GROUP POLICY / POINT OF SERVICE AND HMO
~DS)
< .
I
I
UNITED HEAL THCARE OF FLORIDA, INC.
GROUP POLICY
City of Clearwater
Copyright United HealthCare Corporation
April 1995
A0
/r """'_ /, "'I .,
0;
( ~/
.'
1
I
GROUP POLICY
This Group Policy ("Policy") is entered into by and between United HealthCare of Florida, Inc. "PLAN"), a Florida
Health Maintenance Organization and City of Clearwater ("Enrolling Unit").
Upon receipt of the Enrolling Unit's application and payment of the required Policy Charges, this Policy is deemed
executed. The PLAN agrees with the Enrolling Unit to provide Coverage for Health Services set forth herein,
subject to the terms, conditions, exclusions, and limitations of this Policy. The Enrolling Unit's application is made
a part of this Policy.
This Policy replaces and supersedes any previous agreements relating to the Coverage of Health Services between
the Enrolling Unit and the PLAN. The terms and conditions of this Policy shall in turn be superseded by those of
any subsequent agreements relating to the Coverage of Health Services between the Enrolling Unit and the PLAN.
This Policy shall become effective at 12:0 I a.m. January 1,2000 Eastern Time and will be continued in force by the
timely payment of the required Policy Charges when due, subject to termination of this Policy as provided herein.
When the Policy is terminated, as provided for in Article 5, this Policy and all Coverage under this Policy will end
at 12:00 midnight on the date of termination.
This Policy is delivered in and governed by the laws of the State of Florida.
04/18/95 POLICY
/Jj
I ,
/~
,v
I
I
ARTICLE 1
DEFINITIONS
The tenns used in this Policy have the same meaning given those tenns in the Certificate of Coverage, unless
otherwise specifically defined in this Policy.
ARTICLE 2
HEALTH SERVICES
Subscribers and their Enrolled Dependents are entitled to Coverage for Health Services subject to the tenns,
conditions, limitations and exclusions set forth in the Certificate of Coverage included in this Policy as
Attachment A. The Certificate describes the Covered Health Services including any optional Riders, required
Copayments, and the tenns, conditions, limitations and exclusions related to Coverage.
ARTICLE 3
PREMIUM RATES AND POLICY CHARGE
3.1 Premiums. Monthly Premiums payable by or on behalf of Covered Persons are specified on Exhibit A to the
Policy entitled "Premiums".
The PLAN reserves the right to change the schedule of rates for Premiums on the first anniversary of the effective
date of the Policy specified in the application or on any monthly due date thereafter, or on any date the provisions of
the Policy are amended. The PLAN will provide written notice of any change in Premiums to the Enrolling Unit at
least 45 days prior to the effective date of the change.
3.2 Computation of Policy Charge. Each Policy Charge shall be calculated based on the number of Subscribers
in each Coverage classification the PLAN shows in its records at the time of calculation, at the Premiums then in
effect. A full calendar month's Premiums shall be charged for Covered Persons whose effective date of Coverage
falls on or before the 15th of that calendar month. No Premiums shall be charged for Covered Persons whose
effective date of Coverage falls after the 15th of that calendar month. A full calendar month's Premiums shall be
charged for Covered Persons whose Coverage is terminated after the 15th of that calendar month. No Premiums
shall be charged for Covered Persons whose Coverage is terminated on or before the 15th of that calendar month.
3.3 Adjustments to the Policy Charge. Retroactive adjustments may be made for any additions or terminations of
Subscribers or changes in Coverage classification not reflected in the PLAN's records at the time the Policy Charge
is calculated by the PLAN. However, no retroactive credit shall be granted for any change occurring more than 60
days prior to the date the PLAN received notification of the change from the Enrolling Unit, nor shall retroactive
credit be granted for any calendar month in which a Subscriber has received Health Services.
