employe e Contributi ons Required?
No
ADOC-SCH-1 Schedule of Benefits
-2-
-3-
SECTION 1- SCHEDULE OF BENEFITS
(C ontinued)
LONG TERM DIS ABILIT Y COVE RAGE
Wha t is the Eliminati on Period?
90 days
What is the Amo unt of Insur ance Benefits?
60% of Basic Mo nthly Earnings n ot to exceed a Maximum M onthly
Benefit of $6,000 less O ther Income Benefits and Other Inc ome
Earnings as o utlined in Sectio n 4.
Wha t is the Maximum Basic Mo nthly Earnings on which the Benefit
is Based?
$10,000
What is the Own Occupation Duratio n?
36 Mo nth O wn Occupatio n
A DOC-SCH-3 Schedule of Benefits
SECTI ON 1- SCHEDULE OF BENEFITS
(C ontinued)
LONG TERM DISABILITY CO VER AGE (C ontinued)
What is the Minimum Monthly Benefit?
The Minimum Monthly Benefit is $100 or 15% of your Gr oss M onthly
Benefit, which ever is gre at er.
What is the Maximum Benefit Period?
Age at Disability Maximum Benefit Peri od
Less than age 60
60
61
62
63
64
65
66
67
68
69 and over
Age 65 (but n ot less than 5 years)
60 months
48 m onths
42 m onths
36 m onths
30 m onths
24 m onths
21 months
18 m onths
15 months
12 months
ADOC -SC H-4 Schedule of Benefits
-4-
-5-
SECTION 2 - DEFINITIONS
In this secti on Liberty defines some basic terms needed to understand
this plan.
"Active Employment" means you must be actively at work f or the
Spo nso r:
1. on a full-time basis and paid regular earnings;
2. for at least the minimum number of h ours shown in the
Schedule of Benefits; and either perform such work:
a.
b.
at the Sponsor's usual place of business; or
at a location to which the Sponsor's business requires
yo u to travel.
You will be considered actively at work if you were actually at work
on the day immediately preceding:
1. a weekend (except where one or both of these d ays are
scheduled work days);
2. ho lidays (ex cept when the holiday is a scheduled work day);
3. paid vacatio ns;
4. any no n-scheduled work da y;
5. an ex cused leave of a bsence (ex cept medica l leave fo r yo ur
o wn disabling co ndition and lay-off); and
6. an emergency leave of absence (ex cept emergency medical
leave for your own disabling condition).
"Administrative Office" means Liberty Life Assurance C ompany of
Bo ston, 9 Riverside Ro ad, Weston, MA 02493.
ADOC -DEF-1 Definitions
SECTION 2 - DEFINITIONS
(C ontinued)
"Any Occupati on" means any occupatio n that you are or bec ome
reas onably fitted by tr aining, educati on, e xperience, age, physical
and mental capacity.
"Appr opriate Available Treatment" means care or services which
are:
1. gener ally acknowledged by Physicians to cure, correct, limit,
treat or ma nage the disabling conditi on;
2. accessible within y our geographical region;
3. pr ovided by a Physici an who is licensed and qualified in a
discipline suitable to treat the dis abling Injury or Sickness;
4. in accordance with generally accepted medic al standards of
pr actice .
"B asic M onthly Earnings" means your monthly rate of earnings
from the Sponsor in effect immediately prior to the date Disability
or Partial Disability begins . However, such earnings will not include
bonuses, commissions, o vertime pay and extr a c ompensation .
ADOC-DEF-2 Definiti ons
-6-
-7-
SECTION 2 - DEFINITIONS
(C ontinued)
"Disability" or "Dis abled" means:
1. For persons other than pilots, co-pil ots, and crewmembers of
an aircraft:
"Disability" or "Disabled" me ans that during
the Elimination Period and the next 36 months of
D isability you, as a result of Injury or Sickness, are
unable to perf orm the Material and Substantial
D uties of your Own Occupation; and
ii. thereafter, you are un able to perform, with
reaso nable continuity, the Material and Substantial
Duties of Any Occupation.
2. With respect to Covered Perso ns employed as pilots, co-
pilots and crewmembers of an aircraft:
"D isability" or "Disabled" means as of a result of Injury or
Sickness: (a) yo u cannot perfo rm the material and substa ntial
duties of your own o ccupation; a nd (b) after benefits ha ve
been paid for 12 mo nths, you are unable to perform the
Material and Substa ntial Duties of Any O ccupation.
"Disability Benefits under a R etirement Plan" means money which:
1. is payable under a Retirement Plan due to D isability as
defined in that plan; and
2. do es not reduce the amount of mo ne y which would have
been paid as retirement benefits at the normal retirement
age under the plan if the Disability had no t occurred. (If the
payment do es cause such a reduction, it will be deemed a
Retirement Benefit as defined in this plan.)
ADOC-DEF-3.1 Definitions
SECTION 2 - DEFINITIONS
(C ontinued)
"Eligibility Date" means the date y ou become eligible for insurance
under this plan . The Eligibility Requirements are sh own in the
Schedule of Benefits.
"Eligible Sur viv or" means your spo use, if living, otherwise yo ur
children under age 25 .
"Eligibility Waiting Peri od" me ans the c ontinuous length of time
you must be in Active Empl oyment in an eligible class to reach y our
Eligibility Date .
"Elimin ation Peri od" means a peri od of c onsecutive days of
Dis ability or Partial Disability f or which no benefit is payable . The
Elimination Period is shown in the Schedule of Benefits and begins
on the first day of Disability .
If y ou return to work for any thirty or fewer days during the
Elimination Period and can not c ontinue, Liberty will c ount only those
days you are Disabled or Partially Disabled to satisfy the Elimination
Period .
"Employee" means a person in Active Employment with the Sp onsor .
"Enr ollment Form" is the d ocument completed by y ou, if required,
when enrolling for coverage . This form m ust be satisfactory to
Liberty.
ADOC -DEF-4.8 Definiti ons
-8-
-9-
SECTION 2 - DEFINITIONS
(Continued)
"Extended Treatment Pl an" means c ontinued care th at is c onsistent
with the American Psychi atric Association's standard principles of
Treatment, and is in lieu of confinement in a H ospital or Institution .
It must be approved in writing by a Physician.
