Daemen College Personnel Department

DAEMEN COLLEGE HEALTH INSURANCE PLAN
	Introduction ________________________________________ The Daemen College Health Insurance Plan is a group medical plan that provides medical benefits to participants and their eligible family members through subscriber contracts with insurance carriers and health maintenance organizations ("HMOs"). The Daemen College Health Insurance Plan also provides dental benefits to participants and their eligible family members. In this document, the Daemen College Health Insurance Plan is referred to as the "Plan." This document, together with the subscriber contracts and coverage certificates, is a summary plan description of the Plan as in effect as of July 1, 2002. This document, together with the subscriber contracts and coverage certificates is also considered the plan document for the Plan for purposes of Section 402 of the Employee Retirement Security Act of 1974 ("ERISA"). The actual benefits under the Plan are provided in accordance with the subscriber contracts or coverage certificates issued to participants. Daemen College itself does not guarantee any of the medical benefits described in the subscriber contracts or coverage certificates. Daemen College self-insures the dental benefits described in the coverage certificate issued by The Guardian.
Plan Name	Daemen College Health Insurance Plan
Plan Number	501
Employer	Daemen College
Address	4380 Main Street Amherst, NY 14226 (716) 839-3600
Employer Identification Number	16-0759798
Type of Plan	The Plan is a welfare benefit plan that provides medical benefits through subscriber contracts issued by insurance carriers and HMOs. A list of the current carriers and HMOs is attached as Exhibit A to this Summary Plan Description. The Plan also provides dental benefits which are self-insured by Daemen College, but which are administered by The Guardian.
Plan	Daemen College
Administrator	4380 Main Street Amherst, NY 14226 (716) 839-3600
Type of Administration	The Plan is administered by Daemen College. Benefit claim and coverage decisions for medical benefits are made by the insurance carrier or HMO through which a participant or beneficiary is covered. Benefit claim and coverage decisions for dental benefits are made by The Guardian.
Agent for Service of Legal Process	Daemen College 4380 Main Street Amherst, NY 14226
Contributions	The premiums for your coverage under the Plan are paid in part by Daemen College and in part by you.
Plan Records	The records for the Plan are kept on a plan year basis.
Plan Year	The plan year for the Plan is the 12 month period beginning each July 1st and ending on the following June 30th.
Eligibility Requirements	An employee is eligible to participate in this Plan if the employee is a full-time employee of Daemen College, including a limited full-time employee as defined in the Daemen College Employee Handbook. However, an employee whose employment at Daemen College is incidental to the employee's education program at Daemen College is not eligible to participate in the Plan. An eligible employee may enroll for Individual or Family coverage. Family coverage provides coverage not only for you and your spouse but also for: a child, a stepchild dependent on you for support, a legally adopted child (or a child for whom you are the proposed adoptive parent and who is dependent upon you during the waiting period prior to the adoption becoming final) and a child for whom you are the legal guardian. All children must be unmarried and under the age of 19. unmarried children who are 19 years of age and older who are incapable of self-support due to mental illness, developmental disability, mental retardation or physical handicap, provided the condition existed prior to the 19th birthday and was certified by a physician. the attached "Comparison For: Daemen College" contains a section entitled Dependents which you should consult for additional dependent coverage and restrictions for medical benefits for dependent children 19 years and older. For dental benefits, your unmarried dependent child will be covered until age 23 provided the child is enrolled as a full-time student. An employee who is eligible to participate in the Plan may begin participation on the first day of the month following the employee's date of hire. If the employee waives coverage at that time, he or she would not be eligible to enroll in the Plan until the next Open Enrollment Period (see "Open Enrollment Period" below). You may change from Individual coverage to Family coverage by applying for Family coverage within 30 days after you marry or after the birth, adoption or placement for adoption of a child. If you apply, your new coverage becomes effective on the date of your marriage, or the date of birth, adoption or placement for adoption of your child. Married employees who do not change their coverage when first eligible may change later to Family coverage during a subsequent Open Enrollment Period (see "Open Enrollment Period" below).
Initial Enrollment	You will be provided with the appropriate enrollment forms before you become eligible to participate in the Plan. Your enrollment forms should be returned to the Personnel Office of Daemen College.