The Enrolling Unit shall notify the PLAN in writing within 30 days of the effective date of enrollments,
terminations or other changes; provided, however, that the Enrolling Unit shall notify the PLAN in writing each
month of any changes in the Coverage classification of any Subscriber.
04/18/95 POLICY
2
. 1 '
;JO
"
I
I
3.4 Payment of the Policy Charge. The Policy Charge is payable in advance on a monthly basis by the Enrolling
Unit to the PLAN. The first Policy Charge is due and payable on the effective date of the Policy. Subsequent
Policy Charges are due and payable no later than the first day of each period thereafter that the Policy is-in effect.
A late payment charge will be assessed for any Policy Charge not received by the last day of the grace period. A
service charge will be assessed for any non-sufficient-fund check received in payment of the Policy Charge. All
Policy Charge payments shall be accompanied by supporting documentation which states the names of the Covered
Persons for whom payment is made.
The PLAN reserves the right to collect attorney's fees and any other costs related to collecting delinquent Policy
Charges.
3.5 Grace Period. A grace period of 10 days shall be granted for the payment of any Policy Charge, during which
time the Policy shall continue in force. In no event shall the grace period extend beyond the date the Policy
terminates.
This Policy shall automatically terminate retroactive to the last paid date of Coverage if the grace period expires and
any Policy Charge remains unpaid, or if the PLAN receives written notice of termination from the Enrolling Unit
during the grace period.
ARTICLE 4
ENROLLMENT AND ELIGIBILITY
4.1 Initial Eligibility Period. Eligible Persons and their Dependents may enroll for Coverage under the Policy
during the Initial Eligibility Period. The Initial Eligibility Period shall begin on December I, 1999 and shall end on
January 31, 2000. Eligible Persons and Dependents who do not submit an application for enrollment to the
Enrolling Unit during the Initial Eligibility Period may not apply for Coverage under this Policy until the Enrolling
Unit holds an Open Enrollment Period.
4.2 Open Enrollment. The Enrolling Unit shall provide an annual Open Enrollment Period of 30 days, In
accordance with state law, during which Eligible Persons may enroll for Coverage under the Policy.
4.3 Eligibility Conditions. The following conditions are in addition to those specified in Section 2 of the
Certificate:
(a) The term "Dependent" shall not include any unmarried dependent child 19 years of age or older
unless the unmarried dependent child is 19 years of age or older and less than 25 years of age and
meets the criteria described in Section 1 of the Certificate, the definition of "Dependent,"
items 2.a. through 2.c.
(b) Waiting or probationary period for newly Eligible Persons shall be as follows:
Date of Hire
(c) Excluded persons, if any:
Part-time, Temporary
04/18/95 POLICY
3
I
I
(d) Coverage classifications other than employee, if any:
(e) Other:
4.4 Effective Date of Coverage. Coverage for properly enrolled Eligible Persons and their Dependents shall begin
on:
The day following the last day of the required waiting period.
X The first day of the month following the month in which the waiting period was completed.
The date the Eligible Person joins the Enrolling Unit.
X Other: Retirees may return to the group insurance plan once a year at open enrollment.
Non-Medicare eligible spouses of retired employees who are enrolled in Medicare.
ARTICLE 5
POLICY TERMINATION
5.1 Conditions for Termination of This Entire Policy. This Policy and all Coverage under this Policy shall
automatically terminate on the earliest of the dates specified below:
(a) At the PLAN's option, retroactive to the last paid date of Coverage, if the grace period expires and
any Policy Charge remains unpaid.
(b) On the date specified by the Enrolling Unit, after at least 45 days prior written notice to the PLAN
that this Policy shall be terminated.
(c) On the date specified by the PLAN, after at least 45 days prior written notice to the Enrolling Unit
that this Policy shall be terminated, except for (d) below.
(d) On the date specified by the PLAN in written notice to the Enrolling Unit that this Policy shall be
terminated because the Enrolling Unit provided the PLAN with false information material to the
execution of this Policy or to the provision of Coverage under this Policy. The PLAN has the
right to rescind this Policy back to the effective date.
