Yerke v. Aetna

MOTION TO DISMISS FOR FAILURE TO STATE A CLAIM and Certificate of Service

E.D. Pa.December 27, 2016

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA ALBERT YERKE, Plaintiff, v. AETNA, Defendant. : : : : : : : Civil Action No. 2:16-cv-6512-GJP MOTION TO DISMISS PLAINTIFF’S COMPLAINT Defendant, styled as “Aetna,”1 by and through its undersigned counsel, moves to dismiss Plaintiff’s Complaint. As set forth in the attached Memorandum of Law, incorporated herein by reference, Plaintiff’s claim to recover benefits is preempted by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1001, et seq. Accordingly, Plaintiff’s claim fails as a matter of law and must be dismissed with prejudice. WHEREFORE, Defendant respectfully requests this Court grant its Motion and dismiss Plaintiff’s Complaint with prejudice. ELLIOTT GREENLEAF, P.C. /s/ Melissa M. Weber MELISSA MURPHY WEBER Dated: December 26, 2016 925 Harvest Drive; Suite 300 Blue Bell, PA 19422 (215)977-1000 Attorney for Defendant “Aetna” 1 The proper Defendant is “Aetna Life Insurance Company” (“Aetna”). The Plan Sponsor, and Plaintiff’s employer, AutoZone, Inc., maintained an employee welfare benefit plan providing long term disability benefits to eligible employees and funded those benefits through a Group Insurance Policy issued to it by Aetna Life Insurance Company. The AutoZone Long Term Disability Plan constitutes an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq. Case 2:16-cv-06512-GJP Document 4 Filed 12/27/16 Page 1 of 1 IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA ALBERT YERKE, Plaintiff, v. AETNA, Defendant. : : : : : : : Civil Action No. 2:16-cv-6512-GJP ORDER AND NOW, this ____ day of ____________________, 2016, upon consideration of Defendant’s Motion to Dismiss, and Plaintiff’s Response thereto, if any, it is hereby ORDERED that Plaintiff’s Complaint is DISMISSED WITH PREJUDICE. BY THE COURT: Gerald J. Pappert U.S. District Judge Case 2:16-cv-06512-GJP Document 4-1 Filed 12/27/16 Page 1 of 1 IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA ALBERT YERKE, Plaintiff, v. AETNA, Defendant. : : : : : : : Civil Action No. 2:16-cv-6512-GJP DEFENDANT’S MEMORANDUM OF LAW IN SUPPORT OF ITS MOTION TO DISMISS PLAINTIFF’S COMPLAINT I. INTRODUCTION Plaintiff seeks damages based on a claim that Defendant “Aetna”1 failed to pay long term disability benefits to Plaintiff. While Plaintiff acknowledged these benefits are provided through an employer-sponsored welfare benefit plan, Plaintiff fails to recognize that Plan is governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1001, et seq and, as such, his state-law claim pursuant to the Unfair Trade Practice and Consumer Protection Law is preempted. By seeking to recover allegedly unpaid benefits, Plaintiff duplicates an ERISA civil enforcement claim under Section 502 of the Act. The claim is thus expressly preempted under Section 514 of the Act. His claim accordingly fails as a matter of law, and must be dismissed with prejudice. 1 The proper Defendant is “Aetna Life Insurance Company” (“Aetna”). The Plan Sponsor, and Plaintiff’s employer, AutoZone, Inc., maintained an employee welfare benefit plan providing long term disability benefits to eligible employees and funded those benefits through a Group Insurance Policy issued to it by Aetna Life Insurance Company. The AutoZone Long Term Disability Plan constitutes an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq. Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 1 of 9 2 II. FACTUAL BACKGROUND Plaintiff initiated this matter in Magisterial District Court in Montgomery County. Plaintiff’s Complaint, which is a form civil complaint for that court, alleges he was “covered under a long-term disability plan through his employment with Autozone [sic], which was insured by Defendant.” Dkt. No. 1-1 at p.3. Plaintiff further alleges that he was entitled to long- term disability benefits but that Aetna “has failed and refused to pay these benefits, despite demand for same.” Plaintiff attached, as an Exhibit to his Complaint, AutoZone’s “Leave of Absence Guide for AutoZoners” which, as expressly stated in the Disclaimer section, is intended to “only provide a brief summary of the insurance programs and benefits referenced herein. For more detailed information about these benefits, please refer to the applicable Summary Plan Description or insurance certificate. These documents will provide you with more important information or benefit provisions, including any conditions, limitations and exclusions which may apply. See Benefit Plan Booklet-Certificate, attached hereto as Exhibit “1” (and which is identical to Doc. 1 – 2, Notice of Removal Exhibit “B” at Aetna 164) (emphasis