"Family and Medical Leave" me ans a leave of absence f or the birth,
adoptio n or fo ster care of a child, or for the care of y our child, spouse
or parent or fo r your own serious health conditi on as those terms
are defined by the Federal Family and Medical Leave Act of 1993
(FMLA ) and any amendments, or by applicable state law .
"G ross Monthly Benefit" means your Monthly Benefit before any
reductio n for Other Income Benefits and Other Income Earnings.
"Hospital" or "Institutio n" means a facility licensed to pr ovide
Treatment fo r the co nditio n ca using your D isability.
ADOC-DEF-5 Definitions
SECTION 2 - DEFINITIONS
(Continued)
"Initial Enr ollment Period" means one of the f ollowing peri ods
during which you may first enroll for coverage under this plan:
1. if y ou are eligible for insurance on the plan effecti ve date, a
peri od before the pla n effecti ve date set by the Sp onsor and
Liberty .
2. if y ou bec ome eligible for insurance after the plan effective
date, the peri od which e nds 31 days after y our Eligibility
Date .
"Injury" means bodily impairment resulting directly from an
accident and independently of all other ca uses. For the p urpose of
determining benefits under this plan:
1. any Disability which begins m ore than 60 days after an Injury
will be considered a Sickness; and
2. any Injury which occurs before y ou are c overed under this
plan, but which accounts for a medical conditi on th at arises
while y ou are c overed under this plan will be treated as a
Sickness .
"Last M onthly Benefit" means the gr oss M onthly Benefit payable to
you pri or to y our death without any reducti on for earnings recei ved
from empl oyment .
"Material and Substantial Duties" means responsibilities that are
normally required to perf orm y our Own Occupati on, or any other
occupation, and cannot be reas onably eliminated or m odified .
ADOC-DEF-6 Definiti ons
-10-
-11-
SECTION 2 - DEFINITIONS
(C ontinued)
"Mental Illness" means a psychiatric or psychol ogical conditi on
cla ssified as such in the most current editi on of the Di agnostic and
Statistical Manual of Mental Disorders ( DSM) regardless of the
underlying cause of the Mental Illness. If the DSM is disc ontinued,
Liberty will use the replacement chosen or published by the American
Psychia tric Association .
"Mo nthly Benefit" means the monthly amo unt pay able by Liberty to
you if you are Disabled or Partially Disabled.
"No n -Verifiable Sympto ms" means your subjective complaints to
a Physician which cannot be diagnosed using tests, procedures or
clinical ex aminatio ns typically accepted in the pr actice of medicine .
Such sympto ms may include, but are not limited to, dizziness,
fatigue, headache, loss of energy, numbness, pain, ringing in the ear,
and stiffness.
"Own Occupa tion" means your occupation that you were performing
when your D isability or Partial Disability began. For the purposes of
determining D isability under this plan, Liberty will consider y our
o ccupatio n as it is normally performed in the nationa l economy.
ADOC-DEF-7 Definitio ns
SECTIO N 2 - DEFINITIONS
(Continued)
"Partial Disability" or "Partially Disabl ed" means y ou, as a res ult of
Injury or Sickness, are able t o:
1. perform one or more, but not all, of the Material and
Substantial Duties of your Own Occupati on or Any
Occupati on on an Acti ve Empl oyment or a part-time b asis;
or
2. perform all of the Materi al and Substantial Duties of your
Own Occupati on or Any Occupation on a part-time basis;
and
3. earn between 20% and 80% of y our Basic M onthly Earnings .
"Physician" means a person who:
1. is licensed to practice medicine and is pr acticing within the
terms of his license; or
2. is a licensed practitioner of the healing arts in a category
specifically fav ored under the he alth insurance laws of the
state where the Treatment is received and is practicing within
the terms of his license .
It does n ot include you, any family member or d omestic partner .
ADOC -D EF-8 Definiti ons
-12-
-13-
SECTION 2 - DEFINITIONS
(Continued)
"Proof" means the evidence in support of a claim for benefits and
includes, but is not limited to, the foll owing:
1. a claim form completed and signed (or otherwise formally
submitted) by you claiming benefits;
2. an attending Physician's statement complet ed and signed ( or
otherwise formally submitted) by your attending Physician;
and
3. the provision by the attending Physici an of standard
diagno sis, chart no tes, lab findings, test results, x-rays and/
or other forms of objective medical evidence in supp ort of a
claim for benefits.
Proof must be submitted in a fo rm or fo rmat satisfactory to Liberty .
"Regular Attendance" means yo ur persona l visits to a Physici an
which a re medically necessary according to generally accepted
medical standards to effectively manage and trea t your Disability or
Partial D isability.
"Retirement Benefit under a R etirement Plan" means money which:
1. is paya ble under a Retirement Plan either in a lump sum or
in the fo rm of perio dic payments;
2. does no t represent contributio ns made by yo u (payments
which represent yo ur co ntributions are deemed to be
received over your expected remaining life regardless of
when such pa yments are actually received); a nd
3. is payable upon:
a.
b.
early or normal re tire me nt; or
Disa bility, if the payment do es reduce the amount of
money whic h would ha ve be en pa id under the plan at
the no rmal retirement age.
ADOC-DEF-9 Definitio ns
SE CTION 2 - DEFINITIONS
(C ontinued)
" Retirement Plan" means a plan which pr ovides retirement benefits to
y ou and which is not funded wh olly by y our c ontributions. The term
sh all not include a pr ofit-sharing plan, i nf ormal salary continuation
pl an, registered retirement savings plan, stock ownership plan,
401(K) or a non -qualified plan of deferred compensatio n.
"Schedule of Benefits" means the section of this plan which shows,
am ong other things, the Eligibility Requirements, Eligibility Waiting
Peri od, Eliminati on Peri od, Am ount of Insurance, Minimum Benefit,
and Maximum Benefit Period.
"Sickness" means illness, disease, pregnancy or complic ations of
pregnancy .
"Spons or" means the entity to whom this plan is issued.
"Sponsor's Retirement Plan" is deemed to include any Retirement
Plan:
1. which is part of any Federal, State, Municipal or Association
retirement system; or
2. for which you are eligible as a result of empl oyment with the
Sponsor .
"Substance Abuse" means alcohol and/or drug abuse, addiction or
dependency .
"Treatment" means receiving medical advice, receiving care or
services provided by or under the direction of a Physician including
diagnostic measures, being prescribed drugs and/ or medicines,
whether you ch ooses to t ake them or n ot, and taking drugs and/ or
medicines.
