EXHIBIT 10(at)
PLAN DOCUMENT
AND
SUMMARY PLAN DESCRIPTION
FOR
NATIONAL WESTERN LIFE
INSURANCE COMPANY
NATIONAL WESTERN LIFE INSURANCE COMPANY EMPLOYEE HEALTH PLAN
It is the intention of the Plan sponsor, National Western Life Insurance Company , to hereby amend and restate the National Western Life Insurance Company Employee Health Plan, a program of benefits constituting a self-funded "Employee Welfare Benefit Plan" under the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments thereto.
IN WITNESS WHEREOF, the Plan Sponsor has executed, and the Claims Administrator has acknowledged, this Plan Document as of the Plan effective date shown herein.
Original effective date of the Plan: November 1, 1993; as hereby amended and restated effective:
April 1, 2004.
/S/Carol Jackson
/S/Kathy Enochs
Date
Date
For Plan Sponsor:
For Claims Administrator:
Carol Jackson, Vice President Human Resources
Kathy Enochs, Chief Operating Officer
National Western Life Insurance Company
Group & Pension Administrators, Inc.
TABLE OF CONTENTS
PAGE
GENERAL INFORMATION
3
INTRODUCTION
4-7
STATEMENT OF ERISA RIGHTS
8-9
SCHEDULE OF BENEFITS
10-15
OUT-OF-AREA-BENEFIT
16
PRESCRIPTION DRUG PLAN
17-19
UTILIZATION REVIEW (UR) PROGRAM
20
CASE MANAGEMENT
21
NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT
21
VOLUNTARY SECOND SURGICAL OPINION
21
PRE-EXISTING CONDITION EXCLUSION LIMITATION
22
PORTABILITY AND CREDITABLE COVERAGE
23
COMPREHENSIVE MEDICAL BENEFITS
24-26
MAJOR MEDICAL EXPENSE BENEFITS
27-32
MAJOR MEDICAL PLAN EXCLUSIONS AND LIMITATIONS
33-36
ORGAN TRANSPLANT PROGRAM
37-39
COORDINATION OF BENEFITS
40
COORDINATION PROCEDURES
41
COORDINATION WITH MEDICARE
42
COORDINATION WITH AUTOMOBILE INSURANCE COVERAGE
42-43
SUBROGATION
44-45
CLAIM FILING PROCEDURES
46-49
GENERAL PROVISIONS
50-52
ELIGIBILITY FOR COVERAGE
53-54
QUALIFIED MEDICAL CHILD SUPPORT ORDERS/PLACEMENT FOR ADOPTION
55
EFFECTIVE DATE OF COVERAGE
56
EMPLOYEE AND DEPENDENT SPECIAL ENROLLMENT PERIODS
56-57
ANNUAL OPEN ENROLLMENT PERIOD FOR THE EMPLOYEE HEALTH PLAN
58
LATE ENROLLEE
58
COVERAGE CHANGES
59
TERMINATION OF COVERAGE
60
COVERAGE DURING LEAVE OF ABSENCE
61
REINSTATEMENT OF COVERAGE / REHIRES
61
FAMILY AND MEDICAL LEAVE
62
CONTINUATION OF GROUP HEALTH COVERAGE (COBRA)
63-66
DEFINITIONS
67-81
GENERAL INFORMATION
This Plan Document describes the benefits for the Employees of National Western Life Insurance Company and its subsidiaries. National Western Life Insurance Companies affiliates. This statement is required by the Employee Retirement Income Security Act of 1974 (ERISA) and provides important information regarding your rights under this law.
Name of the Plan
National Western Life Insurance Company Employee Health Plan
Plan Sponsor
National Western Life Insurance Company
850 E. Anderson Lane
Austin, Texas 78752-1602
(512) 836-1010
Plan Administrator
National Western Life Insurance Company
850 E. Anderson Lane
Austin, Texas 78752-1602
(512) 836-1010
Type of Plan
Self-Funded Welfare Benefit Plan
Agent for Service of Legal Process
Legal Process may also be served on the Plan Administrator
Ross R. Moody, COO/President
National Western Life Insurance Company
850 E. Anderson Lane
Austin, Texas 78752-1602
(512) 836-1010
Claims Administrator
Group & Pension Administrators, Inc.