5.2 Payment and Reimbursement Upon Termination. Upon any termination of this Policy, the Enrolling Unit
shall be and shall remain liable to the PLAN for the payment of any and all Premiums which are unpaid at the time
of termination.
04/18/95 POLICY
4
"
I
I
ARTICLE 6
G ENERA:L PROVISIONS
6.1 Entire Policy. The group Policy, including the Certificate of Coverage as Attachment A, the application of the
Enrolling Unit, any individual Subscriber applications, Amendments and Riders shall constitute the entire Policy
between parties. All statements made by the Enrolling Unit or by a Subscriber shall, in the absence of fraud, be
deemed representations and not warranties. No such statement shall void or reduce Coverage under this Policy or
beused in defense of a legal action unless it is contained in a written application.
6.2 Dispute Resolution. No legal proceeding or action may be brought without first completing the complaint
procedure specified in Section 5 of the Certificate. If the Enrolling Unit wishes to seek further review of the
decision or the complaint or dispute, it shall submit the complaint or dispute to binding arbitration pursuant to the
rules of the American Arbitration Association. This is the only right the Enrolling Unit has for further
consideration. The matter must be submitted to binding arbitration within I year of the date the final decision was
furnished to the Enrolling Unit, as described in Section 5. The arbitrators shall have no power to award any punitive
or exemplary damages or to vary or ignore the provisions of the Policy, and shall be bound by controlling law.
6.3 Time Limit on Certain Defenses. No statement made by the Enrolling Unit, except a fraudulent statement,
shall be used to void this Policy after it has been in force for a period of 2 years.
6.4 Amendments and Alterations. Amendments to this Policy are effective 45 days after PLAN sends written
notice to the Enrolling Unit. No change will be made to this Policy unless made by an Amendment or a Rider
which is signed by an executive officer of the PLAN. No agent has authority to change this Policy or to waive any
of its provisions.
6.5 Relationship Between Parties. The relationships between the PLAN and Participating providers and
relationships between the PLAN and Enrolling Units, are solely contractual relationships between independent
contractors. Participating providers and Enrolling Units are not agents or employees of the PLAN, nor is the PLAN
or any employee of the PLAN an agent or employee of Participating providers or Enrolling Units.
The relationship between a Participating provider and any Covered Person is that of provider and patient. The
Participating provider is solely responsible for the services provided by it to any Covered Person. The relationship
between any Enrolling Unit and any Covered Person is that of employer and employee, Dependent, or other
Coverage classification as defined in this Policy. The Enrolling Unit is solely responsible for enrollment and
Coverage classification changes (including termination of a Covered Person's Coverage through the PLAN) and for
the timely payment of the Policy Charge.
6.6 Records. The Enrolling Unit shall furnish the PLAN with all information and proofs which the PLAN may
reasonably require with regard to any matters pertaining to this Policy. PLAN may at any reasonable time inspect
all documents furnished to the Enrolling Unit by an individual in connection with the Coverage, and the Enrolling
Unit's payroll, and any other records pertinent to the Coverage under this Policy.
By accepting Coverage under this Policy, each Covered Person, including Enrolled Dependents, whether or not
such Enrolled Dependents have signed the application of the Subscriber, authorizes and directs any person or
institution that has provided services to the Covered Person, to furnish the PLAN or any of the PLAN's designees at
any reasonable time, upon its request, any and all information and records or copies of records relating to the
services provided to the Covered Person. The PLAN agrees that such information and records will be considered
confidential. The PLAN and any of the PLAN's designees shall have the right to release any and all records
concerning health care services which are necessary to implement and administer the terms of this Policy or for
appropriate medical review or quality assessment.