ADOC-DEF-10.1 Definiti ons
-14-
-15-
SECTION 3 - ELIGIBILITY AND EFFECTIVE D ATES
Who is Eligible f or C overage?
The eligibility requirements for insurance benefits are shown in the
Schedule of Benefits .
What is Yo ur Eligibility Date for Insurance Benefits?
If you are in an eligible class you will qualify for insurance on the
later of:
1. this plan's effective date; or
2. the day a fter you complete the Eligibility Waiting Period
shown in the Schedule of Benefits.
ADOC-ELG-1 Eligibility a nd Effective Da tes
SECTION 3 - ELIGIBILITY AND EFFECTIVE D ATES
(C ontinued)
What is Your Effective Date of Insurance?
Your insurance will be effective at 12:01 A .M . St andard Time in the
g overning j urisdicti on on the day determined as foll ows, but only if
your application or enrollment for insurance is made with Liberty
through the Sponsor in a form or f ormat satisfactory to Liberty.
You will be insured on your Eligibility D ate .
When will Y our Effective Date of Insurance be Del ayed?
Y our effective dat e of any initial, incre ased or additional insurance
will be delayed if you are not in Active Employment because of
Injury or Sickness . The initial, increased or additional insurance will
begin on the date you return to Active Employment.
ADOC-ELG-2 Eligibility and Eff ective D ates
-16-
-17-
SECTION 3 - ELIGIBILITY AND EFFECTIVE D ATES
(Continued)
What Happens to Your C overage During a Family and Medical
Leave?
Your co verage may be continued under this pl an f or an appr oved
family or medical leave of absence for up to 12 weeks following the
da te coverage would have terminated, subject to the f oll owing:
1. the authorized leave is in writing;
2. the required premium is paid;
3. yo ur benefit level, or the amount of earnings up on which
yo ur benefit may be based, will be that in effect on the date
befo re the leave begins; and
4. continuatio n of co vera ge will cease immediately if any one of
the fo llowing events sho uld occur:
a.
b.
c.
d.
e.
yo u return to work;
this plan terminates;
you are no longer in an eligible class;
nonpayment of premium when due by the Sponsor or
yo u;
your employment terminates.
Wha t Happens if You are R ehired?
If yo u are a former Employee and are re -hired by the Sponsor within
12 months of your terminatio n date , a ll past periods of Active
Emplo yment with the Spo nsor will be used in determining your
Eligibility D ate. If you are a fo rmer Emplo yee a nd a re re -hired by the
Spo nsor mo re than 12 mo nths after your termination date, yo u are
co nsidered to be a new Emplo yee when determining your Eligibility
D ate.
Fa mily a nd Medical Leave/Rehire
ADOC-ELG-7 Eligibility and Effective Da tes
SECTION 3 - ELI GIBILITY AND EFFECTIVE D ATES
(C ontinued)
What Happens During Leave of Absence?
The Spons or may continue y our c overage(s) by paying the required
premiums, if you are given a leave of absence.
Your c overage will n ot c ontinue beyond the end of the plan m onth
f ollowing the plan m onth in which the leave of absence begins. In
continuing such coverage u nder this provision, the Sponsor agrees to
treat all c overed Employees equally.
What H appens During Lay-off?
The Sp onsor may continue y our c overage(s) by paying the required
premiums, if y ou are temp orarily laid off.
Y our coverage will not c ontinue beyo nd the end of the plan month
in which the l ay-off begins. In continuing such coverage under this
pro vision, the Sponsor agrees to treat all covered Empl oyees equally .
Le ave of Absence/Lay-Off
ADOC-ELG-8 Eligibility and Effective Dates
-18-
-19-
SE CTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
What Happens if There is a Transfer of Insurance Carriers?
In o rder to prevent loss of coverage for y ou because of transfer of
insurance carriers, this plan will provide co verage for you as follows:
If Yo u are no t in Active Employment Due to Injury or Sickn ess
Subject to premiu m payments, this plan will cover you if:
1. at the time of transfer you were covered under the prior
carrier's plan; and
2. yo u are not in A ctive Employment due to Injury or Sickness
on the effective date of this plan.
Benefits will be determined based on the lesser of:
1. the amo unt of the Disability benefit that would have been
pa yable under the prior plan and subject to any applicable
plan limitations; or
2. the amount of D isability benefits payable under this plan. If
benefits are payable under the prio r plan fo r the Disability,
no benefits a re payable under this plan.
Transfer Pro vision
AD OC-ELG-9 Eligibility and Effective Dates
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
If Y ou are Disabled Due to a Pre -E xisting Conditi on
If y ou were insured under the prior carrier's plan at the time of
transfer and were in Active Empl oyment and insured under this plan
on its effective date, benefits may be payable for a Disability d ue to a
Pre -Existing C ondition .
If y ou can satisfy this plan's Pre -Existing C ondition E xclusi on, the
benefit will be determined acc ording to this plan .
If y ou cann ot s atisfy this plan's Pre -E xisting Conditi on Exclusi on,
then:
1. Liberty will apply the Pre -Existing C ondition E xclusion of
the prior carrier's plan; and
2. if you would have satisfied the prior carrier's pre-existing
condition exclusion, giving consideration t owards contin uous
time cover age under this plan and the prior carrier's plan, the
benefit will be determined according to this plan. However,
the Ma ximum M onthly Benefit amount payable under this
plan sh all n ot exceed the ma ximum m onthly benefit payable
under the pri or carrier's plan .
No benefit will be paid if you cannot satisfy the Pre -E xisting C onditi on
Excl usions of either plan .
Transfer Pr ovisi on
ADOC-ELG-9 Eligibility and Effective D ates
-20-
-21-
SECTION 4 - DISABILITY IN COME BENEFITS
LONG TERM DISABILITY COVE RAGE
Disability Benefit
When is Yo ur Disability Benefit Payable?
When Liberty receives Proof that y ou are Disabled due to Injury or
Sickness a nd require the Regular Attendance of a Physician, Liberty
will pay yo u a Mo nthly Benefit after the end of the Eliminati on Peri od,
subject to any o ther provisions of this plan . The benefit will be paid
fo r the period of D isa bility if you give to Liberty Pr oof of continued:
1. D isability;
2. Regular A ttendance of a Physician; and
3. Appropriate Available Treatment.
The Pro of must be given upo n Liberty's request and at your e xpense .