added). AutoZone, the long term disability plan Sponsor and Plaintiff’s employer, provided to certain welfare benefits to its eligible employees, including disability and funded these long term disability (“LTD”) benefits through a Group Insurance Policy, GP-866266-GI, issued to AutoZone by Aetna Life Insurance Company. See Id. at Aetna 77. The Booklet-Certificate of the Group Insurance Policy identified inter alia limitations to LTD coverage. Plaintiff’s complaint is nothing more than a series of conclusory allegations wholly void of any facts or supporting documents from which this Court could draw factual inferences. Plaintiff alleges he was disabled but fails to state the nature of his disability in his complaint. See Doc. 1 – 1, ECF header page 3 of 31. Further, Plaintiff merely alleges he made a demand for Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 2 of 9 3 benefits but fails to plead how the “demand” was made or whether it was made in compliance with the administrative requirements established in the LTD Plan. Id. Plaintiff also alleges Aetna refused to pay “these benefits” but Plaintiff fails to include evidence of Aetna’s denial, including the basis for its decision or the date of its decision. Id. Plaintiff further includes a demand for attorneys’ fees without any factual or legal basis for same. III. LEGAL ARGUMENT A. Standard of Review A motion to dismiss pursuant to Fed.R.Civ.P. 12(b)(6) tests the legal sufficiency of the pleading. To survive the Motion, Plaintiff must aver “enough facts to state a claim to relief that is plausible on its face.” Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007); see Richardson v. CSS Industries, Inc., C.A. No. 08-3900, 2009 WL 1383310, *2 (E.D. Pa. May 13, 2009) Plaintiffs “must set forth sufficient information to outline the elements of their claims or to permit inferences to be drawn that these elements exist.” Jones v. Middletown Twp., 2006 WL 1805995, *1 (E.D. Pa. June 21, 2006), aff’d, 253 Fed.Appx. 184 (3d Cir. 2007). Plaintiff’s obligation to provide the grounds for his entitlement to relief requires more than labels and conclusions, and a formulaic or “threadbare recitation of the elements of a cause of action, supported by mere conclusory statements, do not suffice.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (citing Twombly, 550 U.S. at 555). Courts in the Third Circuit engage in a three-step analysis at the motion to dismiss stage: First, the court must “tak[e] note of the elements a plaintiff must plead to state a claim.” Iqbal, 129 S. Ct. at 1947. Second, the court should identify allegations that, “because they are not more than conclusions, are not entitled to the assumption of truth.” Id. at 1950. Finally, “where there are well- pleaded factual allegations, a court should assume their veracity and then determine whether they plausibly give rise to an entitlement for relief.” Id. Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 3 of 9 4 Santiago v. Warminster Twp., 629 F.3d 121, 130 (3d Cir. 2010) (alterations in original; footnote omitted). If the “well-pleaded facts do not permit the court to infer more than the mere possibility of misconduct, the complaint should be dismissed for failing to show that the pleader is entitled to relief.” Guariglia v. Local 464A United Food & Commer. Workers Union Welfare Serv. Benefit Fund, 2013 U.D. Dist. LEXIS 167629 (D.N.J. Nov. 25, 2013) (citing Iqbal, 556 U.S. at 679). In ruling on a motion to dismiss, a court may consider an undisputedly authentic document that a defendant attaches as an exhibit to a motion to dismiss if the plaintiff’s claims arise out of that document. Pension Benefit Guar. Corp. v. White Consol. Indus., 998 F.2d 1192, 1196 (3d Cir. 1993), cert. denied, 510 U.S. 1042 (1994). See also In re Burlington Coat Factory Securities Litigation, 114 F.3d 1410, 1426 (3d Cir. 1997); Maio v. Aetna Inc., 1999 WL 800315, at *2 (E.D. Pa. Sept. 29, 1999). Otherwise, a plaintiff with a legally deficient claim could survive a motion to dismiss simply by failing to attach a dispositive document upon which its own pleading relies. White Consol., 998 F.2d at 1196. Accordingly, numerous courts have considered plan documents referenced in complaints in ruling on motions to dismiss, even though the defendant provided the documents to the court. See, e.g., Teagardener v. Republic- Franklin Inc. Pension Plan, 909 F.2d 947, 949-50 (6th Cir. 1990) (district court properly considered pension plan document on a motion to dismiss, even though the plaintiffs failed to attach such document to the complaint), cert. denied, 498 U.S. 1027 (1991); Ed Miniat, Inc. v. Globe Life Ins. Group, Inc., 805 F.2d 732, 739 & n.12 (7th Cir. 1986) (in dismissing ERISA claim, court may consider documents referred to in complaint pertinent to ERISA plan), cert. denied, 482 U.S. 915 (1987). Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 4 of 9 5 Thus, in ruling on this motion, this Court may consider the Booklet/Certificate of Coverage detailing the terms and conditions governing a participant’s entitlement to benefits, attached as Exhibit 1, as well as the Policy which inter alia establishes that the Plan Sponsor delegated complete discretionary authority for claim determinations to Aetna, attached hereto as Exhibit 2. B. Plaintiff’s Claims are Preempted by ERISA. Plaintiff’s claim, styled as a claim under the Pennsylvania Unfair Trade Practices and Consumer Protection Law, for LTD benefits, is preempted by Section 502 of ERISA. As confirmed by the United States Supreme Court, under ERISA’s complete preemption doctrine, “any state-law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement remedy conflicts with the clear congressional intent to make the ERISA remedy exclusive and is therefore preempted.” Aetna Health, Inc. v. Davila, 542 U.S. 200, 209 (2004). Section 514 of ERISA, 29 U.S.C. §1144(a) is the express preemption section of ERISA, which contains a broadly worded express preemption provision that is “deliberately expansive” and “conspicuous for its breadth.” Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 137-138 (1990). Section 514(a) provides that ERISA “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan . . ..” 2 The Supreme Court has repeatedly recognized the “expansive sweep” of ERISA’s preemption clause, noting “the phrase ‘relate to’ was given its broad common-sense meaning, such that a state law ‘relate[s] to’ a benefit plan ‘in the normal sense of the phrase, if it has a connection with or reference to such a plan.’” Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 47 (1987) (citing Metropolitan Life Ins. Co. 2 As is made clear by the attached Exhibits hereto, the Plan is an employer-sponsored plan, sponsored by AutoZone, Inc. Exhibit 1 at Aetna 77, Exhibit 2 at Aetna 69. As such, and as set forth in the Policy, the Plan is governed by ERISA, and Aetna is a claim fiduciary for purposes of ERISA. Id. Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 5 of 9 6 v. Massachusetts, 471 U.S. 724, 739 (1985) (quoting Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 97 (1983))); see also Ingersoll-Rand Co., 498 U.S. at 138. “Under this ‘broad common-sense meaning,’ a state law may ‘relate to’ a benefit plan, and thereby be pre-empted, even if the law is not specifically designed to affect such plans, or the effect is only indirect.” Ingersoll-Rand, 498 U.S. at 139 (citing Pilot Life, 481 U.S. at 47). Put simply, a “state law cause of action is expressly preempted by ERISA where a plaintiff, in order to prevail, must prove the existence of, or specific terms of, an ERISA plan.” Young v. Reconstructive Orthopaedic Assocs. II, P.C., 2005 WL 627796, *6 (E.D. Pa. Mar. 16, 2005) (citing Ingersoll-Rand, 498 U.S. at 140). In Ingersoll-Rand, the Supreme Court held that ERISA preempts state law claims where “there simply is no cause of action if there is no plan.” Id. at 140 (emphasis in original). In Davila, the Supreme Court held that claims by individuals against their HMOs, pursuant to a state health care liability statute that imposed a duty of care on HMOs and insurance carriers, were completely preempted by ERISA because the duties that were imposed by the statute under which they sued did not arise independently of ERISA: [I]nterpretation of the terms of respondents’ benefit plans forms an essential part of their THCLA claim, and THCLA liability would exist here only because of petitioners’ administration of ERISA-regulated benefit plans. Petitioners’ potential liability under the THCLA in these cases, then, derives entirely from the particular rights and obligations established by the benefit plans. * * * [R]espondents bring suit only to rectify a wrongful denial of benefits promised under ERISA-regulated plans, and do not attempt to remedy any violation of a legal duty independent of ERISA. We hold that respondents’ state causes of action fall ‘within the scope of’ ERISA §502(a)(1)(B), . . . and are therefore completely pre-empted by ERISA §502 . . .. Davila, 542 U.S. at 213-14. This preemption rule thus applies equally to claims under the Unfair Insurance Practices Act, as well as other statutory and common law claims. See Cooperstein v. Independence Blue Cross, 2005 U.S. Dist. LEXIS 15757 (August 2, 2005, E.D.Pa.)