Definitions

Some features of the Plan described on this page have been affected by the December 2010 Summary of Material Modifications (SMM), effective January 1, 2011. Click here to access the SMM.

Ambulatory Surgical Center - A licensed free-standing facility that is wholly owned and operated by a hospital on the same basis as the outpatient department of its main facility, or a legally constituted institution that is established, equipped and operated primarily for the purpose of performing surgical procedures.

Approved Treatment Facility for Substance Abuse - A rehabilitation facility for the treatment of individuals suffering from substance abuse. To be an approved treatment facility under this Plan, the facility must be accredited by the Joint Commission on Accreditation of Healthcare Organizations or meet certain requirements specified by the Trustees.

Note - If a covered person receives outpatient treatment for substance abuse under an outpatient treatment program that is provided through a hospital or through a facility that is part of or affiliated with a hospital, the hospital does not have to meet the definition of a hospital (page 80) as long as ValueOptions has precertified the treatment program.

Association - A chapter of the National Electrical Contractors Association, Incorporated, which is a party to a collective bargaining agreement requiring contributions to the Fund.

Calendar Year - The 12-month period starting on January 1 of any year and ending on December 31 of that year.

Chiropractic Care - Any services or supplies that are provided or ordered by a chiropractor.

Collective Bargaining Agreement - The negotiated labor agreement between a union and an employer or association requiring the employer or association to make contributions to the Fund on behalf of its bargaining unit employees.

Contributions - Payments made to the Fund by contributing employers on behalf of their employees.

Covered; Covered Under the Plan - A term used to indicate that a person is eligible to receive the Plan benefits which apply to his status as an employee, a retiree or a dependent.

Dependent

  1. A person who is your (employee's or retiree's) spouse, provided she is not legally separated from you. A certified copy of your marriage certificate must be on file at the Fund Office before claims for your spouse can be processed. If your spouse is a full-time active member of the military or armed forces of any country, she won't be considered a dependent under this Plan (see COBRA Coverage for a possible exception).
  2. A person who is your (employee's or retiree's) unmarried child (see Definition of Child on page 78):
    1. Who is less than 19 years old; or
    2. Who is 19 but less than 25, provided he is a registered full-time student in an accredited secondary school, college, university, vocational or technical school, and is dependent on you for the major portion of his support (proof of full-time student status for each school term must be submitted to the Fund Office before such a child will be covered); or
    3. Who is 19 or older and who is disabled because of mental retardation, mental incapacity or physical handicap. The child must have become disabled before becoming age 19; must remain disabled and be incapable of self-sustaining employment; and must be dependent on you for the major portion of his support. When the first claim is filed for the child, you must furnish proof that he became disabled before he became 19. You must furnish the proof at your own expense except that, if the Trustees require a physical examination, the Plan will pay for it. If the Trustees request proof of the child's disability in the future, you must furnish the proof or the child's coverage will terminate.

Definition of Child - For purposes of this definition, a child means any of the following:

  1. A natural child of yours.
  2. Any child legally adopted by you or placed in your home for adoption.
  3. A stepchild of yours, meaning any child of your spouse who was born to your spouse or who was legally adopted by your spouse before your marriage to your spouse, provided that the stepchild is primarily dependent on you for support and lives with you in a regular parent-child relationship.
  4. A child who is determined to be an alternate recipient under the terms of a court order which the Trustees determine to be a Qualified Medical Child Support Order. A copy of the court order will be required by the Fund Office before claims for the child will be considered for payment. You can obtain, without charge, a copy of the Plan's procedures governing Qualified Medical Child Support Order determinations by calling or writing the Fund Office.
  5. A child who is either your or your spouse's grandchild, sibling, nephew or niece, and who lives in a parent-child relationship with you.
  6. A foster child who was placed in your home by a state or private social service agency, subject to the following provisions:
    1. The child must live in a parent-child relationship with you and must have received more than one-half of his support from you for at least 180 days immediately before the date the claim was incurred, or since birth, whichever is shorter; and the social service agency that placed the child with you must not pay any support or compensation to you or any member of your household for the support or maintenance of the child; and
    2. The maximum amount the Plan will pay for all preexisting conditions of a foster child during the first 12 months of the child's coverage is $500,000. A preexisting condition is a sickness, injury, disease, or other mental or physical condition for which medical advice, diagnosis, care or treatment (including the use of prescription drugs or medicines) was recommended or received by the child during the 6-month period immediately before the date the child became covered under this Plan. (Genetic information is not considered a "condition.") If the child had coverage under another group health plan before becoming covered under this Plan, and if there was not a break in coverage of 63 or more consecutive days between coverage under the prior plan and under this Plan, some of that prior coverage (called "creditable coverage") may be used to reduce the 12-month limitation period for preexisting conditions. In determining the validity and amount of creditable coverage, the Plan may rely upon a written Certificate of Coverage or other information which it receives. This Plan will assist you in obtaining a Certificate if necessary. Contact the Fund Office at 2000 Springer Drive, Lombard, Illinois 60148, telephone 1-(800)-323-7268, if you need assistance in obtaining this information.