Open Enrollment Period	You will be given the opportunity to change your benefit option for each year and make other elections with regard to your benefits under the Plan. More detailed coverage and election material will be furnished to you each year during the annual open enrollment period. The annual open enrollment period is held approximately 8 weeks before July 1st, with all elections effective as of July 1st.
Description of Benefits	Medical benefits provided under the Plan are fully described in the subscriber contract or coverage certificate issued to the Participant by the insurance carrier or HMO. Dental benefits provided under the Plan are fully described in the coverage certificate issued to the Participant by The Guardian. You should keep them with this document. Please note that your subscriber contract or coverage certificate may contain some of the same general information about Daemen College or the Plan that is specified in this document. If any of that general information in a subscriber contract or coverage certificate conflicts with the information in this document, the information in this document will be controlling. The "Comparison For: Daemen College" you will receive from Daemen College provides a comparison of the general coverage provisions of the different medical benefit coverage options offered under the Plan.
Coordination of Benefits	When a Participant is also covered under another group health plan or policy, each carrier will coordinate benefit payments with any payments made under the other plan or policy. One plan or policy will pay the benefit as a primary benefit. The other plan or policy will pay secondary benefits, to the level covered by that plan or policy, if necessary to cover the Participant's expenses. In order to determine which plan or policy is primary, the benefit payment under each plan or policy will be coordinated with the benefit payments under the other plan or policy. The coordination of benefit rules for each medical benefit coverage option are set forth in the subscriber contract or coverage certificate issued by the insurance carrier or HMO. The coordination of benefit rules for dental benefits are set forth in the coverage certificate issued by The Guardian.
Qualified Medical	In accordance with section 609(a) of ERISA, the Plan will
Child Support Orders	provide coverage to a child of a participant in accordance with the terms of any medical child support order that the Plan Administrator determines to be a "qualified medical child support order." A qualified medical child support order is a judgment, decree or order issued by a court, which provides for child support or health benefit coverage relating to benefits under the Plan and which meets certain requirements regarding substance and form. Medical child support orders should be submitted to the Personnel Office of Daemen College. The Personnel Office will promptly notify the involved individuals of its receipt of the order and of the Plan's procedure for determining whether the order is a qualified order. You may request a copy of the Plan's procedure for determining whether an order is a qualified medical child support order from the Personnel Office of Daemen College.
Certificate of Creditable Coverage	A certificate of creditable coverage is a document that reports the period of time that you and/or a dependent have had medical benefits coverage under the Plan without a significant break in coverage. This information may be helpful if you or a dependent become covered under a group health plan other than the Daemen College Health Insurance Plan and that other group health plan contains a preexisting condition limitation. Under Federal law, your coverage or your dependent's coverage under this Plan may reduce or eliminate the application of the other plan's preexisting condition limitation. A certificate of creditable coverage will be provided automatically when your coverage or your dependent's coverage under the Plan terminates. You or your dependent also have the right to request a certificate of creditable coverage from the Plan at any time, as long as your request is made within 24 months after your coverage or your dependent's coverage under the Plan terminates. Requests should be directed to the Personnel Office of Daemen College. The medical coverage options offered under the Plan do not contain any preexisting condition limitations, so it is not necessary for you or your dependents to provide a certificate of creditable coverage to Daemen College when you enroll for medical coverage under the Plan. However, the Personnel Office of Daemen College will assist you in obtaining a certificate of creditable coverage from your former group health plan if you are having difficulty in obtaining one.
Medicaid-Eligible Individuals	In determining whether an individual is eligible for coverage and in making benefit payments, the Plan will not take into account the fact that an individual is eligible for or is covered by Medicaid. In addition, the Plan will make benefit payments in accordance with any assignment of rights made by or on behalf of an individual as required by a state Medicaid program and in accordance with any state law which provides that the state has acquired rights to payment with respect to a participant.
Mastectomy Benefit Coverage	Under Federal law, group health plans, insurance companies, and health maintenance organizations (HMOs) that provide coverage for medical and surgical benefits for mastectomy must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Required coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas. These benefits are subject to the normal deductible and coinsurance provisions that apply to other benefits under your coverage.