(finding Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 6 of 9 7 Plaintiffs class action for breach of contract and violations of the Pennsylvania Unfair Trade Practice and Consumer Protection Law were completely preempted by ERISA); Harding v. Provident Life & Accident Ins. Co., 809 F.Supp. 2d 403 (W.D. Pa. 2011)(specifically holding that ERISA preempted claims of breach of contract, bad faith, and unfair insurance practices); McCall v. Metropolitan Life Ins. Co., 956 F. Supp. 1172, 1184 (D. N.J. 1996) (holding ERISA broadly preempts a range of state law claims, including unfair insurance practices claims) (citing Cote v. Durham Life Ins. Co., 754 F. Supp. 18 (D. Conn. 1991) (specifically holding that ERISA preempted claims of breach of contract, bad faith, unfair insurance practices, and intentional infliction of emotional distress)); Sanders v. Hartford, 2003 U.S. Dist. LEXIS 26874, *24 n.8 (W.D. Pa. June 17, 2003) (noting ERISA preempts state law claim for unfair insurance practices under Pennsylvania law); Pane v. RCA Corp., 868 F. 2d 631 (3d Cir. 1989) (holding state law claims of breach of contract, covenants of good faith and fair dealing and intentional infliction of emotional distress are preempted). Here, as in Davila, Plaintiff’s purported claim for denial of disability benefits falls within the scope of ERISA’s civil enforcement mechanism because Plaintiff seeks to recover benefits due under the terms of an employee welfare benefit plan and/or to enforce rights under the terms of the plan. See Barber, 383 F.3d at 140; Russo v. Abington Memorial Hosp., 881 F. Supp. 177, 181 (E.D. Pa. 1995) (citing 29 U.S.C. § 1132(a)(1)(B)); Institute of Penn. Hosp. v. Travelers Ins. Co., 825 F. Supp. 727, 731 (E.D. Pa. 1993) (plaintiff-hospital’s claim for payment in full for the medical services and benefits pursuant to an employee benefit plan preempted by ERISA.). Thus, like the respondents in Davila, here, Aetna’s “liability would exist here only because of [its] administration of [an] ERISA-regulated benefit plan[].” Davila, 542 U.S. at 213. Moreover, Aetna’s “potential liability . . . derives entirely from the particular rights and Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 7 of 9 8 obligations established by the benefit plans.” Id. Likewise, Plaintiff here brings suit “only to rectify a wrongful denial of benefits promised under [an] ERISA-regulated plan[], and do[es] not attempt to remedy any violation of a legal duty independent of ERISA.” Id. at 214. Section 502 of ERISA, 29 U.S.C. §1132, sets out the enforcement mechanism available under the ERISA statute, and Section 520(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B) permits a participant or beneficiary to recover benefits due under the terms of a plan. Plaintiff is affirmatively seeking benefits under an ERISA-governed policy, and his attempted state law claims, “duplicat[e], supplemen[t], or supplan[t]” the civil enforcement mechanism set out in §1132(a)(1)(B) and (a)(3). As such, Plaintiff’s attempted state law claim is the kind of claim that is routinely recognized as preempted by the courts of this circuit. See Barber v. Unum Life Ins. Co. of America, 383 F.3d 134, 139-140 (3d Cir. 2004); Feinstein v. St. Luke’s Hospital, 2011 WL 5008362 (E.D. Pa. Oct. 19, 2011). Thus, Plaintiff’s state law claim falls within the scope of ERISA §502(a)(1)(B) and is completely preempted. Accordingly, for all the foregoing reasons, Aetna respectfully requests that this Court grant its Motion to Dismiss Plaintiff’s Complaint. Plaintiff’s claim is expressly preempted by ERISA, and the benefits he seeks are specifically excluded under the terms of the Plan. Respectfully submitted, ELLIOTT GREENLEAF, P.C. /S/ Melissa M. Weber MELISSA MURPHY WEBER 925 Harvest Drive, Suite 300 Dated: December 27, 2016 Blue Bell, PA 19422 Counsel for Defendant “Aetna” Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 8 of 9 CERTIFICATE OF SERVICE The undersigned hereby certifies that a copy of the foregoing was served in the following manner upon the following individuals: Via First Class Charles W. Campbell, Esquire 1 East Airy Street Norristown, PA 19401 Telephone No. 610-272-2400 Email: cwcampbell3@gmail.com Dated: December 27, 2016 /s/ Melissa Murphy Weber Melissa Murphy Weber Case 2:16-cv-06512-GJP Document 4-2 Filed 12/27/16 Page 9 of 9 BENEFIT PLAN Prepared Exclusively For AutoZone, Inc. Full-Time Hourly Employees Long-Term Disability (Core/ Buy-Up) Plan, Excluding Executives, Assistant Store Managers(ASM), Managers in Training (MIT) and California Store Managers What Your Plan Covers and How Benefits are Paid Aetna Life Insurance Company Booklet-Certificate This Booklet-Certificate is part of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder CONFIDENTIAL AETNA 0075 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 1 of 30 Table of Contents Schedule