Erisa Plan Number 504
Download the Travel Accident Plan Beneficiary Form (75 K)
At no cost to you, American Academy of Ophthalmology provides the additional protection of a Business Travel Accident Plan for all members and employees who travel on Academy business. This Plan will provide you or your beneficiary benefits in the event you sustain an injury or death while traveling on bonafide Academy business. Coverage is automatic and becomes effective on the first day of employment
All benefits under this Plan are in addition to any other benefits to which you may be entitled under other group insurance plans or from any other source.
A bonafide trip commences when you leave your residence or place of regular employment, whichever occurs last and terminates when you return to your residence or regular place of employment, whichever occurs first. This is not coverage for travel to or from work, or for other travel not connected with Academy business.
The Plan is not an employment contract.
Life and Accidental Death and Dismemberment Benefits
The maximum life and accidental death & dismemberment benefit under the Business Travel Accident Plan is called the “Principal Sum." The principal sum is payable in the event of your death or for certain specified injuries. For other injuries the amount of the benefits is one-half of the principal sum.
Schedule of Benefits
If you are in an accident during a business trip and you sustain any of the following losses within one year after the date of the accident, you or your beneficiary will be paid in accordance with the following schedule; however, if more than one of the described losses are sustained as a result of any one accident, payment will be made for one loss only – the one for which the larger amount is payable.
Loss / Amount of Benefit
- Life: The Principal Sum
- Two Hands or Two Feet: The Principal Sum
- Sight of Two Eyes: The Principal Sum
- One Hand and One Foot: The Principal Sum
- One Hand and Sight of One Eye: The Principal Sum
- One Foot and Sight of One Eye: The Principal Sum
- One Hand or One Foot: One-half Principal Sum
- Sight of One Eye: One-half Principal Sum
Principal Sum Defined
Class I - $200,000
All members in good standing of the policyholder under age 70, to include the following:
- Board Members
- Standing Committee Members & Representatives
- Advisory Committee Members
- Academy Employees
- Executive Vice President
- Deputy Executive Vice President
Class II - $100,000
All members of Class l over the age of 70.
Aggregate Limit of Liability $2,000,000 per accident.
The Company shall not be liable for any amount in excess of the above stated aggregate limit of liability.
If the aggregate amount of all indemnities otherwise payable by reason of coverage provided under this policy exceeds such aggregate limit of liability, the Company shall not be liable as respects each Insured for a greater proportion of the indemnity otherwise payable than the aggregate limit of liability bears to the aggregate amount of all such indemnities.
Death Benefit Payment
If death occurs as a result of an accident which occurred during a business trip, the Principal Sum will be paid in a lump sum to the beneficiary or beneficiaries you have designated to receive your non-contributory life insurance. If for some reason this is unsatisfactory, you must designate the different beneficiary on a special form which you may obtain from your Personnel Office. The change of beneficiary form must be filed with your Personnel Office to become effective. If at your death, your designated beneficiary is not living, then the benefits will be payable in one sum to the first surviving class of the following classes of beneficiaries in order of preference: spouse, children, father, mother.,brothers or sisters. Your estate if none of the preceding classes survive.
These benefits are not payable for any loss, fatal or nonfatal, caused by or resulting from the following: suicide or any attempt at suicide; declared or undeclared war or any act thereof in the United States of America or Canada; service in the Armed Forces of any country; piloting or serving as a crew member in any aircraft; riding as a passenger in any aircraft owned or operated by the policyholder; commuting between your home and regular place of employment; sickness or disease, except pyogenic infections which occur through accidental cut or wound.
Termination of Coverage
The right is reserved in the Plan for the Academy to terminate, suspend, withdraw, and/or modify this Plan at any time subject to the contractual provisions of the Group Insurance Contract.
Termination of your individual rights to benefits under the plan is summarized in the Termination of Coverage Table displayed below:
|Reason for Termination
||When Coverage Terminates
|Termination of Employment
||Date of separation
||Date of lay-off
|Approved Leave of Absence
||Date leave commences
There are no conversion rights under this Plan.
Claims Processing Procedure
Step #1: Filing a Claim for Benefits
To receive benefits under this Plan, you or your beneficiary must file a preliminary accident report form within thirty days after the accident or as soon thereafter as is reasonably possible. These forms may be obtained from your Personnel Office. When receiving the form, study each question carefully and answer each accurately. Your Personnel Office will answer any questions you may have. Submit the completed accident report to your Personnel Office. Your Personnel Office will send directly to you or your beneficiary a claim form appropriate for your state of residency.
