Schedule of Benefits
About the Plan
Board of Trustees
Contract Administrator
Health & Welfare Plan Document
The Plan provides a benefit for surgical operations performed on you or your dependent. A Schedule of Surgical Benefits is listed here. Once again this benefit is only available as a result of an accident or disease which is not related to your job and for which benefits are not payable under any worker's compensation or occupational disease law.
How Can I Figure Out The Amount Of My Surgical Benefit? As before, the amount of your surgical benefit depends on your Classification. In this case however, the surgical benefit is the same regardless of whether you or your dependent has the operation. Set forth at pages 35-44 is a schedule showing the maximum amount of money that the Fund provides as a surgical benefit for each Classification. The schedule also refers to "Surgical Units." This is something different than you have seen before. We will explain how you can figure out exactly what your benefit is for any operation by referring to your maximum surgical benefit and your "surgical units". To show how you can compute the actual amount of your surgical benefit for any given operation, we will use the example of operations known as a tonsillectomy & adenoidectomy for persons over 15 years of age. The amount of the benefit allowed for such procedure is set forth at page 43 of the Schedule of Benefits contained in this booklet. As you can see the amount for the surgical procedure set forth in the Schedule of Benefits is $75.00. To figure out the amount of surgical benefit to which you are entitled if you or your dependent has this operation, you simply multiply the $75.00 times the Òsurgical unitsÓ which are applicable to your Classification.
For example, if you are in Classification IV you multiply $75.00 times your surgical unit of 20 which gives you a resulting surgical benefit of $1,500.00. If you are in Classification I you would multiply $75.00 times your surgical unit of 7 with a result of $525.00.
| Your Surgical Units Are | |
| Class | Scheduled Units |
| I | 7 |
| II | 9 |
| III | 16 |
| IV | 20 |
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When Surgery Is Due To Cancer, Heart Disease Or Stroke. When you or your dependent have a surgical procedure due to cancer, heart disease or stroke and you are covered by a Schedule of Benefits for a contribution rate of $1.63 per hour or above, the amount of the surgical benefit is double the amount calculated under the paragraph entitled "How Can I Figure Out The Amount Of My Surgical Benefit?"
What If The Actual Charge For The Operation Is Less Than The Amount Of The Benefit Provided By The Fund? If the actual charges made to you by the operating physician are less than the amount provided by the Fund, the Fund will pay an amount which equals the actual charges.
When Are Surgical Benefits Payable? Surgical benefits are payable whether the procedure is performed in a hospital, doctor's office or elsewhere, but the procedure must be performed by a legally qualified physician during a time when you are eligible for benefits. No benefits are payable for charges incurred for cosmetic plastic surgery unless brought about by injury or disease occurring while you are eligible for benefits.
What If Two Or More Surgical Procedures Are Performed During A Single Operation? When two or more surgical procedures are performed during the course of a single operation through the same incision or in the same operative area, they will be considered as one surgical procedure and the maximum amount will be the largest of the maximum amounts for the respective surgical procedures. Otherwise, when more than one surgical procedure is performed, payment will be made for each surgical procedure unless the Schedule of Surgical Benefits sets out a maximum amount for a particular combination of surgical procedures.
Open Reductions and Compound Fractures. For compound fractures the maximum amount will be one and one-half times, and for fractures or dislocations requiring an open operation will be twice the amount shown for the corresponding simple fracture or dislocation, but in no case more than the maximum amount allowed in your Schedule of Benefits.
Unlisted Procedures. In addition to the procedures listed in this schedule, amounts may be payable for any other surgery. The maximum amounts for such procedures may be determined by the Trustees in amounts consistent with those listed.
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