of Benefits ....................................................................................................................... Issued with Your Booklet Preface ........................................................................1 Important Information Regarding Availability of Coverage Coverage for You .....................................................3 Long Term Disability Coverage Eligibility, Enrollment and Effective Date of Your Coverage ...........................................................4 Who Is Eligible .........................................................4 Employees Determining if You Are in an Eligible Class How and When to Enroll ........................................5 Enrollment When Your Coverage Begins ..................................5 Your Effective Date of Coverage Your Disability Plan ..........................................6 Long Term (LTD) Disability Coverage ................6 Long Term Disability Benefit Eligibility When Benefits Are Payable Premium and Contribution Waiver Premium/Contribution Reinstatement Test of Disability Benefits Payable Adjustments to Your Benefits If You Work While Disabled When Long Term Disability Benefit Eligibility Ends Limitations Which Apply to Long Term Disability Coverage If You Become Disabled Again (Successive Disabilities) Pre-existing Conditions Approved Rehabilitation Program Other Income Benefits What Happens When Other Income Benefits Increase Other Income Benefits That Do Not Reduce Monthly Benefits How Aetna Applies Other Income Benefits Aetna Requires Proof of Other Income Exclusions That Apply to Long Term Disability How Prior Coverage Affects Coverage Under This Plan Additional Benefits .................................................. 15 Survivor Benefit When Coverage Ends ....................................... 15 When Coverage Ends For Employees Reinstating Coverage ............................................... 16 Extension of Benefits ....................................... 16 Coverage for Long Term Disability Benefits General Provisions ........................................... 17 Physical Examinations ............................................. 17 Legal Action .............................................................. 17 Confidentiality ........................................................... 17 Additional Provisions .............................................. 17 Assignments .............................................................. 17 Misstatements ........................................................... 17 Incontestability ......................................................... 18 Subrogation ............................................................... 18 Recovery of Overpayments .................................... 19 LongTerm Disability Coverage Reporting of Claims ................................................. 19 Payment of Benefits ................................................. 20 Contract Not a Substitute for Workers’ Compensation Insurance ........................................ 20 Contacting Aetna ...................................................... 20 Glossary * ......................................................... 21 *Defines the Terms Shown in Bold Type in the Text of This Document. CONFIDENTIAL AETNA 0076 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 2 of 30 GR-9N 1 Preface (GR-9N-02-005-01 TN) Aetna Life Insurance Company (ALIC) is pleased to provide you with this Booklet-Certificate. Read this Booklet-Certificate carefully. The plan is underwritten by Aetna Life Insurance Company of Hartford, Connecticut (referred to as Aetna). This Booklet-Certificate is part of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder. The Group Insurance Policy determines the terms and conditions of coverage. Aetna agrees with the Policyholder to provide coverage in accordance with the conditions, rights, and privileges as set forth in this Booklet-Certificate. The Policyholder selects the products and benefit levels under the plan. A person covered under this plan and their covered dependents are subject to all the conditions and provisions of the Group Insurance Policy. The Booklet-Certificate describes the rights and obligations of you and Aetna, what the plan covers and how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions in this Booklet-Certificate. Your Booklet-Certificate includes the Schedule of Benefits and any amendments or riders. If you become insured, this Booklet-Certificate becomes your Certificate of Coverage under the Group Insurance Policy, and it replaces and supersedes all certificates describing similar coverage that Aetna previously issued to you. Group Policyholder: AutoZone, Inc. Group