5803 Sebastian Place
San Antonio, Texas 78249
(210) 691-0500
The Plan Administrator has retained the services of the Claims Administrator to administer claims under the Plan.
Regional Office of Employee Benefits Security Administration
Employee Benefits Security Administration (EBSA)
Department of Labor
Dallas Regional Office
525 Griffin Street, Rm 707
Dallas, Texas 75202-5025
214-767-6831 w 866-444-EBSA (3272)
www.askebsa.dol.gov for electronic inquiries w www.dol.gov/eb sa
Plan Year
The twelve (12) month period beginning January 1 and ending December 31 of the same Calendar Year
Employer Tax ID Number
84-0467208
IRS Plan ID Number
501
INTRODUCTION
National Western Life Insurance Company , hereinafter referred to as "Company," hereby amends and restates the National Western Life Insurance Company Employee Health Plan, a self-funded Employee Welfare Benefit Plan hereinafter referred to as the "Plan" pursuant to which Plan benefits and administration expenses are paid directly from the Employer's general assets, and the rights and privileges of which shall pertain to Employees and their Dependents with respect to such Plan. The Plan is not insured. Contributions received from Covered Persons are used to cover Plan costs and are expended immediately.
GENERAL AUTHORITY OF THE PLAN ADMINISTRATOR
Subject to the claims administration duties delegated to the Claim Administrator, the Plan Administrator reserves the unilateral right and power to administer and to interpret, construe and construct the terms and provisions of the Plan, including, without limitation, correcting any error or defect, supplying any omission, reconciling any inconsistency and making factual determinations.
The Plan will be interpreted by the Plan Administrator in accordance with the terms of the Plan and their intended meanings. However, the Plan Administrator shall have the discretion to interpret or construe ambiguous, unclear or implied (but omitted) terms in any fashion it deems to be appropriate in its sole judgment. The validity of any such finding of fact, interpretation, construction or decision shall be upheld in any legal action and shall be binding and conclusive on all interested parties unless clearly arbitrary and capricious.
To the extent the Plan Administrator has been granted discretionary authority under the Plan, the prior exercise of such authority by the Plan Administrator shall not obligate it to exercise its authority in a like fashion thereafter.
If due to errors in drafting, any Plan provision does not accurately reflect its intended meaning, as demonstrated by prior interpretations or other evidence of intent, or as determined by the Plan Administrator in its sole and exclusive judgment, the provision shall be considered ambiguous and shall be interpreted by the Plan Administrator in a fashion consistent with its intent, as determined by the Plan Administrator. The Plan may be amended retroactively to cure any such ambiguity, notwithstanding anything in the Plan to the contrary.
The foregoing provisions of this Plan may not be invoked by any person to require the Plan to be interpreted in a manner which is inconsistent with its interpretations by the Plan Administrator. All actions taken and all determinations by the Plan Administrator shall be final and binding upon all persons claiming any interest under the Plan subject only to the claims appeal procedures of the Plan.
ADMINISTRATION OF THE PLAN
The Plan Administrator has full charge of the operation and management of the Plan. The Plan Administrator has retained the services of the Claims Administrator, an independent claims processor experienced in claims review.
The Plan Administrator is the named fiduciary of the Plan except as noted herein. The Plan Administrator maintains discretionary authority to interpret the terms of the Plan, including but not limited to, determination of eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan; any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect and shall be binding on all persons, unless it can be shown that the interpretation or determination was arbitrary and capricious.