In determining whether yo u are D isabled, Liberty will not consider
employment fa ctors including, but not limited to , interpersonal
conflict in the wo rkplace, recessio n, jo b obsolescence, paycuts,
job sharing and loss of a pro fessio na l or o ccupatio nal license or
certification.
For pu rpo ses of determining Disability, the Injury must o ccur and
Disability must begin while yo u are insured fo r this co vera ge.
The Mo nthly Benefit will not:
1. exceed your Amount of Insurance; or
2. be pa id fo r lo nger than the Max imum Benefit Period.
The Amo unt of Insurance and the Max imum Benefit Period are
shown in the Schedule of Benefits.
Lo ng Term Disability
ADOC-LTD-1 Sta ndard Integration
SECTION 4 - DIS ABILITY INCOME BENEFITS
(C ontinued)
L ON G TERM DISABILITY CO VER AGE (C ontinued)
Disability Benefit (Continued)
How is Your Am ount of Disability Monthly Benefit Figured?
To figure the amount of your M onthly Benefit:
1. Take the lesser of:
a. your Basic M onthly Earnings multiplied by the benefit
percentage sh own in the Schedule of Benefits; or
b. the Ma ximum M onthly Benefit shown in the Schedule of
Benefits; and then
2. Deduct Other Inc ome Benefits and Other Inc om e Earnings,
(shown in th e Other Inc ome Benefits and Other Income
Earnings pr ovisi on of this plan), fr om this am ount .
The M onthly Ben efit p ay able will not be less than the Minimum
Monthly Benefit shown in the Schedule of Benefits . Howe ver, if
an overpayment is due to Liberty, the Minimum M onthly Benefit
otherwise payable under this pr ovisi on will be applied toward
satisfying the overpayment .
L ong Term Disability
A DOC -LTD-1 Standard Integrati on
-22-
-23-
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DIS ABILITY COVERAGE (Continued)
Partial Disability
When is Yo ur Partial Disability Benefit Payable?
When Liberty receives Proof that you are Partially Disabled and have
ex perienced a loss of earnings due to Injury or Sickness and require
the Regular Attendance of a Physician, y ou may be eligible to receive
a Mo nthly Benefit, subject to any other pr ovisi ons of this plan. To be
eligible to receive Pa rtial D isability benefits, y ou may be empl oyed
in your Own Occupatio n or another occupati on, must satisfy the
Elimination Period and must be earning between 20% and 80% of
yo ur Basic Monthly Earnings.
A Mo nthly Benefit will be paid for the period of P artial Disability if
you give to Liberty Proof of continued:
1. Partial D isability;
2. Regu lar Attendance of a Physician; and
3. Appropriate Av ailable Trea tment.
The Proof must be given upo n Liberty's request and at your ex pense.
In determining whether yo u are Partially Disabled, Liberty will
not consider employment facto rs including, but not limited to,
interperso nal conflict in the workplace, recession, job obsolescence,
paycuts, jo b sharing and loss of a pro fessional or o ccupational license
or certificatio n.
Fo r purposes of determining Partia l D isability, the Injury must occur
and Partial Disability must begin while you are insured fo r this
coverage.
Lo ng Term Partial Disability with Work Incentive
ADOC-LTD-5 Loss of Ea rnings
I!
SECTI ON 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVER AGE (Continued)
Partial Disability (Continued)
How is Y our Loss of Earnings Partial Disability Benefit Fig ured using
the L oss of Earnings with W ork I ncentive Monthly C alculati on?
For the first 12 months, the w ork incentive benefit will be an
am ount equal to your Basic Monthly E arnings multiplied by the
benefit percentage shown in the Schedule of Benefits, without any
reducti ons fr om earnings . The work incenti ve benefit will only be
reduced, if the Monthly Benefit payabl e plus any earnings exceed
100% of your B asic Monthly Earnings. If the combined t otal is more,
the Monthly Benefit will be reduced by the e xcess am ount so that the
M onthly Benefit plus your earnings d oes n ot exceed 100% of your
Basic M onthly Earnings .
Lo ng Term Parti al Disability with W ork Incentive
ADOC-LT D-5 Loss of Earnings
-24-
-25-
SECTION 4 - DISABILITY IN COME BENEFITS
(C ontinued)
LONG TERM DISABILITY COVE RA GE (Continued)
Pa rtial Disability (Continued)
How is Yo ur Loss of Earnings Partial Disability Benefit Figured
using the Loss of Earnings with Work Incentive M onthly
Calculation? (Continued)
Thereafter, the Mo nthly Benefit will be calcul ated as f ollows:
1. Your Basic Monthly Earnings minus y our earnings received
while you are Partially Disabled . This figure represents the
a mount of lost earnings.
2. Multiply the amo unt of lost earnings by 75%; and then
3. deduct Other Inco me Benefits (sho wn in the Other Income
Benefits and Other Inco me Earnings provision of this pla n)
fro m this amo unt.
The Mo nthly Be ne fit payable will no t be less tha n the Minimum
Mo nthly Benefit sho wn in the Schedule of Benefits. However, if
an overpayment is due to Liberty, the Minimum Monthly Benefit
otherwise payable under this prov isio n will be applied toward
satisfying the o verpayment.
Long Term Partial Disa bility with Wo rk Incentive
AD OC-LTD-6 Loss of Earnings
SECTION 4 - DISABILITY INCOME BENEFITS
(C ontinued)
LONG TERM DISABILITY COVE RAGE (C ontinued)
Mental Illness, Substa nce Abuse and/or Non -Verifiable Symptoms
Limitation
Wh at Limitati ons will Apply f or Ment al Illness, Subst ance Abuse
and/or Non -Verifiable Sympt oms?
The benefit f or Disability due to Ment al Illness, Subst ance Abuse
and/ or N on -Verifiable Sympt oms will not exceed a period of 24
months of M onthly Benefit payments while y ou are insured under
this plan.
If yo u are in a Hospital or Institution for Mental Illness and/or
Substa nce Ab use at the end of the period of 24 mo nths, the M onthly
Benefit will be paid during the c onfinement .