Policy Number: GP-866266-GI Effective Date: January 1, 2014 Issue Date: May 11, 2016 Booklet-Certificate Number: 2 Mark T. Bertolini Chairman, Chief Executive Officer and President Aetna Life Insurance Company (A Stock Company) CONFIDENTIAL AETNA 0077 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 3 of 30 GR-9N 2 Important Information Regarding Availability of Coverage (GR-9N 02-005 02) Important Information Regarding Availability of Coverage (GR-9N 02-005 02) No benefits are covered under this Booklet-Certificate in the absence of payment of current premiums subject to the Grace Period and the Premium section of the Group Insurance Policy. Unless specifically provided in any applicable termination provision described in this Booklet-Certificate or under the terms of the Group Insurance Policy, the plan does not pay benefits for a disability that starts before coverage starts under this plan. This plan will also not pay any benefits for any disability that starts after coverage ends. Benefits may be modified during the term of this plan as specifically provided under the terms of the Group Insurance Policy or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or elimination of benefits) apply to any disabilities that start on or after the effective date of the plan modification. There is no vested right to receive the benefits described in the Group Insurance Policy or in this Booklet-Certificate if the disability starts on or after the effective date of the plan modification, but prior to your receipt of amended plan documents. CONFIDENTIAL AETNA 0078 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 4 of 30 GR-9N 3 Coverage for You Long Term Disability Coverage The plan may pay to you a portion of your income earnings as a monthly benefit for a period of long term disability caused by an illness or injury that occurs while your coverage is in effect. Coverage under this plan is occupational and non-occupational. Occupational injuries and illnesses and non- occupational injuries and illnesses are covered. Conditions that are related to pregnancy may be covered under this plan. Please refer to the Long Term Disability section for more details about your coverage. CONFIDENTIAL AETNA 0079 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 5 of 30 GR-9N 4 Eligibility, Enrollment and Effective Date of Your Coverage Who Is Eligible How and When to Enroll When Your Coverage Begins Throughout this section you will find information on who can be covered under the plan, how to enroll and what to do when there is a change in your life that affects coverage. In this section, “you”, "your" and "yours" means the employee to whom this Booklet-Certificate is issued and whose insurance is in force under the terms of this group insurance policy. Who Is Eligible Your employer determines the criteria that are used to define the eligible class for coverage under this plan. Such criteria are based solely upon the conditions related to your employment. Aetna will rely upon the representation of the employer as to your eligibility for coverage under this plan and as to any fact concerning such eligibility. Employees You are eligible for coverage under this plan if you are actively at work and:  You are in an eligible class, as defined below;  You have completed any probationary period required by the policyholder; and  You have reached your eligibility date. Determining if You Are in an Eligible Class You are in an eligible class if:  You are a regular full-time employee, as defined by your employer. In addition, to be in an eligible class you must be:  scheduled to work on a regular basis at least 30 hours per week during your Employer’s work week; and  working within the United States. Probationary Period (GR-9N 29-005 02 TN) Once you enter an eligible class, you will need to complete the probationary period before your coverage under this plan begins. Determining When You Become Eligible You become eligible for the plan on your eligibility date, which is determined as follows. On the Effective Date of the Plan If you are in an eligible class on the effective date of this plan, and you had previously satisfied the plan's probationary period, your coverage eligibility date is the effective date of this plan. If you are in an eligible class on the effective date of this plan, but you have not yet satisfied the plan's probationary period, your coverage eligibility date is the date you complete 90 days of continuous service with your employer. This is defined as the probationary period. If you had already satisfied the plan's probationary period before you entered the eligible class, your coverage eligibility date is the date you enter the eligible class. CONFIDENTIAL