You will be notified in writing if any benefits are denied in whole or in part, or if any additional information is required.
Step #2: Denial of Claim for Benefits
If claim is wholly or partially denied, you or your beneficiary will ordinarily receive written notice of the denial within 90 days of the date the claim was received by your Personnel Office. If special circumstances require an extension, written notice of any extension will be given to you or your beneficiary before the end of the initial 90-day period. The extension notice will explain the reason for the delay and estimate the decision date. In no case will the extension period exceed 90 days.
The written denial notice will contain the specific reasons for denial; specific reference to the pertinent plan provisions on which the denial was based; if deemed appropriate, a description of any material required for the re submission of the claim; and, who to contact if you decide to appeal.
Step #3: Review and Appeal of Denied Claims
If you or your beneficiary do not agree with a claim denial, you or your beneficiary may request that a review be made of the claim.
Contact your Personnel Office and explain why you or your beneficiary believe the declination of benefits to be improper. If your Personnel Office cannot resolve the problem to you or your beneficiary's satisfaction, file an appeal by completing the appropriate appeal form within 60 days of receiving the notice declining the benefit. Complete the appeal form by providing a statement as to why you or your beneficiary believe the claim should not have been denied, including any questions or comments deemed appropriate, and attach to the form data or documents that support your or your beneficiary position. Your Personnel Office will receive the appeal form and provide a copy. Your appeal form will be transmitted to the Plan Administrator for complete review.
Step #4: Decision Review
The appeal will be thoroughly reviewed by the Plan Administrator and Insurer. You or your beneficiary will be notified in writing by the Plan Administrator of the final decision within 60 days of receipt of the appeal form. If more time is required to evaluate the appeal, you or your beneficiary will be so notified in writing, and the reasons why more time is required will be explained. After giving such notice, a decision will be rendered as soon as possible, but not later than 120 days from the date the Plan Administrator received your appeal form.
Your Rights Under The Employee Retirement Income Security Act
Federal Regulations at Section 2520.102-3 require American Academy of Ophthalmology to furnish you with the following statement of rights of participants under the employee Retirement Income Security Act of 1974. The statement was written by the U.S. Department of Labor as authorized by Section 104(c) of the Employee Retirement Income Security Act of 1974:
As a participant in the Business Travel Accident 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 Administrator's office and at any other specified location, all Plan documents and copies of all documents filed by the Plan with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.
Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. 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 each participant with a copy of this Summary annual report.
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the administration of the plan. The people who administer your plan, called “fiduciaries," have a duty to do so prudently and in the interest to 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 plan benefit or exercising your rights under ERISA. If your claim for a benefit 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 Administrator 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 a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $100 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. 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 suite 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. 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, you should contact the nearest Area Office of the U.S. Labor-Management Services Administration, Department of Labor.
Name of Plan: Business Travel Accident Plan
- Plan Identification: When referring .to this Plan in oral or written communications, identify the Plan by using the following numbers: Employer Identification Number 41-1336784 and Plan Number 504.
- Type of Plan: This welfare plan provides accidental death and dismemberment benefits.
- Plan Year: The records of this Plan are maintained on a Plan Year basis. "Plan Year" means a 12-month period beginning on January 1 and ending the following December 31st.
- Employer, Plan Sponsor & Plan Administrator:
American Academy of Ophthalmology
655 Beach Street
San Francisco, CA 94109
- Type of Plan Administration: This Plan is administrated by the American Academy of Ophthalmology (the "Plan Administrator") and benefits are provided in accordance with the provisions of the Group Insurance Contract Number issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA, (the "Insurer"), 1600 Arch Street, Philadelphia, PA 19103.
- Funding: The Plan is funded by the payment of the premiums required by the Group Insurance Contract issued by the Insurer.
- Contributions: The Plan Sponsor pays all premiums required by the Group Insurance contract from its own funds.
- Agent for Service: It is anticipated that the Plan will be administered strictly in accordance with the provisions of the Plan and in compliance with any governmental regulations. However, legal process, should the need occur, can be served on the Plan Sponsor by directing such legal process to:
American Academy of Ophthalmology
655 Beach Street
San Francisco, CA 94109
Download the Travel Accident Plan Beneficiary Form(75 K)