04/18/95 POLICY
5
,~
I
I
6.7 Administrative Services. The services necessary to administer this Policy and the Coverage provided under it
will be provided in accordance with the PLAN's or its designee's standard administrative procedures. If the
Enrolling Unit requests thafsuch administrative services be provided in a manner other than in accordance with
these standard procedures, including requests for non-standard reports, the Enrolling Unit shall pay for such services
or reports at the PLAN's or its designee's then-current charges for such services or reports.
6.8 ERISA. When this Policy is purchased by the Enrolling Unit to provide benefits under a welfare plan governed
by the Employee Retirement Income Security Act 29 U.S.c. ~ I 00 I et seq., the PLAN shall not be named as and
shall not be the Plan Administrator or named fiduciary of the welfare plan, as those terms are used in ERISA.
6.9 Examination of Covered Persons. In the event of a question or dispute concerning Coverage for Health
Services, the PLAN may reasonably require that a Covered Person be examined at the PLAN's expense by a
Participating Physician acceptable to the PLAN.
6.10 Clerical Error. Clerical error shall not deprive any individual of Coverage under this Policy or create a right
to additional benefits. Failure to report the termination of Coverage shall not continue such Coverage beyond the
date it is scheduled to terminate according to the terms of this Policy. Upon discovery of a clerical error, any
necessary appropriate adjustment in Premiums shall be made. However, no such adjustment in Premiums or
Coverage shall be granted by the PLAN to the Enrolling Unit for more than 60 days of Coverage prior to the date
the PLAN received notification of such clerical error.
6.11 Workers' Compensation Not Affected. The Coverage provided under this Policy does not substitute for and
does not affect any requirements for coverage by Workers' Compensation Insurance.
6.12 Conformity with Statutes. Any provision of this Policy which, on its effective date, is in conflict with the
requirements of statutes or regulations of the jurisdiction in which it is delivered is hereby amended to conform to
the minimum requirements of such statutes and regulations.
6.13 Notice. Written notice given by the PLAN to an authorized representative of the Enrolling Unit is deemed
notice to all affected Subscribers and their Enrolled Dependents in the administration of this Policy, including
termination of this Policy. The Enrolling Unit is responsible for giving notice to Covered Persons.
Any notice sent to PLAN under this Policy shall be addressed to:
United HealthCare of Florida, Inc.
4350 W. Cypress Street
Tampa, FL 33607
Any notice sent to Enrolling Unit under this Policy shall be addressed to:
City of Clearwater
100 S. Myrtle A venue
Clearwater, Florida, 33756
04/18/95 POLICY
6
,<M
f
., . ~
I
i
6.14 Continuation Coverage. The PLAN agrees to provide Coverage under the Policy for those Covered Persons
who are eligible to continue Coverage under federal or state law, as described in Section 8 of Attachment A,
Certificate of Coverage.
The PLAN will not provide any administrative duties with respect to the Enrolling Unit's compliance with federal or
state law. All duties of the plan sponsor or plan administrator, including but not limited to notification of COBRA
and state law continuation rights, and billing and collection of Premium, remain the sole responsibility of the
Enrolling Unit.
UNITED HEALTH CARE OF FLORIDA, INC.
By:
~r&j ~ ~/
, T i~nothy ". . Love
Regional V.P. Sales and Marketing
Countersigned:
Bri?~~
Mayor Commissioner
--......
::~ OF t::ARWATER. FLORIDA
~ael J. Roberto
City Manager
Approved as to form:
Attest:
~
~ ..
..~,l~.~
j,vcynt ~ud.ac; / c &fr
o City Clerk - ~
~Q-
o n Carassas
Assistant City
Attorney
04/18/95 POLICY
7
IKJ
, .
. c
I
I
EXHIBIT A
PREMIUMS
Monthly Premiums payable by or on behalf of Covered Persons are specified below:
Premium
Class 01
$217.15
Class 02
$376.89
Class 03
$610.51
Enrolling Unit Contribution
Subscriber Contribution
100% for single, 54% for dependents on the average.