If you are n ot c onfined in a H ospital or Institution for Mental Illness
and/or Substance Abuse, but are fully participating in an Extended
Treatment Pl an for the condition that caused Disability, the Mo nthly
Benefit will be payable to y ou f or up to a peri od of 36 m onths.
In no e vent will the Monthly Benefit be payable beyond th e Maximum
Benefit Peri od shown in the Schedule of Benefits.
ADOC-LTD-9
L ong Term Disability
Mental Illness, Subst ance Abuse and/or
Non -Verifiabl e Sympt oms Limit ation
-26-
-27-
SECTION 4 - DISABILITY INCOME BENEFITS
(C ontinued)
LONG TERM DISABILI TY COVERAGE (Continued)
Reha bilitation Incentive Benefit
Whe n is Yo ur Rehabilitati on Incentive Benefit Payable?
Liberty will pay an increased M onthly Benefit while you are fully
participating in a R ehabilitati on Pr ogram. Liberty must first appr ove
the Rehabilitatio n Pro gram in writing before y ou can be c onsidered
fo r this benefit. If Liberty does n ot appr ove a Rehabilit ati on
Pro gram, the regular Disa bility benefit will be pay able provid ed
yo u are D isabled under the terms of this plan. To be eligible f or a
Rehabilitation Incentive Benefit, you must:
1. be D isabled and receiving benefits under this plan; and
2. be fully pa rticipating in a Rehabilitation Progr am appr oved
by Liberty.
What is Your Increased Monthly Benefit?
If yo u are eligible fo r a Rehabilitatio n Incentive Benefit, the benefit
perce ntage, sho wn in the Schedule of Benefits, will be increa sed to
70%. The increased benefit will begin on the first day of the month
after Liberty receives written Pro of of your full participatio n in the
Re habilitatio n Program.
Wha t is Yo ur Decrea sed Monthly Benefit?
If yo u, at any time , decline to fully participa te in an appro ved
Rehabilita tio n Progra m reco mmended by Liberty, the benefit
percentage sho wn in the Schedule of Benefits will be reduced to 50%
beginning on the first day of the mo nth fo llowing your declin atio n to
fully participate in the appro ved Rehabilitation Program. If Liberty
recommends rehabilitatio n, benefits will be paid at the reduced
a mount fro m the date recommendation is made until Liberty receives
your written agreement to fully participate in the Rehabilitation
Progra m.
Lo ng Te rm Disability
ADOC-LTD-10 Rehabilitatio n
SECTION 4 - DIS ABILITY INCOME BENEFITS
(C ontinued)
LONG TERM DISABILITY COVER AGE (C ontinued)
Rehabilitation Incentive Benefit (Continued)
When will Your Rehabilitati on Incentive Benefit be Discontinued?
The Rehabilitati on Incentive Ben efit will cease:
1. when you are no l onger fully participating in a Rehabilitati on
Program appr oved by Liberty;
2. in acc ordance with the pr ovisi ons entitled "When will Y our
Long Term Disability Benefit Be Disc ontinued?"; or
3. when the Rehabilitati on Pr ogr am ends .
F or the purp ose of this provisi on, " Rehabilitati on Pr ogram" means
a c omprehensive individu ally tail ored, g oal oriented program to
return y ou, if y ou are Disabled, to gainful employment . The services
offered may include, but are n ot limited to, the f oll owing:
1. physical therapy;
2. occupational therapy;
3. work hardening progr ams;
4. functional c apacity evaluati ons;
5. psych ol ogical and vocati onal counseling;
6. rehabilitative empl oyment; and
7. v ocati onal r eh abilitati on services .
Long Term Disability
ADOC -LT D-10/11 Rehabilitati on
-28-
-29-
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVE RAGE (C ontinued)
Three Month Survivor Benefit
What Happens to Your Benefit if Y ou Die?
Liberty will pay a lump sum benefit to the Eligible Survivor when
Proo f is receiv ed that you died:
1. after Disability had continued for 180 or m ore c onsecutive
days; and
2. while receiving a Monthly Benefit .
The lump sum benefit will be an amount equal to thr ee times y our
Last Monthly Benefit.
If the survivor benefit is payable to your children, payment will be
made in equa l shares to the children, including step children and
legally adopted children. Ho wever, if any of said children are min ors
or incapacitated, payment will be made on their behalf to the c ourt
a ppo inted guardian of the children's pro perty. This payment will
be v alid and effective a gainst all claims by o thers representing or
claiming to represent the children.
If there is no Eligible Survivor, the benefit is payable to the esta te.
If an o verpa yment is due to Liberty at the time of your death, the
benefit paya ble under this provision will be a pplied towa rd satisfying
the o verpayment.
Long Term Disability
ADOC-LTD-12 Three Month Survivo r
SEC TION 4 - DIS ABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY C OVERAGE (Continued)
Workplace M odificati on Benefit
When is Y our W orkplace M odificati on Benefit Payable?
If you are Disabled or Partially Disabled and receiving a benefit
fr om Liberty, a benefit may be payable to the Sponsor as part of y our
benefit for m odificati ons to the w orkplace to acc omm odate y our
return to w ork or to assist y ou in rem aining at work .
Liberty will reimburse the Sponsor for up to 100% of reas onable costs
the Sp ons or inc urs for the modific ation, up to the greater of:
1. $1,000; or
2. the equiv alent of tw o m onths of your M onthly Benefit.
To qualify for this benefit:
1. the Disability or Partial Disability must prevent you from
performing s ome or all of the Materi al and Substantial Duties
of y our occupation; and
2. any pr op osed m odificati ons must be approved in writing
and signed by you, the Sponsor and Liberty; and
3. the Sponsor must agree to make the m odificatio ns to the
workplace to reaso nably accommodate y our return to w ork
or to assist y ou in remaining at work.
The Spons or's c osts f or the appr oved m odificati ons will be
reimbursed after:
1. the pr op osed modifications have been made;
2. written pro of of the expenses incurred by the Sp onsor has
been provided to Liberty; and
3. Liberty has received proof that you ha ve returned to and/ or
remain at work .
Long Term Disability
ADOC-LTD-16 W orkplace Modification
-30-
-31-
SE CTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVE RA GE (Continued)
Other Income Benefits and Other Inc ome Earnings
What are Yo ur Other Income Benefits and Other Incom e Earnings?
Other Inco me Benefits means:
1. The amo unt for which you are eligible under:
a.
b:
d.
e.
f.
g.