PHYSICIAN-PATIENT RELATIONSHIP
The Plan is not intended to disturb the Physician-Patient relationship. Physicians and other healthcare providers are not agents or delegates of the Plan Sponsor, Company, Plan Administrator, Employer or Benefit Services Manager. The delivery of medical and other healthcare services on behalf of any Covered Person remains the sole prerogative and responsibility of the attending Physician or other healthcare provider.
FREE CHOICE OF HOSPITAL AND PHYSICIAN
Nothing contained in this Plan shall in any way or manner restrict or interfere with the right of any person entitled to benefits hereunder to select a Hospital or to make a free choice of the attending Physician or professional provider. However, benefits will be paid in accordance with the provisions of this Plan, and the Covered Person may have higher Out-of-Pocket expenses if the Covered Person uses the services of a Non-preferred Provider.
PREFERRED PROVIDER INFORMATION
This Plan contains provisions under which a Plan Participant may receive more benefits by using certain providers. These providers are individuals and entities that have contracted with the Plan to provide services to Plan Participants at pre-negotiated rates. A list of these Preferred Providers will be periodically provided automatically and free of charge by the Plan Administrator. In addition, a Plan Participant may request a Preferred Provider list by contacting the Plan Administrator. The Preferred Provider list changes frequently; therefore, it is recommended that a Plan Participant verify with the provider that the provider is still a Preferred Provider before receiving services.
PURPOSE
The purpose of the Plan Document is to set forth the provisions of the Plan which provide for the payment or reimbursement of all or a portion of Covered Medical Expenses.
EFFECTIVE DATE
Original effective date of the Plan: November 1, 1993 ; as hereby amended and restated effective: April 1, 2004 .
CLAIMS ADMINISTRATOR
The Claims Administrator of the Plan is shown in the General Information Section.
NAMED FIDUCIARY
The named Fiduciary for purposes of applying the provisions of ERISA to the Plan is National Western Life Insurance Company , who, as Plan Administrator, shall have the authority to control and manage the operation and administration of the Plan. The Company may delegate responsibilities for the operation and administration of the Plan. The Company shall have the authority to amend or terminate the Plan, to determine its policies, to appoint and remove service providers, adjust their compensation (if any), and exercise general administrative authority over them. The Company has the sole authority and responsibility to review and make final decisions on all claims to benefits hereunder.
CONTRIBUTIONS TO THE PLAN
The amount of contributions to the Plan are to be made on the following basis:
The Company shall from time to time evaluate the costs of the Plan and determine the amount to be contributed by the Employer and the amount to be contributed by each Covered Employee.
Notwithstanding any other provision of the Plan, the Company's obligation to pay claims otherwise allowable under the terms of the Plan shall be limited to its obligation to make contributions to the Plan as set forth in the preceding paragraph. Payment of said claims in accordance with these procedures shall discharge completely the Company's obligation with respect to such payments.
In the event that the Company or Board of Directors of the Company terminates the Plan, then as of the effective date of termination, the Employer and Covered Employees shall have no further obligation to make additional contributions to the Plan and the Plan shall have no obligation to pay claims incurred after the termination date of the Plan.
CLAIMS PROCEDURE
In accordance with Section 503 of ERISA, the Plan Administrator shall provide adequate notice in writing to any covered Plan Participant whose claim for benefits under this Plan has been denied, setting forth the specific reasons for such denial and written in a manner calculated to be understood by the Plan Participant. Further, the Plan Administrator shall afford a reasonable opportunity to any Plan Participant, whose claim for benefits has been denied, for a fair review of the decision denying the claim by the person designated by the Plan Administrator for that purpose. Details of the claims procedure, which are in compliance with ERISA regulations, are found in this Plan Document under the section entitled "Claim Filing Procedures."