Loss of Coverage	Employee - Your coverage under the Plan as an employee will terminate on the earliest of the following dates: 1) the date you die; 2) the last day of the month in which your employment terminates (see "Post Retirement Medical Coverage" below); 3) in limited circumstances (see "Medicare Entitlement" below), the date on which you become entitled to Medicare; 4) The date on which you became a member of a bargaining unit whose members do not participate in this Plan; 5) The last day of the month in which you change from full-time status to part-time status. Spouse - The spouse of an employee who has enrolled for Family coverage will cease to be covered under the Plan on the earlier of the last day of the month in which the employee and spouse are legally divorced or the date on which the employee ceases to be covered under the Plan. Dependent Children - A dependent child of an employee who has enrolled for Family coverage will cease to be covered under the Plan on the earlier of the last day of the month in which the child ceases to be eligible for coverage as a dependent child (under the rules explained under the "Eligibility Requirements" section) or the date on which the employee ceases to be covered under the Plan.
Post-Retirement Medical Coverage	An employee who retires from employment with the Daemen College and who, on the date of his or her retirement, has 15 years of service with Daemen College and is covered by the Plan shall be eligible for post-retirement medical and dental coverage. A retiree who elects such coverage will be required to pay all or a portion of the cost of such coverage. Information regarding retiree contribution amounts will be provided to retirees at initial enrollment and at each annual enrollment. Although Daemen College intends to make coverage available to retirees on the terms described above, Daemen College does not guarantee that post-retirement medical or dental coverage will remain for life or for any period. Daemen College may amend this Plan to reduce or eliminate post-retirement medical and dental coverage.
Medicare Entitlement	Active Employees. If you are actively employed and covered under the Plan and become entitled to Medicare, this Plan will pay benefits on a primary basis with Medicare paying on a secondary basis while you are actively employed unless you elect Medicare as your primary coverage and refuse coverage under this Plan. If you elect Medicare as your primary coverage and refuse coverage under this Plan, this Plan is prohibited by law from making any benefit payments on your behalf, even secondary payments. If you have Family coverage and elect Medicare as your primary coverage, your covered family member(s) will lose coverage under this Plan unless they elect to purchase continuation coverage (see "Continuation Coverage" section below regarding their right to purchase continued coverage under the Plan). Retirees. If you are eligible to and elect to continue your coverage under the Plan as described above, your entitlement to Medicare will not cause you to lose coverage under the Plan.
Medicare Entitlement	Active Employees. If you are actively employed and covered under the Plan and become entitled to Medicare, this Plan will pay benefits on a primary basis with Medicare paying on a secondary basis while you are actively employed unless you elect Medicare as your primary coverage and refuse coverage under this Plan. If you elect Medicare as your primary coverage and refuse coverage under this Plan, this Plan is prohibited by law from making any benefit payments on your behalf, even secondary payments. If you have Family coverage and elect Medicare as your primary coverage, your covered family member(s) will lose coverage under this Plan unless they elect to purchase continuation coverage (see "Continuation Coverage" section below regarding their right to purchase continued coverage under the Plan). Retirees. If you are eligible to and elect to continue your coverage under the Plan as described above, your entitlement to Medicare will not cause you to lose coverage under the Plan.
