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IBEW Local 11-LA NECA Active Health Plan
Summary Plan Description (SPD)

Accidental Death & Dismemberment (AD&D)

Insuring Clause for Accidental Death and Dismemberment Insurance

The insured individual will be paid the applicable amount of benefits if he sustains a loss described below. The loss must be due to an accident sustained while insured. Such loss must be incurred within 90 days from the date of such accident.

Payment will be made in accordance with the Payment of Claims provision.

Accidental Death and Dismemberment Benefits

The amount and payment of such benefits shall be as follows:

  1. If injury results in loss of life, the amount of insurance in effect on the date of injury will be payable to the beneficiary. The beneficiary is the same as under the Life Insurance unless the insured individual names a separate beneficiary. Payment will be made in the same manner as under Life Insurance. (Interest will be paid, at the Company's current rate, on proceeds that are not paid by the Company within 30 days from the date of death.) Interest is paid, if state-mandated, from date of death to date of payment.

    A separate beneficiary may be named in the same manner as described under Life Insurance;
  2. If such injury results in dismemberment as listed below, the amount payable will be one-half the maximum amount in effect on the date of injury:
    1. loss of a hand (all of the hand is cut off at or above the wrist);
    2. loss of a foot (all of the foot is cut off at or above the ankle);
    3. loss of eye or sight of an eye (loss of sight of an eye means that the eye is entirely blind and that no sight can be restored in that eye).
This section added by: Amendment 49.
  1. If such injury results in any of the following losses as listed below, the amount payable will be based on the Full Amount in effect on the date of injury in accordance with the following schedule injuries occurring on and after October 1, 2010 (The "Full Amount" is the full amount of your AD&D coverage which is payable for the loss of life):
    1. For the loss of an arm, the amount payable is 75% of the Full Amount in effect on the date of the injury;
    2. For the loss of a hand, the amount payable is 50% of the Full Amount in effect on the date of the injury;
    3. For the loss of a foot, the amount payable is 50% of the Full Amount in effect on the date of the injury;
    4. For the loss of a leg, the amount payable is 75% of the Full Amount in effect on the date of the injury;
    5. For the loss of a thumb and index finger on the same hand, the amount payable is 25% of the Full Amount in effect on the date of the injury;
    6. For the loss of speech and hearing, the amount payable is 100% of the Full Amount in effect on the date of the injury;
    7. For the loss of speech or hearing, the amount payable is 50% of the Full Amount in effect on the date of the injury;
    8. For the paralysis of both arms and legs, the amount payable is 100% of the Full Amount in effect on the date of injury;
    9. For the paralysis of both legs, the amount payable is 50% of the Full Amount in effect on the date of injury;
    10. For the paralysis of the leg and arm on either side of the body, the amount payable is 50% of the Full Amount in effect on the date of injury;
    11. For the paralysis of one arm or one leg, the amount payable is 25% of the Full Amount in effect on the date of injury;
    12. For the loss of sight in one eye, the amount payable is 50% of the Full Amount in effect on the date of injury;
    13. For brain damage, the amount payable is 100% of the Full Amount in effect on the date of injury; and
    14. For a coma, the amount payable is 1% of the Full Amount on a monthly basis up to a maximum of 60 months."

    In addition, the following AD&D benefits are payable:

    The Air Bag Benefit is payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car equipped with an air bag, while riding in a seat protected by an air bag and wearing a properly fastened seat belt (or a child restraint if the insured is a child). In such case, his or her benefit will be increased by 5% of the Full Amount-but not less than $1,000 or more than $10,000.

    The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car and wearing a properly fastened seat belt (or a child restraint if the insured is a child). In such case, his or her benefit will be increased by 10% of the Full Amount-but not less than $1,000 or more than $25,000.

    The Common Carrier Benefit is payable if an insured person dies as a result of injuries sustained while traveling in a Common Carrier. The additional amount payable is 100% of the Full Amount.

    The Child Care Center Benefit provides funds for your eligible dependent children, 12 years old or younger, to attend a licensed child care facility for up to four consecutive years if you should suffer a fatal accident. The yearly benefit for each eligible child is equal to $5,000 or the actual amount of child care costs incurred (whichever is less), and cannot exceed an overall total of 12% of the Full Amount. In order to be eligible, dependent children must be enrolled in a licensed child care center at the time of your accidental death.

    The Child Education Benefit provides tuition funds for each of your eligible dependent children to attend a college or other accredited institution for up to 4 years if you should suffer a fatal accident. To qualify, your dependent children must be enrolled in the institution at the time of your accidental death or must enroll within one year of your accidental death. The yearly benefit for each eligible child is equal to $10,000 or the actual amount of tuition costs incurred, whichever is less. The total benefit maximum is 20% of the Full Amount for each eligible child.

    The Spouse Education Benefit provides tuition funds for your spouse if you should suffer a fatal accident. The benefit is payable for up to one year and is equal to the lesser of the actual cost of tuition, $5,000 or 3% of the Full Amount. Your spouse must be enrolled in an accredited school at the time of your accidental death.

    The Hospitalization Benefit helps defray hospitalization costs that result from an accident. It is provided as a monthly income to the insured and is equal to one percent of your Full Amount per month, subject to a four-day waiting period and a maximum of $2,500 per month, with a maximum duration of 12 months.

    The following Accelerated Benefits Option is also available to participants:

    A Participant may receive up to 80% of the Life Insurance amount up to a maximum of $40,000.00 in the event that the Participant becomes terminally ill and are diagnosed with less than twelve months to live.

    The amount payable for all losses as a result of any one accident may not exceed the individual's maximum amount determined by the schedule of benefits.

Exceptions

Benefits are not payable for losses connected in any way with the following:

  1. Bodily or mental conditions existing at the time of or prior to the accident;
  2. Suicide (or attempt threat) while sane or insane; or intentionally self-inflicted injury;
  3. Ptomaine or bacterial infection other than pyogenic infection of and through a visible accidental cut or wound;
  4. Act or incident of war, declared or undeclared;
  5. Taking part in the commission of an assault or felony;
  6. Travel or flight in (including boarding or alighting therefrom and learning to operate) any type of aircraft or any other aerial device while such aircraft or device is:
    1. being used for a test purpose;
    2. being operated by or for, or under the command of the military authority (other than a transport type aircraft operated by the Military Air Transport Service (MATS) of the United States or a like air service of some other country;
    3. being used while the insured individual is flying, learning to fly or to operate, or acting as a member of the crew;
    4. owned or leased by or on behalf of the Policyholder of a firm under its control.
 

 

 

 

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