As a participant in the Screen Actors Guild – Producers Health 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:
Examine, without charge, at the Plan Office, all Plan documents, including insurance contracts, 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 Pension and Welfare Benefits Administration.
Obtain, upon written request to the Chief Executive Officer, copies of documents governing the operation of the Plan, including insurance contracts, Collective Bargaining Agreements and copies of the latest annual report (Form 5500 Series). The Chief Executive Officer may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan is required by law to furnish each participant with a copy of this summary annual report.
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 SPD and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary period of coverage for preexisting conditions under your group health plan if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, 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 preexisting condition exclusions for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
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 benefits under the Plan or exercising your rights under ERISA.
If your claim for a benefit under the Plan is denied, in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan 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 Chief Executive Officer.
If you have a claim for health benefits which is denied or ignored, in whole or in part, you may request an external review of the decision by an Independent Review Organization (IRO), following the exhaustion of the Plan's appeal process. External review may also be available if your health coverage has been retroactively terminated unless the decision to terminate coverage was made because you did not meet the Health Plan's eligibility rules. Not all claims are eligible for external review. See pages 92 through 94 for additional information.
You must request an external review within four
months after the Plan Trustees' written decision on
appeal has been provided. You may also have the
right to file suit in state or federal court. However,
no legal action may be commenced against the Plan
more than 90 days after the final written decision on
appeal or external review has been provided. The
Plan Trustees' written decision on appeal and the
IRO decision on external review, if applicable, will be
deemed to have been provided on the fifth business
day following the postmark date, if mailed, or the date
of delivery, if personally delivered or delivered by facsimile. A copy of this Statement of ERISA Rights, which shall constitute written notice of any applicable limitations period, shall be provided to the applicant along with the written notification of the Plan Trustees' decision on appeal.
If Plan fiduciaries are misusing the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in 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 frivolous.
If you have any questions about your Plan, you should contact the Chief Executive Officer. If you have any questions about this statement or your rights under ERISA, or if you need assistance in obtaining documents from the Plan, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits 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 publication hotline of the Pension and Welfare Benefits Administration at (866) 444-EBSA (3272).