Continuation Coverage	In certain circumstances that would otherwise result in the termination of coverage, you, your spouse, and/or your dependent children will be eligible to purchase continuation coverage under the Plan. The circumstances that give rise to the right to purchase continuation coverage for you, your spouse and your dependent children are known as "Qualifying Events." Qualifying Events 1. Termination of Employment/Reduction of Hours. One Qualifying Event is the termination of your employment with Daemen College, or the reduction in your hours of employment to the point where you are no longer eligible for coverage under the Plan. If this Qualifying Event occurs, you may elect to continue the coverage you had in effect for up to 18 months following the date your coverage would otherwise terminate. If you had Family coverage, your spouse and any covered dependents will have the right to elect to purchase coverage individually. If you elect to purchase continued Family coverage, your spouse and covered dependents will not need to elect to continue their coverage individually. If you (or your spouse or children, if you had Family coverage) are determined to be disabled for purposes of Social Security at any time during the first 60 days of your continuation coverage period, coverage may be continued for an additional 11 months, for a total of 29 months of continuation coverage. In order for you to qualify to purchase the additional 11 months of continuation coverage, you must notify the Personnel Office of Daemen College within 60 days of the date the Social Security Administration makes its disability determination, but in no case later than the last day of the 18th month of continuation coverage. 2. Death of Employee. If you have Family coverage at the time of your death, your spouse and any covered dependents will have the right to purchase 36 months of continuation coverage from the date their coverage would otherwise terminate under the Plan as a result of your death. 3 Divorce or Legal Separation. If you have Family coverage and become divorced or legally separated from your spouse, your spouse and any covered dependents who will lose coverage as a result of the divorce or separation will have the right to purchase 36 months of continuation coverage from the date their coverage would otherwise terminate under the Plan as a result of the divorce or separation. 4. Employee Entitlement to Medicare. If you are an active employee with Family coverage and become eligible for Medicare and elect Medicare as your primary coverage, this Plan will be prohibited from providing any medical benefit to you. Your spouse and any covered dependents who lose coverage under this Plan as a result of your election will have the right to purchase 36 months of continuation coverage from the date their coverage would otherwise terminate under the Plan. 5. Child Ceases to be Eligible Dependent. If your child ceases to qualify as a dependent eligible for coverage (see "Eligibility Requirements"), he or she may purchase 36 months of continuation coverage from the date his or her coverage would otherwise terminate under the Plan. 6. Multiple Qualifying Events. If your employment terminates or your hours of employment are reduced to the point where you are no longer eligible for coverage and you elect to continue Family coverage and then one of the events listed above in paragraphs 2 5 occurs, your spouse and/or dependent(s) may elect to continue coverage for an additional period of time not to exceed the date that is 36 months from the date you originally lost your coverage due to your termination of employment or reduction in hours of employment. Electing Continuation Coverage Each individual who is eligible to elect continuation coverage must make written election for continuation coverage no later than the date that is 60 days after the later of the date coverage would otherwise end or the date Daemen College provides written notice of the right to purchase continuation coverage. The election form must be hand delivered to the Personnel Office of Daemen College or postmarked on or before the 60th day or the individual will not be permitted to elect continuation coverage. Notice Requirements You or your spouse and/or dependents must notify the Personnel Office of Daemen College as soon as possible (but not later than 60 days) after you and your spouse are divorced, your child ceases to be eligible for coverage as a dependent child under the Plan, or one of you receives a Social Security disability determination. If notice is not provided to the Personnel Office within 60 days after one of these events occurs, continuation coverage will not be available (in the case of a disabled individual, extended continuation coverage will not be available). If the Qualifying Event is termination of employment or reduction in hours of employment, the Personnel Office will notify you (and your spouse and dependent children, if you had Family coverage in effect) of your right to purchase continuation coverage. The Personnel Office of Daemen College will provide you with written notice of your rights within 44 days after the date your coverage would terminate due to your termination of employment or reduction in hours. If the Qualifying Event is your death or your entitlement to Medicare (and election of Medicare as your primary coverage) and you had Family coverage, the Personnel Office will notify your spouse and dependent children of their right to purchase continuation coverage. The Personnel Office will provide them with written notice of their rights within 44 days after the date their coverage would terminate due to the Qualifying Event. If the Qualifying Event is divorce or loss of dependent child status and you or a Family member have notified the Personnel Office within 60 days after the occurrence, the Personnel Office will provide your spouse and/or dependent child with written notice of their rights within 14 days of the date you notify the Personnel Office. Cost of Continuation Coverage The monthly premium Daemen College can charge for continuation coverage is up to 102% of the normal full monthly premium for single or Family coverage under the Plan and 150% of the normal full monthly premium for coverage during the 19th through 29th months of coverage for disabled individuals who are eligible for 11 additional months of continuation coverage. Premiums are due by the first day of each month, except that the initial premium payment must be made within 45 days after continuation coverage is elected. Termination of Continuation Coverage Continuation coverage will end as of the date any of the following occurs: The required premiums are not paid on a timely basis. The maximum (18 month, 29 month, or 36 month) continuation coverage period expires. Daemen College ceases to provide any group health coverage to any employees. The date you, your spouse and/or children become covered under another group health plan that does not contain any exclusion or limitation with respect to a preexisting condition of the individual who becomes covered. The date you, your spouse and/or children become entitled to Medicare. If you, your spouse, or your child are in the extended 19th through 29th month of continuation coverage as a result of a Social Security disability determination, coverage will terminate the month that begins more than 30 days after the date a final determination is made that you, your spouse or your child is no longer disabled for purposes of Social Security.