0% for single, 46% for dependents
04/18/95 POLICY
8
...
(1+ IV\ 0)
..
I
I
I
UNITED HEAL THCARE OF FLORIDA, INC.
GROUP POLICY
City of Clearwater
Copyright United HealthCare Corporation
April 1995
ifJ
c(
(:z)
I
I
GROUP POLICY
This Group Policy ("Policy") is entered into by and between United HealthCare of Florida, Inc. "PLAN"), a Florida
Health Maintenance Organization and City of Clearwater ("Enrolling Unit").
Upon receipt of the Enrolling Unit's application and payment of the required Policy Charges, this Policy is deemed
executed. The PLAN agrees with the Enrolling Unit to provide Coverage for Health Services set forth herein,
subject to the terms, conditions, exclusions, and limitations of this Policy. The Enrolling Unit's application is made
a part of this Policy.
This Policy replaces and supersedes any previous agreements relating to the Coverage of Health Services between
the Enrolling Unit and the PLAN. The terms and conditions of this Policy shall in turn be superseded by those of
any subsequent agreements relating to the Coverage of Health Services between the Enrolling Unit and the PLAN.
This Policy shall become effective at 12:01 a.m. January 1,2000 Eastern Time and will be continued in force by the
timely payment of the required Policy Charges when due, subject to termination of this Policy as provided herein.
When the Policy is terminated, as provided for in Article 5, this Policy and all Coverage under this Policy will end
at 12:00 midnight on the date of termination.
This Policy is delivered in and governed by the laws of the State of Florida.
04/18/95 POLICY
/Xl
. ,
)
I
ARTICLE 1
DEFINITIONS
The terms used in this Policy have the same meaning given those terms in the Certificate of Coverage, unless
otherwise specifically defined in this Policy.
ARTICLE 2
HEALTH SERVICES
Subscribers and their Enrolled Dependents are entitled to Coverage for Health Services subject to the terms,
conditions, limitations and exclusions set forth in the Certificate of Coverage included in this Policy as
Attachment A. The Certificate describes the Covered Health Services including any optional Riders, required
Copayments, and the terms, conditions, limitations and exclusions related to Coverage.
ARTICLE 3
PREMIUM RATES AND POLICY CHARGE
3.1 Premiums. Monthly Premiums payable by or on behalf of Covered Persons are specified on Exhibit A to the
Policy entitled "Premiums".
The PLAN reserves the right to change the schedule of rates for Premiums on the first anniversary of the effective
date of the Policy specified in the application or on any monthly due date thereafter, or on any date the provisions of
the Policy are amended. The PLAN will provide written notice of any change in Premiums to the Enrolling Unit at
least 45 days prior to the effective date of the change.
3.2 Computation of Policy Charge. Each Policy Charge shall be calculated based on the number of Subscribers
in each Coverage classification the PLAN shows in its records at the time of calculation, at the Premiums then in
effect. A full calendar month's Premiums shall be charged for Covered Persons whose effective date of Coverage
falls on or before the 15th of that calendar month. No Premiums shall be charged for Covered Persons whose
effective date of Coverage falls after the 15th of that calendar month. A full calendar month's Premiums shall be
charged for Covered Persons whose Coverage is terminated after the 15th of that calendar month. No Premiums
shall be charged for Covered Persons whose Coverage is terminated on or before the 15th of that calendar month.
3.3 Adjustments to the Policy Charge. Retroactive adjustments may be made for any additions or terminations of
Subscribers or changes in Coverage classification not reflected in the PLAN's records at the time the Policy Charge
is calculated by the PLAN. However, no retroactive credit shall be granted for any change occurring more than 60
days prior to the date the PLAN received notification of the change from the Enrolling Unit, nor shall retroactive
credit be granted for any calendar month in which a Subscriber has received Health Services.