PROTECTION AGAINST CREDITORS
No benefit payment under this Plan shall be subject in any way to alienation, sale, transfer, pledge, attachment, garnishment, execution or encumbrance of any kind, and any attempt to accomplish the same shall be void. If the Plan Administrator shall find that such an attempt has been made with respect to any payment due or to become due to any Plan Participant, the Plan Administrator in its sole discretion may terminate the interest of such Plan Participant or former Plan Participant in such payment. And in such case the Plan Administrator shall apply the amount of such payment to or for the benefit of such Plan Participant or former Plan Participant, his/her spouse, parent, adult child, guardian of a minor child, brother or sister, or other relative of a Dependent of such Plan Participant or former Plan Participant, as the Plan Administrator may determine, and any such application shall be a complete discharge of all liability with respect to such benefit paym ent. However, at the discretion of the Plan Administrator, benefit payments may be assigned to health care providers.
PLAN AMENDMENTS
This Document contains all the terms of the Plan and may be amended by the Plan Sponsor from time to time. Any such Plan Amendment shall become effective as of the date specified in the enabling resolution. A copy of any Plan Amendment shall be furnished to the Plan Administrator, the Trustees (if any) and any outside provider of plan administrative services.
MATERIAL MODIFICATIONS
The Plan Administrator shall notify all Covered Employees of any Plan Amendment considered a Material Reduction in covered services or benefits provided by the Plan as soon as administratively feasible after its adoption, but no later than sixty (60) days after the date of adoption of the modification or change. Covered Employee and beneficiaries must be furnished a Summary of such modifications or changes, and any changes so made shall be binding on each Covered Person. The sixty (60) day period for furnishing a summary of Material Modifications or changes does not apply to any Employee covered by the Plan who would reasonably expect to receive a summary through other means within the next ninety (90) days.
Material Reductions disclosure provisions are subject to the requirements of ERISA and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any related amendments.
TERMINATION OF PLAN
The Plan Sponsor reserves the right at any time to terminate the Plan or any benefit under the Plan by a written resolution of the Board of Directors of the Employer to that effect. Previous contributions by the Employer and Employees shall continue to be used for the purpose of paying benefits under the provisions of this Plan with respect to claims arising before such termination.
PLAN IS NOT A CONTRACT
This Plan Document constitutes the entire Plan. The Plan will not be deemed to constitute a contract of employment or give any Covered Employee the right to be retained in the service of the Employer or to interfere with the right of the Employer to discharge or otherwise terminate the employment of any Covered Employee.
STATEMENT OF ERISA RIGHTS
As a Plan Participant in the National Western Life Insurance Company Employee Welfare Benefit Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan Participants shall be entitled to:
RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual report. The Plan Administrator is required by law to furnish each Plan Participant with a copy of this summary annual report.
CONTINUE GROUP HEALTH PLAN COVERAGE
Continue health care coverage for yourself, spouse or Dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your Dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for Pre-existing Conditions under your group health Plan, if you have creditable coverage from another plan. You should be provided a Certificate of Coverage (COC), free of charge, from your group health Plan or health insurance issuer when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of Creditable Coverage, you may be subject to a Pre-existing Condition exclusion for twelve (12) months (18 months for Late Enrollees) after your Enrollment Date in your coverage.
PRUDENT ACTIONS BY PLAN FIDUCIARIES
In addition to creating rights for Plan Participants ERISA imposes duties upon the people who are responsible for the operation of the Employee Benefit Plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including your Employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
ENFORCE YOUR RIGHTS
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance f rom the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
ASSISTANCE WITH YOUR QUESTIONS
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
SCHEDULE OF BENEFITS
Major Medical Benefits for Covered Persons
Benefit Levels for services rendered in the geographical zip code area serviced by the Preferred Provider Organization (PPO):
The "PPO Benefit" applies to services rendered by Preferred Providers in the designated PPO Network (In-Network); the "Non-PPO Benefit" applies to services rendered by providers other than Preferred Providers (Out-of-Network). In addition, the "PPO Benefit" also applies to the following situations:
1.
If a PPO Provider refers a Covered Person to a facility which is not in the PPO Network because no appropriate PPO facility is available;
2.
If a PPO Provider refers a Covered Person to a Physician who is not in the PPO Network because there is no appropriate specialist available among PPO Providers;
3.