Workers' or Workmen's Compensati on Laws;
O ccupatio nal D isease Law;
Title 46, United States Code Secti on 688 (The Jones Act);
any work loss pro vision in mandat ory "No -Fault" auto
insurance;
Railroad Retirement Act;
any governmenta l co mpulso ry benefit act or law; or
a ny o ther act or law of like intent.
2. The amount of any D isability benefits which you are eligible
to receive under:
a. any other gro up insurance plan of the Sponsor;
b. any governmental retirement system as a result of your
emplo yment with the Spo nso r; or
c. any individual insurance plan where the premiu m is
wholly or partially paid by the Sponso r. Ho wever, Liberty
will o nly re duce the Monthly Benefit if yo ur Mo nthly
Benefit under this plan, plus any benefits that yo u are
eligible to receive under such individual insurance plan
exceed 100% of yo ur Ba sic Mo nthly Earnings. If this sum
exceeds 100% of Basic Monthly Earnings, your Mon thly
Benefit under this plan will be reduced by such excess
amou nt.
ADOC-LTD-24
Long Term Disa bility Primary and
Family Integra tio n
Other Income Benefits and
Other Income Earnings
SEC TION 4 - DIS ABILITY INCOME BENEFITS
(C ontinu ed)
LON G TERM DISABILITY COVERAGE (C ontinued)
Other Income Benefits and Other Income Earnings(Continued)
What are Your Other Inc ome Be nefits and Other Income Earnings?
(C ontinued)
Other Income Benefits means: (C ontinued)
3. The am ount of benefits y ou receive under the Sponsor's
Retirement Pl an as follows:
a. the am ount of any Disability Benefits under a Retirement
Plan, or Retirement Benefits under a Retirement Pl an
you voluntarily elect to receive as retirement payme nt
under the Sponsor's Retirement Plan; and
b. the am ount you recei ve as retirement payments when
y ou reach the l ater of age 62, or n ormal retirement age as
defined in the Sponsor's plan.
4. The am ount of Disability and/or Retirement Benefits under
the United St ates S ocial Security Act, the Canada Pensi on
Plan, the Quebec Pensi on Plan, or any similar pl an or act,
which:
a. y ou receive or are eligible to rec eiv e; and
b. your sp ouse, child or children receive or are eligible to
recei ve because of y our Disability; or
c. your spouse, child or children receive or ar e eligible to
receive becaus e of your eligibility for r etirement benefits.
5. Any am ount y ou receive fr om any unemployment benefits.
ADOC-LTD-24
Long Term Disability Primary and
Family Integrati on
Other Income Benefits and
Oth er Income Earnings
-32-
-33-
SECTION 4 - DISABILIT Y INCOME BENEFITS
( Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Other Income Benefits and Other Income Earnings (C ontinued)
What a re Your Other Inc ome Benefits and Other Inc ome Earnings?
(Continued)
Other Inco me Earnings means:
1. any amo unt you receive from any formal or informal sick
leave or salary co ntinuation plan(s); and
2. the amount of earnings you earn or receive from any f orm of
employment including severa nce.
Other Income Benefits, except retirement benefits, must be payable as
a result of the same Disa bility for which Liberty pays a benefit . The
sum of O ther Inco me Benefits and Other Inco me Earnings will be
deducted in accordance with the provisions of this plan.
A DOC-LTD-25
Lo ng T erm Disa bility Primary and
Family Integration
Other Inco me Benefits and
Other Inco me Earnings
SECTION 4 - DISABILITY IN COME BENEFITS
(Conti nued)
LONG TE RM DIS ABILITY COVE RAGE (C ontinued)
Estimati on of Benefits
H ow will Y our Benefits be Estimated?
Liberty will reduce your Disability or Partial Disability benefits by
the am ount of Other Inc ome Benefits that we estimate are pay able to
y ou and your dependents.
Y our Disability benefit will n ot be reduced by the estimated am ount
of Other Income Benefits if you:
1. provide satisfactory proof of application for Other Inc ome
Benefits;
2. sign a reimbursement agreement under which, in p art, y ou
agree to repay Liberty f or any overpayment resulting fr om
the award or receipt of Other Inc ome Benefits;
3. if applicable, provide s atisfactory pr oof that all appeals f or
Other Inc ome Benefits h ave been made on a timely basis to
the highest administrative lev el unless Liberty determines
that further appeals are n ot likely to succeed; and
4. if applicable, submit satisfact ory pr oof that Other Inc ome
Benefits ha ve been denied at the highest administrati ve le vel
unless Liberty determines that further appeals are n ot likely
to succeed .
Liberty will n ot estimate or reduce for any benefits under the
Spons or's pension or retirement benefit plan acc ording to applicable
law, until y ou actually receive them.
In the event that Liberty overestimates the amount pay able to y ou
fro m any plans referred to in the Other Inc ome Benefits and Other
Inco me Earnings provision of this plan, Liberty will reimburse y ou
fo r such amount up on receipt of written pr oof of the am ount of Other
Income Benefits aw arded (whether by compromise, settlement,
award or judgment) or denied (after appeal through the highest
administrativ e level).
ADOC -LTD-26
L ong Term Disability
Estimati on of Benefits and
S oci al Security Assistance
-R4
-35-
SECTIO N 4 - DISABILITY INCOME BENEFITS
(C ontinued)
LONG TERM DISABILIT Y CO VERAGE (C ontinued)
Estimatio n of Benefits (Continued)
When May Liberty Provide S ocial Security Assistance?
Liberty may help you in applying for S ocial Security Disability Income
Benefits. In order to be eligible for assistance you must be receiving a
Mo nthly Benefit fro m Liberty. Such assistance will be pr ovided only
if Liberty determines that assistance w ould be beneficial.
ADOC-LTD-26
Lo ng T erm Disability
Estimation of Benefits and
Social Security A ssista nce
SECTION 4 - DISABILIT Y INCOME BENEFITS
(C ontinued)
LONG TERM DISABILITY CO VER AGE (C ontinued)
What Happens if Y ou Receive a Lump Sum Payment?