The Enrolling Unit shall notify the PLAN in writing within 30 days of the effective date of enrollments,
terminations or other changes; provided, however, that the Enrolling Unit shall notify the PLAN in writing each
month of any changes in the Coverage classification of any Subscriber.
04/18/95 POLICY
2
L>4
)
I
3.4 Payment of the Policy Charge. The Policy Charge is payable in advance on a monthly basis by the Enrolling
Unit to the PLAN. The first Policy Charge is due and payable on the effective date of the Policy. Subsequent
Policy Charges are due and payable no later than the first day of each period thereafter that the Policy is in effect.
A late payment charge will be assessed for any Policy Charge not received by the last day of the grace period. A
service charge will be assessed for any non-sufficient-fund check received in payment of the Policy Charge. All
Policy Charge payments shall be accompanied by supporting documentation which states the names of the Covered
Persons for whom payment is made.
The PLAN reserves the right to collect attorney's fees and any other costs related to collecting delinquent Policy
Charges.
3.5 Grace Period. A grace period of 10 days shall be granted for the payment of any Policy Charge, during which
time the Policy shall continue in force. In no event shall the grace period extend beyond the date the Policy
terminates.
This Policy shall automatically terminate retroactive to the last paid date of Coverage if the grace period expires and
any Policy Charge remains unpaid, or if the PLAN receives written notice of termination from the Enrolling Unit
during the grace period.
ARTICLE 4
ENROLLMENT AND ELIGIBILITY
4.1 Initial Eligibility Period. Eligible Persons and their Dependents may enroll for Coverage under the Policy
during the Initial Eligibility Period. The Initial Eligibility Period shall begin on December 1,'1999 and shall end on
January 31, 2000. Eligible Persons and Dependents who do not submit an application for enrollment to the
Enrolling Unit during the Initial Eligibility Period may not apply for Coverage under this Policy until the Enrolling
Unit holds an Open Enrollment Period.
4.2 Open Enrollment. The Enrolling Unit shall provide an annual Open Enrollment Period of 30 days, 10
accordance with state law, during which Eligible Persons may enroll for Coverage under the Policy.
4.3 Eligibility Conditions. The following conditions are in addition to those specified in Section 2 of the
Certificate:
(a) The term "Dependent" shall not include any unmarried dependent child 19 years of age or older
unless the unmarried dependent child is 19 years of age or older and less than 25 years of age and
meets the criteria described in Section I of the Certificate, the definition of "Dependent,"
items 2.a. through 2.c.
(b) Waiting or probationary period for newly Eligible Persons shall be as follows:
Date of Hire
(c) Excluded persons, if any:
Part-time, Temporary
04/18/95 POLICY
3
I
I
(d) Coverage classifications other than employee, if any:
(e) Other:
4.4 Effective Date of Coverage. Coverage for properly enrolled Eligible Persons and their Dependents shall begin
on:
The day following the last day of the required waiting period.
X The first day of the month following the month in which the waiting period was completed.
The date the Eligible Person joins the Enrolling Unit.
X Other: Retirees may return to the group insurance plan once a year at open enrollment.
Non-Medicare eligible spouses of retired employees who are enrolled in Medicare.
ARTICLE 5
POLICY TERMINATION
5.1 Conditions for Termination of This Entire Policy. This Policy and all Coverage under this Policy shall
automatically terminate on the earliest of the dates specified below:
(a) At the PLAN's option, retroactive to the last paid date of Coverage, if the grace period expires and
any Policy Charge remains unpaid.
(b) On the date specified by the Enrolling Unit, after at least 45 days prior written notice to the PLAN
that this Policy shall be terminated.
(c) On the date specified by the PLAN, after at least 45 days prior written notice to the Enrolling Unit
that this Policy shall be terminated, except for (d) below.
(d) On the date specified by the PLAN in written notice to the Enrolling Unit that this Policy shall be
terminated because the Enrolling Unit provided the PLAN with false information material to the
execution of this Policy or to the provision of Coverage under this Policy. The PLAN has the
right to rescind this Policy back to the effective date.