Amendment or Termination of Plan	Daemen College reserves the right to amend or terminate the Plan at any time.
Claim Procedures	With certain of the carriers (refer to the claims submission section of your contract or certificate) the claim forms are completed and forwarded to the insurance carrier, HMO or The Guardian by the health care provider. If the provider does not submit the claims directly to the HMO, insurance carrier or The Guardian, a claim for benefits should be made to the insurance carrier, HMO or The Guardian on claims forms provided by the insurer, HMO or The Guardian and in accordance with the procedure for submitting claims set forth in the subscriber contract or coverage certificate issued to you by the insurance carrier, HMO or The Guardian. Claim forms may be obtained from the Personnel Office of Daemen College. If you are required to obtain pre-approval from your insurance carrier, HMO or The Guardian as a prerequisite to obtaining a benefit, you should follow the pre-approval procedures set forth in the subscriber contract or coverage certificate issued to you by the insurance carrier, HMO or The Guardian. If you contact your insurance carrier, HMO or The Guardian to obtain pre-approval but you fail to follow the pre-approval procedure for filing a pre-service claim, the insurance carrier, HMO or The Guardian is required to notify you of this failure and the proper procedure for filing the pre-service claim. A pre-service claim is a benefit claim that requires some form of pre-approval by the insurance carrier, HMO or The Guardian. The notice is required to be provided to you as soon as possible but not later than 5 days after the failure, or, in the case of an urgent care claim (see below), within 24 hours of the failure. The notice may be given to you orally, unless you request a written notice. You may designate a representative to act on your behalf in pursuing a benefit claim or appealing a denial of a benefit claim by filing a Designation of Representative form with the Personnel Office. You may obtain a Designation of Representative form from the Personnel Office. Alternatively, your insurance carrier or HMO, or The Guardian may have developed its own Designation of Representative form which may be filed directly with the insurance carrier, HMO or The Guardian. Even if you have not filed a Designation of Representative form, your physician or licensed health care professional may act on your behalf as your authorized representative if the benefit claim is an urgent care claim (see below). The period within which the insurance carrier, HMO or The Guardian is required to decide your claim depends upon the type of claim being made. There are generally three types of claims that can be made under the Plan - a pre-service claim, an urgent care claim, and a post-service claim. Pre-Service Claim - A pre-service claim is a claim for a benefit which requires some form of pre-approval by the insurance carrier, HMO or The Guardian. The insurance carrier, HMO or The Guardian must decide a pre-service claim within 15 days. This 15 day period may be extended for up to an additional 15 days if the insurance company, HMO or The Guardian determines the extension is necessary for reasons beyond it's control. The insurance carrier, HMO or The Guardian is required to notify a claimant in writing if there is an extension. Urgent Care Claim - An urgent care claim is a pre-service claim where application of the normal period for deciding pre-service claims could jeopardize the life, health or ability to regain maximum function of the claimant, or would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is being claimed. The insurance carrier, HMO or The Guardian is required to decide an urgent care claim within 72 hours. Post-Service Claim - A post-service claim is any claim that is not a pre-service claim. It would include a claim in which the medical or dental procedure has already occurred and the claimant is seeking payment of it or reimbursement for it. The insurance carrier, HMO or The Guardian is required to decide a post-service claim within 30 days. This 30 day period may be extended for up to an additional 15 days if the insurance carrier, HMO or The Guardian determines the extension is necessary for reasons beyond it's control. The insurance carrier, HMO or The Guardian is required to notify a claimant in writing if there is an extension. In addition, some special rules apply where the insurance carrier, HMO or The Guardian has already approved an ongoing course of treatment over a period of time or number of treatments. First, if the insurance carrier, HMO or The Guardian reduces or terminates coverage for the course of treatment before it otherwise would have ended, that reduction or termination is a benefit denial. The insurance carrier, HMO or The Guardian must notify the claimant sufficiently in advance of the reduction or termination to allow the claimant to appeal the decision (see Appealing a Claim below) and to obtain a decision on the appeal. Second, if the claimant requests an extension of the course of treatment at least 24 hours before the