Other Income Benefits from a compr omise, settlement, aw ard or
judgment which are paid to y ou in a lump sum and are meant to
compensate y ou f or any one or more of the f ollowing:
1. l oss of p ast or future wages;
2. impaired earnings capacity;
3. lessened ability to compete in the op en l abor market;
4. any degree of permanent impairment; and
5. any degree of loss of bodily function or capacity;
will be pr orated on a monthly basis as follows:
1. over the peri od of time s uch be nefits would ha ve been paid
if not in a lump sum; or
2. if such period of tim e c annot be determined, the lesser of:
a. the remainder of the M aximum Benefit Period; or
b. 5 years.
What Happens if You Receive any Cost of Living Increases?
After the first deduction f or each of the Other Income Benefits, the
Monthly Benefit will n ot be further reduced due to any cost of li ving
increases p ayable under the Other Income Benefits and Other Income
Earnings pr ovisi on of this pl an. This pr ovision does not apply to
increases receiv ed from any f orm of employment .
What H appens if Your Benefit Peri od is Less than a M onth?
For any period f or which a Long Term Disability benefit is p ayable
tha t does not extend thr ough a full month, the benefit will be paid on
a pro rated basis. The rate will be 1/30th for each day for such period
of Disability.
DOC -LTD-27 L ong Term Disability
-36-
-37-
SECTION 4 - DISABILITY INCOME BENEFITS
(C ontinued)
LONG TERM DISABILITY COVERA GE (C ontinued)
When will Your Long Term Disability Benefits be Discontinued?
The Monthly Benefit will cease on the earliest of:
1. the da te yo u fail to pr ovide Pr oof of c ontinued Disability or
Pa rtial Disability and Regular Attendance of a Physician;
2. the date you fail to cooperate in the administration of
the claim. Such co operation incl udes, but is not limited
to, pro viding any info rmation or documents needed to
determine whether benefits are payable or the actual benefit
amo unt due;
3. the date yo u refuse to be examined or evaluated at reas onable
interva ls;
4. the date you re fuse to receive Appropriate Available
Treatment;
5. the da te you refuse a jo b with the Sponsor where workplace
mo difications or acco mmo datio ns were made to a llow you
to perfo rm the Materia l a nd Substantial Duties of the job;
6. the date you are able to work in yo ur Own Occupation on a
part-time basis, but choo se no t to ;
7. the da te yo ur current Pa rtial Disability ea rnings exceed 80%
of yo ur Basic Monthly Earnings;
Because yo ur current earnings may fluctuate, Liberty may
average earnings over thre e consecutive mo nths ra ther than
immediately terminating your benefit once 80% of Basic
Mo nthly Ea rnings has been ex ceeded.
8. the date yo u are no lo nger D isabled a ccording to this plan;
9. the end of the Max imum Benefit Perio d; or
10. the date yo u die.
ADOC-LTD-27/28 Long Term Disability
-38-
SECTION 4 - DISABILITY IN COME BENEFI TS
(Continued)
LONG TERM DIS ABILITY COVER AGE (Continued)
Successive Peri ods of Disability
What H appens if Y ou Ret urn to W ork and Bec ome Disabled Again?
With respect to this plan, "Successive Periods of Disability" means
a Disability which is related or due to the same c ause(s) as a prior
Disability for which a M onthly Be nefit was p ayable.
A Successive Peri od of Disability will be treated as part of the pri or
Disability if, after receiving Disability benefits under this plan, y ou:
1. return to your Ow n Occupation on an Active Empl oyme nt
basis for less than six continu ous m onths; and
2. perf orm all the M aterial and Substantial Duties of your Own
Occ upation.
To qualify f or the Successi ve Peri ods of Disability benefit, yo u must
experience more than a 20% loss of Basic Monthly Earnings.
Benefit payments will be subject to the terms of this plan f or the pri or
Disability.
If you return to your Own Occupation on an Active Employment
basis for six c ontinu ous months or more, the Successive Period of
Dis ability will be treated as a new period of Disability. You must
c omplete another Eliminati on Period .
If you become eligible f or coverage under any other group l ong term
disability c overage, this Successive Peri ods of Disability pr ovisi on
will cease to apply to you.
L ong Term Disability
ADOC-LTD-29 Successive Disability
-39-
SECTION 5 - EXCLUSIONS
GENERAL EXCLUSIONS
What Disabilities are Not C overed?
This plan will not cover any Dis ability due to:
1. war, declared or undeclared, or any act of war;
2. intentio nally self-inflicted injuries, while sane;
3. active Participation in a Riot;
4. the co mmitting of or attempting to commit a felony or
misdemeanor;
5. co smetic surgery unless such surgery is in c onnecti on with
an Injury or Sickness sustained while you are c overed under
this plan;
6. a gender change, including, but no t limited to , any operati on,
dru g thera py or any other procedure related to a gender
change.
No benefit will be payable during any perio d of incarcera tio n.
With respect to this prov isio n, Participation shall include pro moting,
inciting, conspiring to promote or incite, aiding, abetting, and all
forms of taking part in, but shall not include actions taken in defense
of public or priv ate pro perty, or a ctio ns taken in yo ur defense, if such
actions of defense are not taken against persons seeking to maintain
or restore la w and o rder including, but no t limited to , po lice officers
and fire fighters.
With respect to this pro visio n, Riot shall include all fo rms of public
v iolence, diso rder or disturbance of the public peace, by three or more
perso ns assembled to gether, whether or no t a cting with a commo n
intent and whether or no t damage to pe rso ns or property or unlawful
act or acts is the intent or the consequence of such diso rder.
A DOC-EXC-1.2 G ene ral Ex clusio ns
SE CTION 5 - EXCLUSIONS
(Contin ued)
L ONG TERM DISABILITY COVER AGE
Pre -Existing Condition Exclusi on
What Other Dis abilities are Not Covered?
This pl an will n ot c over any Disability or Partial Disability:
1. which is caused or contributed to by, or results from a Pre -
E xisting Condition; and
2. which begins in the first 12 m onths immediately after your
effective date of c overage.
"Pre -Existing Condition" means a c onditi on resulting fr om an Injury
or Sickness for which y ou were diagn osed or received Treatment
within three m onths pri or to y our effective date of coverag e.
L ong Term Dis ability
ADOC -EXC-5 3/12 Pre -Existing Exclusion
-40-
-41-
SECTION 7 - GENER AL PROVISIONS
SECTION 6 - TERMIN ATION PROVISIONS
When will Y our Insurance End?