5.2 Payment and Reimbursement Upon Termination. Upon any termination of this Policy, the Enrolling Unit
shall be and shall remain liable to the PLAN for the payment of any and all Premiums which are unpaid at the time
of termination.
04/18/95 POLICY
4
I
I
ARTICLE 6
GENERAL PROVISIONS
6.1 Entire Policy. The group Policy, including the Certificate of Coverage as Attachment A, the application ofthe
Enrolling Unit, any individual Subscriber applications, Amendments and Riders shall constitute the entire Policy
between parties. All statements made by the Enrolling Unit or by a Subscriber shall, in the absence of fraud, be
deemed representations and not warranties. No such statement shall void or reduce Coverage under this Policy or
be used in defense of a legal action unless it is contained in a written application.
6.2 Dispute Resolution. No legal proceeding or action may be brought without first completing the complaint
procedure specified in Section 5 of the Certificate. If the Enrolling Unit wishes to seek further review of the
decision or the complaint or dispute, it shall submit the complaint or dispute to binding arbitration pursuant to the
rules of the American Arbitration Association. This is the only right the Enrolling Unit has for further
consideration. The matter must be submitted to binding arbitration within 1 year of the date the final decision was
furnished to the Enrolling Unit, as described in Section 5. The arbitrators shall have no power to award any punitive
or exemplary damages or to vary or ignore the provisions of the Policy, and shall be bound by controlling law.
6.3 Time Limit on Certain Defenses. No statement made by the Enrolling Unit, except a fraudulent statement,
shall be used to void this Policy after it has been in force for a period of2 years.
6.4 Amendments and Alterations. Amendments to this Policy are effective 45 days after PLAN sends written
notice to the Enrolling Unit. No change will be made to this Policy unless made by an Amendment or a Rider
which is signed by an executive officer of the PLAN. No agent has authority to change this Policy or to waive any
of its provisions.
6.5 Relationship Between Parties. The relationships between the PLAN and Participating providers and
relationships between the PLAN and Enrolling Units, are solely contractual relationships between independent
contractors. Participating providers and Enrolling Units are not agents or employees of the PLAN, nor is the PLAN
or any employee of the PLAN an agent or employee of Participating providers or Enrolling Units.
The relationship between a Participating provider and any Covered Person is that of provider and patient. The
Participating provider is solely responsible for the services provided by it to any Covered Person. The relationship
between any Enrolling Unit and any Covered Person is that of employer and employee, Dependent, or other
Coverage classification as defined in this Policy. The Enrolling Unit is solely responsible for enrollment and
Coverage classification changes (including termination of a Covered Person's Coverage through the PLAN) and for
the timely payment of the Policy Charge.
6.6 Records. The Enrolling Unit shall furnish the PLAN with all information and proofs which the PLAN may
reasonably require with regard to any matters pertaining to this Policy. PLAN may at any reasonable time inspect
all documents furnished to the Enrolling Unit by an individual in connection with the Coverage, and the Enrolling
Unit's payroll, and any other records pertinent to the Coverage under this Policy.
By accepting Coverage under this Policy, each Covered Person, including Enrolled Dependents, whether or not
such Enrolled Dependents have signed the application of the Subscriber, authorizes and directs any person or
institution that has provided services to the Covered Person, to furnish the PLAN or any of the PLAN's designees at
any reasonable time, upon its request, any and all information and records or copies of records relating to the
services provided to the Covered Person. The PLAN agrees that such information and records will be considered
confidential. The PLAN and any of the PLAN's designees shall have the right to release any and all records
concerning health care services which are necessary to implement and administer the terms of this Policy or for
appropriate medical review or quality assessment.