AETNA 0080 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 6 of 30 GR-9N 5 After the Effective Date of the Plan If you are hired or enter an eligible class after the effective date of this plan, your coverage eligibility date is the date you complete 90 days of continuous service with your employer. This is defined as the probationary period. If you had already satisfied the plan's probationary period before you entered the eligible class, your eligibility date is the date you enter the eligible class. How and When to Enroll (GR-9N 29-015 03 TN) Pertaining to Buy-Up Option Enrollment You will be provided with plan benefit and enrollment information when you first become eligible to enroll. You will need to enroll in a manner determined by Aetna and your employer. To complete the enrollment process, you will need to provide all requested information including any evidence of good health. You will also need to agree to make required contributions for any contributory coverage. Your employer will determine the amount of your plan contributions, and will advise you of the required amount. Your contributions will be deducted from your pay. Remember plan contributions are subject to change. You will need to enroll within 31 days of your eligibility date. When Your Coverage Begins (GR-9N 29-025-02) Your Effective Date of Coverage Your coverage takes effect on:  The date you are eligible for coverage. Active Work Rule: If you happen to be ill or injured and away from work on the date your coverage would take effect, the coverage will not take effect until you return to full-time work for one full day. This rule also applies to an increase in your coverage. CONFIDENTIAL AETNA 0081 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 7 of 30 GR-9N 6 Your Disability Plan (GR-9N 06-005 02 TN) (GR-9N 06-010 02) Benefit Eligibility Benefits Payable Successive Disabilities Important Note As used in this section of the Booklet-Certificate, "you" and "your" refers to a covered employee of the employer sponsoring this plan. The disability plan provides you with a source of income if you should become disabled because of an illness, injury or disabling pregnancy-related condition while covered under this plan. Long Term Disability (LTD) Coverage Long term disability (LTD) coverage will pay a monthly benefit if you are disabled and unable to work because of:  An illness;  An injury; or  A disabling pregnancy-related condition. Long Term Disability Benefit Eligibility You will be considered disabled while covered under this Long Term Disability (LTD) Plan on the first day that you are disabled as a direct result of a significant change in your physical or mental conditions and you meet all of the following requirements:  You must be covered by the plan at the time you become disabled; and  You must be under the regular care of a physician. You will be considered under the care of a physician up to 31 days before you have been seen and treated in person by a physician for the illness, injury or pregnancy- related condition that caused the disability; and  You must be disabled by the illness, injury, or disabling pregnancy-related condition as determined by Aetna (see Test of Disability). When Benefits Are Payable Once you meet the LTD test of disability, your long term disability benefits will be payable after the Elimination Period, if any, is over. No benefit is payable for or during the Elimination Period. The Elimination Period is the amount of time you must be disabled before benefits start. The Elimination Period is shown in the Schedule of Benefits. Your Long Term Disability benefits will be payable for as long as your period of disability benefit eligibility continues but not beyond the end of the Maximum Monthly Benefit Period. The Elimination Period and the Maximum Monthly Benefit Period are shown in the Schedule of Benefits. Premium and Contribution Waiver During your disability while benefits are payable:  You will not have to make any further contributions.  No premium payments will be required from your Employer. CONFIDENTIAL AETNA 0082 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 8 of 30 GR-9N 7 Premium/Contribution Reinstatement If you are eligible to continue coverage, your contributions and the employer's premium payments may be resumed on the first due date following the end of a period of disability during which premiums and contributions were waived. Test of Disability (GR-9N 06-010 02) From the date that you first became disabled and until monthly benefits are payable for 24 months you meet the test of disability on any day that:  You cannot perform the material duties of your own occupation solely because of an illness, injury or disabling