course of treatment ends and it is an urgent care situation (see Urgent Care Claim above), the insurance carrier, HMO or The Guardian must notify the claimant within 24 hours of its decision on the extension request. If your claim is approved, the HMO, insurance carrier or The Guardian will notify you who has been paid and the amount that has been paid, or will be paid, in the case of a pre-service claim. If your claim is denied in whole or in part, you will receive a written notice which must include the following information: The specific reason or reasons for the denial of all or any portion of the claim. The specific provisions of the subscriber contract, certificate of coverage, the Plan and any other document, on which the denial is based. If the decision to deny benefits is based, in whole or in part, on a specific internal rule, guideline, protocol or similar criteria, you may request a copy of such document from the insurance carrier, HMO or The Guardian at no charge. If the decision to deny benefits is based, in whole or in part, on an exclusion or limitation that the treatment is experimental or investigational, or that the treatment is not medically necessary, you may request from the insurance carrier, HMO or The Guardian at no charge an explanation that applies the appropriate terms to your medical circumstances, and which details the scientific or clinical judgment that led to the decision to deny benefits. A description of any additional material or information necessary for you to complete the claim, and an explanation as to why such information or material is necessary. Information as to how you may submit the claim for review (i.e. appeal) and the applicable time limits. A statement regarding your right to bring a civil suit under federal law should your appeal be denied In the case of an urgent care claim, the notice of denial may be provided to you orally within the 72 hour period, so long as a written notice is provided within 3 days thereafter. You may appeal a claim denial by following the appeal procedure explained below.
Appealing a Claim	If you do not agree with the denial or partial denial of your claim or if you have questions concerning your claim, you are encouraged to contact the insurance carrier, HMO or The Guardian. If you wish to appeal a claim denial, you may need to complete a form provided and required by your insurance carrier, HMO or the Guardian, to file your appeal. In your appeal, you must state that you are requesting an official review of your claim and the reason(s) why you do not agree with the denial or partial denial of your claims and any additional information pertinent to the claim. You should review your subscriber contract or coverage certificate to determine who to contact at the insurance carrier, HMO or The Guardian to bring an appeal. Except in the case of urgent care claims, the insurance carrier, HMO or The Guardian need not consider any telephone inquiry as a request for an official review of a denied claim. However, if the claim which is denied is an urgent care claim, you may request an expedited appeal by calling the insurance carrier, HMO or The Guardian. You should review your subscriber contract or coverage certificate to determine who you may call to appeal an urgent case claim. In addition, the Personnel Office can provide you with the appropriate telephone number. If you want to appeal a denied claim, the HMO, insurance carrier or The Guardian must allow you at least 180 days after you receive notice of a denial or partial denial to file the appeal. During the 180 days (or any longer period the HMO, insurance carrier or The Guardian may allow), you or your representative may request from the insurance carrier, HMO or The Guardian copies of all documents, records and information relating to your claim. If you wish, you or your representative may submit written issues, comments and additional justification as to why the claim should be allowed. The insurance carrier, HMO or The Guardian is required to identify each medical or vocational expert whose advice was obtained in connection with your denied claim, regardless of whether the advice was relied upon. When the insurance carrier, HMO or The Guardian reviews your appeal, it may not afford any deference to the initial decision. The review will be conducted by an individual, committee or department identified in your subscriber contract or coverage certificate. If the benefit denial is based in whole or in part on a medical judgment, such as whether the procedure is experimental or is not medically necessary, the person reviewing the claim at the insurance carrier, HMO or The Guardian is required to consult with a health care professional who has appropriate training and experience in the particular field of medicine relating to your claim. This health care professional will be someone who was not consulted on the initial claim denial. The review of a claim denial is required to be done by the insurance carrier, HMO or The Guardian within the following time frames: Pre-Service Claim. If the denied claim was a pre-service claim (other than an urgent care claim) the insurance carrier, HMO or The Guardian is required to decide your appeal within 30 days. Urgent Care Claim. If the denied claim was an urgent care claim, the insurance carrier, HMO or The Guardian is required to decide your appeal within 72 hours. Post-Service Claim. If the denial claim was a post-service claim, the insurance carrier, HMO or The Guardian is required to decide your appeal within 60 days. The insurance carrier, HMO or The Guardian is required to provide you with a written notice of the determination on review. If the denial of your claim is upheld (in whole or in part) the notice is required to include the following information: 1. The specific reason or reasons for the adverse determination. 