If a Covered Person has no choice of PPO Providers in the specialty that the Covered Person is seeking within the PPO service area; or
4.
If a Medical Emergency or initial treatment of an Accidental Injury requires immediate care and services are rendered by Non-PPO Providers.
PPO Benefit
Non-PPO Benefit
Lifetime Major Medical Maximum Benefit
Per Covered Person
$1,000,000
$1,000,000
Calendar Year Deductible
Per Covered Person
$500
$1,000
Family Member Limit
X2
X2
Last Quarter Deductible Carry-over applies
Benefit Percentage after Deductible
80%
60%
(Unless otherwise noted)
Annual Out-of-Pocket Maximum
(In addition to Deductible and Copays)
Per Covered Person
$2,000
$3,000
Family Limit*
$4,000
$6,000
Inpatient Hospital Services
80% after
60% after
(All related charges)
Deductible
Deductible
UR Notification required
Room and Board Limit
Semi-Private
Average Semi-Private
Intensive Care Limit
Negotiated PPO Fee
Usual and Customary
Usual and Customary
Additional Deductible Penalty
Per Admission / Outpatient Surgery
$300
$300
(Failure to notify Utilization Review (UR) Company
of Hospital admission/Outpatient Surgery,
see Utilization Review Program section)
NOTE:
The Calendar Year Deductible and Annual Out-of-Pocket Maximum are determined by combining both PPO and Non-PPO Covered Charges. Upon reaching the Annual Out-of-Pocket Maximum, Covered Medical Expenses are payable at 100% for the remainder of the Calendar Year. The Lifetime and Calendar Year Maximum Benefits are determined by combining the PPO and Non-PPO Covered Charges.
*Applies collectively to all Covered Persons in the same Family
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit
Non-PPO Benefit
Hospital Emergency Room
(All related charges)
Medical Emergency
80% after
80% after
(See page 75 of definitions)
$25 Copay
$25 Copay
Copay waived if admitted Inpatient
Deductible waived
Deductible waived
Non-Medical Emergency
50% after
50% after
Deductible
Deductible
Ambulance Service
80 % after
60 % after
Deductible
Deductible
Outpatient Surgery/Ambulatory
80 % after
60 % after
Surgical Center
Deductible
Deductible
(All related charges)
UR Notification required or penalty applies
Outpatient Hospital Lab/X-ray
80 % after
60 % after
(All related charges)
Deductible
Deductible
Outpatient Independent Lab/X-ray
80 % after
60 % after
(All related charges)
Deductible
Deductible
All Other Lab/X-ray in conjunction with
100 % after
60 % after
PPO Office Visit
Deductible waived
Deductible
(not billed by Physician)
Physician Services
Office Visit
100 % after
60 % after
(Includes examination, treatment, Surgery,
$25 Copay*
Deductible
lab, x-ray, tests and supplies provided by
Physician at the time of the office visit, except
chemotherapy/radiation therapy, infusion therapy,
and physical therapy.
*If charges are less than $25, Copay is actual charge.
Allergy Injections (Including vials/allergens)
100 %
60 % after
Deductible waived
Deductible
Other In-Office Services
100 % after
60 % after
(without Office Visit billed)
$25 Copay
Deductible
Voluntary Second Surgical Opinion
80 % after
60 % after
Deductible
Deductible
All Other Physician Services
80 % after
60 % after
Deductible
Deductible
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit
Non-PPO Benefit
Maternity
80% after
60% after
(Including prenatal, delivery and postnatal care)
Deductible
Deductible
Office Visit Copay does not apply.
Sonogram - Maximum allowable per Pregnancy
1 (one)
1 (one)
Additional allowed ONLY with medical
80% after
60% after
Necessity
Deductible
Deductible
Birthing Center
80% after
60% after
Deductible
Deductible
Routine Newborn Care
80% after
60% after
Inpatient Hospital nursery charges and
Deductible
Deductible
pediatric care to date of baby's discharge
Payable under covered mother's claim.
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