You will cease to be i nsured on the earliest of the f ollowing dates:
1. the date this plan terminates, but without prejudice to any
claim o riginating pri or to th e time of terminati on;
2. the date yo u are no longer in an eligible class;
3. the date yo ur class is no longer included for insurance;
4. the date employment terminates . Cessati on of Active
Employment will be deemed terminati on of empl oyment,
exc ept the insurance will be continued f or an Empl oyee
a bsent due to Disability during:
a. the Elimination Perio d; and
b. any perio d during which premium is being waived.
5. the date yo u cease active wo rk due to 'a labor dispute,
including any strike, work slowdown, or locko ut.
Liberty reserves the right to review and terminate all classes insured
under this plan if any cla ss(es) cease(s) to be covered.
A DOC -TER -1 Te rmina tio n Pro visio ns
Is Assignment All owed?
No assignment of any present or future right or benefit under this
pla n will be all owed .
How will Liberty Conf orm With State Statutes?
Any pr ovisi on of this plan which, on its effective date, is in c onflict
with the st atutes of the g overning jurisdicti on of this plan is hereby
amended to c onf orm to the minimum requirements of such st atute .
What are Liberty's E xamination Rights?
Liberty, at its own expense, may have the right and opp ortunity to
have the claimant, wh ose Injury or Sickness is the basis of a claim,
examined or evaluated at reas onable intervals deemed necessary by
Liberty. This right may be used as often as reasonably required .
Wh o has the Auth ority f or Int erpretation of this Pla n?
Liberty shall p ossess the discretionary auth ority to constru e the terms
of this plan and to determine benefit eligibility hereunder.
When can this Plan be C ontested?
The validity of this plan shall n ot be contested, e xcept for n on-
payment of premiums, after it has bee n in f orce for two years from
the date of issue. The validity of this plan shall n ot be contested on
the b asis of a statement made relating to insurability by you after
such insurance has been in f orce f or tw o years during your lifetime,
and shall n ot be c ontested u nless the statement is c ontained in a
written instrument signed by y ou .
When can Leg al Proceedings Begin?
A claimant or the claimant's authorized representative cann ot begin
any legal action:
1. until 60 days after Pro of of claim has been given; or
2. more than three years after the time Pr oof of claim is requir ed .
ADOC-GNP-1. 10 General Pr ovisi ons
-d7-
-43-
SECTI ON 7 - GENE RAL PROVISIONS
(Continued)
What Happ ens if Y our Age is Misstated?
If your age has been misst ated, an equitable adjustment will be made
in the premium. If the am ount of the benefit is dependent up on your
age, the amount of the benefit will be the amount you w ould have
been entitled to if your corr ect age were known .
A refund of premium will not be made for a period more than 12
mo nths befo re the date Liberty is advised of the err or .
Whe n Must Liberty be No tified of a Claim?
1. Notice of claim must be given to Liberty within 20 days of the
date of the lo ss on which the claim is b ased, if that is possible .
If that is no t possible, Liberty must be notified as s oon as it
is reasonably po ssible to do so. Such notice of claim must be
received in a form or fo rma t satisfa ctory to Liberty.
2. When writte n notice of claim is applicable and has been
received by Liberty, you will be sent claim forms. If the
fo rms a re not received within 15 days after written notice of
claim is sent, yo u can send to Libe rty written Proof of claim
without waiting fo r the forms.
When Must Liberty R eceive Proof of Claim?
1. Proof of lo ss must be given to Liberty no later than 90 days
after the end of the Elimination Period.
2. Fa ilure to furnish such Proo f within such time sha ll no t
inva lidate or reduce any claim if it was not reaso na bly
po ssible to furnish such Pro of within such time. Such Pro of
must be furnished as soo n as reaso nably po ssible, a nd in no
event, except in the absence of legal ca pacity of the claimant,
later than o ne year from the time Proof is otherwise required.
3. Proo f of co ntinued loss, co ntinued Disa bility or Partia l
D isability, when applicable, and Regular A ttendance of a
Physician must be giv en to Liberty within 90 days of the
request for such Proof.
Libe rty reserves the right to determine if your Proo f of lo ss is
satisfacto ry.
ADO C-GNP-1.10/2.12 General Provisions
SECTION 7 - GENE RAL PROVISIONS
(Continued)
Wh o are Claims Paid T o?
The benefit is payable to y ou. But, if a benefit is payable to your
estate, or if you are a min or, or y ou are not c ompetent, Liberty has
the right to pay up to $2,000 to any of your rel atives or any other
pers on whom Liberty c onsiders entitled theret o by reas on of having
incurred e xpense for the maintenance, medical attendance or buri al .
If Liberty in good faith pays the benefit in such a manner, any such
payment shall fulfill Liberty's resp onsibility f or the am ount paid .
What are Liberty's Rights of Rec overy?
Liberty has the right to rec over any overpayment of benefits caused
by, but not limited t o, the f oll owing:
1. fraud;
2. any err or m ade by Liberty in processing a claim; or
3. your r eceipt of any Other Income Benefits .
Liberty may recover an overpayment by, but not limited t o, the
foll owing:
1. requesting a lump s um payment of the overpaid amount;
2. reducing any benefits payable under this plan;
3. taking any appropriate collection activity available including
any legal action needed; and
4. placing a lien, if n ot prohibited by law, in the am ount of the
overpayment on the pr oceeds of any Other Income Benefits,
whether on a periodic or lump sum b asis.
It is required that full reimbursement be made to Liberty.
ADOC -GNP-2.12 General Pr ovisi ons
-44-
-45-
SEC TION 7 - GENERAL PROVISIONS
(C ontinued)
How will Statements Made In Your Application Affect Y our
Co verage?
In the absence of fraud, all statements m ade in any applicati on are
considered representati ons and not warranties (absolute guarantees) .
No representa tio n by:
1. the Spo nso r in applying for this pl an will make it void unless
the representatio n is contained in the sig ned Applicati on; or
2. you in enrolling fo r insurance under this pl an will be used to
redu ce or deny a claim unless a copy of the Enr ollment Form,
signed by yo u if required, is or has been given to y ou .
Ho w does the Po licy Affect Wo rkers' Co mpensation?
This plan a nd the co vera ges pro vided are no t in lieu of, nor will
they a ffect a ny requirements fo r cov era ge under any Workers'
Co mpensa tion Law or o ther similar la w.
ADO C-GNP-3.3 General Pro visio ns
-46-