04/18/95 POLICY
5
I
I
6.7 Administrative Services. The services necessary to administer this Policy and the Coverage provided under it
will be provided in accordance with the PLAN's or its designee's standard administrative procedures. If the
Enrolling Unit requests that such administrative services be provided in a manner other than in accordance with
these standard procedures, including requests for non-standard reports, the Enrolling Unit shall pay for such services
or reports at the PLAN's or its designee's then-current charges for such services or reports.
6.8 ERISA. When this Policy is purchased by the Enrolling Unit to provide benefits under a welfare plan governed
by the Employee Retirement Income Security Act 29 U.S.C. ~1001 et seq., the PLAN shall not be named as and
shall not be the Plan Administrator or named fiduciary of the welfare plan, as those terms are used in ERISA.
6.9 Examination of Covered Persons. In the event of a question or disputlt concerning Coverage for Health
Services, the PLAN may reasonably require that a Covered Person be examined at the PLAN's expense by a
Participating Physician acceptable to the PLAN.
6.10 Clerical Error. Clerical error shall not deprive any individual of Coverage under this Policy or create a right
to additional benefits. Failure to report the termination of Coverage shall not continue such Coverage beyond the
date it is scheduled to terminate according to the terms of this Policy. Upon discovery of a clerical error, any
necessary appropriate adjustment in Premiums shall be made. However, no such adjustment in Premiums or
Coverage shall be granted by the PLAN to the Enrolling Unit for more than 60 days of Coverage prior to the date
the PLAN received notification of such clerical error.
6.11 Workers' Compensation Not Affected. The Coverage provided under this Policy does not substitute for and
does not affect any requirements for coverage by Workers' Compensation Insurance.
6.12 Conformity with Statutes. Any provision of this Policy which, on its effective date, is incontlict with the
requirements of statutes Of regulations of the jurisdiction in which it is delivered is hereby amended to conform to
the minimum requirements of such statutes and regulations.
6.13 Notice. Written notice given by the PLAN to an authorized representative of the Enrolling Unit is deemed
notice to all affected Subscribers and their Enrolled Dependents in the administration of this Policy, including
termination of this Policy. The Enrolling Unit is responsible for giving notice to Covered Persons.
Any notice sent to PLAN under this Policy shall be addressed to:
United HealthCare of Florida, Inc.
4350 W. Cypress Street
Tampa, FL 33607
Any notice sent to Enrolling Unit under this Policy shall be addressed to:
City of Clearwater
100 S. Myrtle Avenue
Clearwater, Florida, 33756
04/18/95 POLICY
6
l'"
"
I
I
6.14 Continuation Coverage. The PLAN agrees to provide Coverage under the Policy for those Covered Persons
who are eligible to continue Coverage under federal or state law, as described in Section 8 of Attachment A,
Certificate of Coverage.
The PLAN will not provide any administrative duties with respect to the Enrolling Unit's compliance with federal or
state law. All duties of the plan sponsor or plan administrator, including but not limited to notification of COBRA
and state law continuation rights, and billing and collection of Premium, remain the sole responsibility of the
Enrolling Unit.
UNITED HEALTH CARE OF FLORIDA, INC.
By:
~
and Marketing
Countersigned:
Briff-LA
Mayor - Commissioner
CITY OF CLEARWATER, FLORIDA
--
By:
Michael J. Roberto
City Manager
Approved as to form:
Attest:
~ -=:>-
ohn Carassas
Assistant City Attorney
~1Ld:~~
j;,Jcynth . Goudeau: J ,::::-:~ '
() City Clerk ...;'-'- -. -
~
04/18/95 POLICY
7
"',
~,
I
i
EXHIBIT A
PREMIUMS
Monthly Premiums payable by or on behalf of Covered Persons are specified below:
Premium
Class 01
$188.67
Class 02
$323.68
Class 03
$534.21
Enrolling Unit Contribution
Subscriber Contribution
100% for single, 54% for dependents on the average
0% for single, 46% for dependents
04/18/95 POLICY
8