    A child who works for a contributing employer and is eligible for benefits under this Plan as an employee is not considered a dependent. If a child is a full-time active member of the military or armed forces of any country, the child is not considered a dependent under this Plan (see COBRA Coverage for a possible exception).

    Any child born of a covered person acting as a surrogate mother, that is, a female who became pregnant with the intent or understanding of relinquishing the child following the child's birth, will not be considered a dependent of the surrogate mother or her spouse.

Note About Other Coverage - If a dependent is also covered by another plan, see Order of Benefit Payments starting on page 90 to determine which plan is primary and which is secondary.

Doctor; Physician - A legally qualified doctor or surgeon who is a Doctor of Medicine (M.D.) a Doctor of Osteopathy (D.O.), a Doctor of Chiropractic (D.C.), a Doctor of Dentistry (D.D.S.), a Podiatrist (D.P.M.), or a Doctor of Optometry (O.D.), provided that any such individual renders treatment only within the scope of his license and specialty.

Additional Covered Providers - Subject to all Plan limitations, other covered providers include the following practitioners who render such services within the scope of each such individual's license and specialty: (a) a licensed clinical psychologist (under the Mental Health and Substance Abuse Benefit only); (b) a licensed nurse practitioner (LNP); (c) a physician's assistant; (d) a certified registered nurse anesthetist (CRNA); (e) a surgical assistant; and (f) a licensed midwife (for pregnancy-related services only).

Eligible Employee - Any employee who has met the eligibility requirements established by the Trustees for being covered under the Plan.

Eligible Family Member - You, the eligible employee or eligible retiree, and any person in your family or household who meets the definition of a dependent.

Eligible Individual; Covered Person - You, the eligible employee or eligible retiree, and any of your eligible dependents.

Eligible Retiree - A retired employee who has met the eligibility requirements established by the Trustees for being covered under the Plan and who is entitled to receive the Plan benefits provided for retirees.

Employee

  1. Any individual on whose behalf an employer makes contributions to the Fund under the terms of a collective bargaining agreement or participation agreement; and
  2. Any individual who is a full-time employee of the Fund.

Employer; Contributing Employer

  1. Any person, firm, association, partnership or corporation which is required, under the terms of a collective bargaining agreement with a union, to make contributions to the Fund on behalf of its employees covered by the agreement; and
  2. Any union, association or other employer which is required, under the terms of a participation agreement with the Trustees, to make contributions to the Fund on behalf of its employees who are not covered by a collective bargaining agreement; and
  3. The Fund, on behalf of its full-time employees.

Experimental or Investigative - A treatment, procedure, facility, equipment, drug, device or supply will be considered to be experimental or investigative if it falls within any one of the following categories:

  1. It is not yet generally accepted among experts as accepted medical practice for the patient's medical condition; or
  2. It cannot be lawfully marketed or furnished without the approval of the U.S. Food and Drug Administration or other federal agency, and such approval had not been granted at the time the treatment, procedure, facility, equipment, drug, device or supply was rendered, provided or utilized; or
  3. It is the subject of ongoing Phase I or Phase II clinical trials, or is the research, experimental, study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnoses, or if the prevailing opinion among experts regarding any such treatment, procedure, facility, equipment, drug, device or supply is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnoses.

    Determination of whether a treatment, procedure, facility, equipment, drug, device or supply is experimental or investigative shall be determined solely by the Trustees, in their sole discretion and judgment, in consultation with medical experts of their choosing.

Fund; Trust Fund - The Line Construction Benefit Fund.

Home Health Agency - A public agency or private organization (or a subdivision of such agency or organization) which meets all of the following requirements: (1) it is primarily engaged in providing skilled nursing services and other therapeutic services in the homes of its patients; (2) it has policies (established by a group of professional personnel associated with the agency or organization) governing the services which it provides; (3) it provides for the supervision of its services by a doctor or a registered professional nurse; (4) it maintains clerical records on all of its patients; (5) it is licensed according to the applicable laws of the state in which the patient receiving the treatment lives and of the locality in which it is located or in which it provides services; and (6) it is eligible to participate in Medicare.

Hospice - A public agency or private organization (or a part of either), primarily engaged in providing a coordinated set of services at home or in outpatient or institutional settings to persons suffering from a terminal medical condition. The agency or organization: (1) must be eligible to participate in Medicare; (2) must have an interdisciplinary group of personnel that includes the services of at least one doctor and one R.N.; (3) must maintain clerical records on all patients; (4) must meet the standards of the National Hospice Organization; and (5) must provide, either directly or under other arrangement, the core services listed as Hospice Care Program Covered Expenses on page 52.

Hospital - An institution which is engaged primarily in providing medical care and treatment to sick and injured persons on an inpatient basis at the patients' expense and which fully meets all of the requirements set forth in No. 1 or No. 2 or No. 3 below:

  1. It is a hospital that is qualified to participate in Medicare and to receive Medicare payments; or
  2. It is a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations; or
  3. It is an institution which: (a) provides diagnostic and therapeutic facilities for the medical and surgical diagnosis, treatment and care of injured and sick persons under the supervision of a staff of doctors licensed to practice medicine; (b) provides on the premises 24-hour-a-day nursing services by or under the supervision of R.N.s; and (c) is operated continuously with organized facilities for operative surgery on the premises.