2. The specific provisions of the subscriber contract, certificate of coverage, the Plan and any other document on which the adverse determination is based. 3. A statement that you may obtain, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits. If any internal rule, guideline, protocol or similar guideline was relied upon in making the adverse determination, the insurance carrier, HMO or The Guardian must either provide it to you with the adverse determination or provide you with a copy of it free of charge upon request. If the adverse determination is based on medical necessity, experimental treatment or a similar exclusion, the insurance carrier, HMO or The Guardian must either provide an explanation of the scientific or clinical judgment for the adverse determination to you with the adverse determination, or provide it to you free of charge upon request. 4. If the insurance carrier, HMO or The Guardian has any voluntary appeal procedures, information regarding those procedures. Should you have any questions regarding the claims procedure, please contact the Personnel Office. For the denial of medical benefits, you may have other appeal options available to you under New York State law. You should contact the insurance carrier or HMO directly about any appeal options available under New York State law.
Discretionary Authority	In carrying out their responsibilities under the Plan, the insurance carriers and HMOs that provide medical coverage under the Plan shall have full discretionary authority to interpret the terms of the subscriber contracts and coverage certificates that they issue and to determine eligibility for benefits in accordance with the terms of such subscriber contracts and coverage certificates. In carrying out its responsibilities under the Plan, The Guardian shall have full discretionary authority to interpret the terms of the coverage certificates that it issues and to determine eligibility for dental benefits in accordance with the terms of the coverage certificates. In carrying out its responsibilities under the Plan, Daemen College shall have full discretionary authority to interpret the terms of the Plan, with the exception of the terms of the subscriber contracts and coverage certificates issued by the insurance carriers or HMOs. Any interpretation or determination made by Daemen College or an insurance carrier or HMO pursuant to such discretionary authority shall be given full force and effect unless found by a court of competent jurisdiction to be arbitrary and capricious.
Statement of Rights	As a participant in the 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 be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specific locations, such as worksites, all documents governing the Plan including insurance contracts and a copy of the latest annual report (Form 5500) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration. Obtain upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish you 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 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 subject to a preexisting condition exclusion for 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 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, 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 Plan 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 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 from 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 Area 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 publications hotline of the Pension and Welfare Benefits Administration.
EXHIBIT A Insurance Carriers and Health Maintenance Organizations Providing Benefits Under Daemen College Health Insurance Plan Provider/Carrier Address/Phone 1. Blue Cross and Blue Shield (medical options) Blue Cross and Blue Shield of Western New York 1901 Main Street Buffalo, New York 14240 (716) 884-0774 (800) 888-0757 2. Community Blue (medical options) Community Blue 1901 Main Street Buffalo, New York 14240 (716) 884-2800 (800) 665-2583 3. Univera Health Care (medical options) Univera Health Care 205 Park Club Lane Buffalo, New York 14221-5239 (716) 847-1480 (800) 427-8490 4. Independent Health (medical options) Independent Health 511 Farber Lakes Drive Buffalo, New York 14221 (716) 631-8701 (800) 501-3439 5. The Guardian (dental options) The Guardian P.O. Box 2459 Spokane, Washington 99210-2459 (800) 541-7846