A hospital is not an institution which is primarily a clinic or, other than incidentally, a place for rest, for the aged, for drug addicts, for alcoholics or a nursing or convalescent home or similar establishment.

Jaw Surgery - Any surgical procedure involving the maxilla and/or mandible, or any surgical procedure to treat TMJ (as defined on page 81).

Medically Necessary - Only those services, treatments or supplies provided by a hospital, a doctor, or other qualified provider of medical services or supplies that are required, in the judgment of the Trustees based on the opinion of a qualified medical professional, to identify or treat an eligible individual's injury or sickness and which are: (1) consistent with the symptoms or diagnosis and treatment of the individual's condition, disease, ailment or injury; (2) appropriate according to standards of good medical practice; (3) not solely for the convenience of the individual, doctor or hospital; (4) if more than one alternative is available, the most cost-effective alternative that can meet the individual's essential health needs; and (5) not experimental or investigative. The fact that the treating doctor finds that the treatment is medically necessary is not binding on the Trustees.

Mental or Nervous Disorder - A neurosis, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder of any kind, regardless of any physiological or traumatic cause or origin of such condition.

Plan; Benefit Plan; Plan of Benefits - The self-funded program of health and welfare benefits provided by the Line Construction Benefit Fund as described in this booklet.

Reasonable and Customary; Reasonable and Customary Charge - For a medical charge, an amount determined by comparing a particular charge with the charges made for similar services and supplies in the locality concerned to individuals of similar age, sex, circumstances and medical condition. For a dental charge, an amount determined by comparing the charges made by other dentists in the locality concerned for services and supplies customarily used for treatment of a particular dental condition. For an orthodontic charge, an amount determined by comparing the charge with the charges made by other orthodontists in the locality concerned for services and supplies customarily used for treatment of a particular orthodontic condition, taking into consideration the age of the patient and the types of orthodontic services which are required for the specific condition of the person on whose behalf the charges are incurred. The result of any such comparison determines the amount that is the maximum allowable charge to be considered a covered medical expense, a covered dental expense, or a covered orthodontia expense under this Plan.

Retiree; Retired Employee - A person who was an eligible employee under this Plan on the day preceding the date of his retirement and who is now retired either under the retirement provisions of a pension plan negotiated or sponsored by the IBEW, a qualified pension plan provided by a contributing employer, or under the provisions of the Social Security program.

Self-Payments - Payments made to the Fund by employees, retirees and dependents on their own behalf for the purpose of maintaining coverage under the Plan.

Skilled Nursing Facility - An institution, or a distinct part of an institution, which complies with all licensing and other legal requirements and which, to be approved for the purposes of this Plan, meets all of the following criteria: (1) it is primarily engaged in providing inpatient skilled nursing care, physical restoration services and related services for patients who are convalescing from injury or sickness and who require medical or nursing care to assist the patients to reach a degree of body functioning to permit self-care in essential daily living activities; (2) it provides 24-hour-a-day supervision by one or more doctors or one or more R.N.'s responsible for the care of its inpatients, it provides 24-hour-a-day nursing services by licensed nurses under the supervision of an R.N., and it has an R.N. on duty at least 8 hours a day; (3) every patient is under the supervision of a doctor, and it has available at all times the services of a doctor who is a staff member of a general hospital; (4) it maintains daily medical records on all patients, and it provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals; (5) it has a utilization review plan; (6) it has a transfer agreement with one or more hospitals; (7) it is eligible to participate under Medicare; and (8) it is not, other than incidentally, an institution which is a place for rest, for custodial care, for the aged, for drug addicts, for alcoholics, a hotel, a place for the care and treatment of mental diseases or tuberculosis, or a similar institution.

Substance Abuse - Alcoholism, alcohol abuse, drug addiction, drug abuse, or any other type of addiction to, abuse of, or dependency on any type of drug or chemical (excluding nicotine).

TMJ - Temporomandibular joint syndrome, maxillary or craniomandibular disorders, and other conditions of the joint linking the jaw bone and the skull, along with the complex of muscles, nerves, and other tissues related to that joint. For the purposes of the Plan, the term TMJ includes all of these conditions.

Totally Disabled; Total Disability

  1. An eligible employee is totally disabled if he is completely unable to perform any and every duty of his occupation or employment because of an accidental bodily injury or sickness.
  2. A dependent or a retiree is totally disabled if he is completely unable to perform the normal activities of a person of like age and sex because of a non-occupational accidental bodily injury or sickness.

A doctor must submit written certification of a person's total disability before the person will be considered totally disabled under the terms of the Plan.

Trustees - The individuals responsible for the operation of the Line Construction Benefit Fund in accordance with the terms of the Trust Agreement, together with such Trustees' successors. Trustees appointed by the association are Employer Trustees; Trustees appointed by the union are Union Trustees.

Union - Any local union affiliated with the International Brotherhood of Electrical Workers which has entered into a collective bargaining agreement requiring contributions to the Fund.