pregnancy-related condition; and  Your earnings are 80% or less of your adjusted predisability earnings. After the first 24 months of your disability that monthly benefits are payable, you meet the plan's test of disability on any day you are unable to work at any reasonable occupation solely because of an illness, injury or disabling pregnancy-related condition. Important Note The loss of a professional or occupational license or certification that is required by your own occupation does not mean you meet the test of disability. You must meet the plan's test of disability to be considered disabled. Benefits Payable (GR-9N 06-015 02) Benefits are paid on a monthly basis. The benefit amount is based on your predisability earnings, up to the maximum monthly benefit shown in the Schedule of Benefits. To calculate your monthly long term disability benefit, multiply:  Your Monthly predisability earnings; times  The Benefit Percentage shown in the Schedule of Benefits. The LTD benefit payable will be the lesser of:  The monthly LTD benefit; and  The maximum monthly benefit. Any other income benefits you are eligible for may affect your benefits from this plan. The amount of the other income benefits will be subtracted from your monthly LTD benefit for which you are eligible. If the result is less than the minimum monthly benefit shown in the Schedule of Benefits, the plan will pay an amount equal to the minimum monthly benefit. Please refer to the Other Income Benefits section of this Booklet-Certificate for details as to which other income benefits may reduce your monthly LTD benefit. Adjustments to Your Benefits If You Work While Disabled (GR-9N 06-020 02) Your long term disability monthly benefit may be reduced if, while monthly benefits are payable, you receive income from:  Your employer or any other employer, employment or self-employment; or  Any occupation for compensation or profit; which is more than 20% of your adjusted predisability earnings. The monthly benefit adjustment is calculated as follows: During the first 12 months months that you have such income, the benefit will be reduced only to the extent the sum of the amount of that income and the monthly benefit payable, without any reduction for other income benefits, exceeds 100% of your adjusted predisability earnings. CONFIDENTIAL AETNA 0083 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 9 of 30 GR-9N 8 Thereafter, The adjusted monthly benefit will be calculated by using the following formula: (A divided by B), times C, where: A = Your adjusted predisability earnings, minus the income you receive while disabled B = Your adjusted predisability earnings C = The monthly benefit payable. Income means income you earn, while disabled and working, from your employer or any other employer. However, any income earned by working for another employer will be considered income only if you:  Become employed after the date your disability started; or  Increase the number of hours you work, or the number or type of duties you perform for another employer after the date of your disability started. In that event, only the amount of the income increase will be taken into consideration for the benefit adjustment. When Long Term Disability Benefit Eligibility Ends (GR-9N 06-025 01) You will no longer be considered as disabled nor eligible for long term monthly benefits when the first of the following occurs:  The date you no longer meet the LTD test of disability, as determined by Aetna.  The date you are no longer under the regular care of a physician.  The date Aetna finds you have withheld information about working, or being able to work, at a reasonable occupation.  The date you fail to provide proof that you meet the LTD test of disability.  The date you refused to be examined by or cooperate with an independent physician or a licensed and certified health care practitioner, as requested. Aetna has the right to examine and evaluate any person who is the basis of your claim at any reasonable time while your claim is pending or payable. The examination or evaluation will be done at Aetna’s expense.  The date an independent medical exam report or functional capacity evaluation does not, in Aetna’s opinion, confirm that you are disabled.  The date you reach the end of your Maximum Benefit Duration, as shown in the Schedule of Benefits.  The date you are not receiving effective treatment for alcoholism or drug abuse, if your disability is caused (in whole or part) by alcoholism or drug abuse.  The date you refuse to cooperate with or accept:  Changes to your work site or job process designed to suit your identified medical limitations; or  Adaptive equipment or devices designed to suit your identified medical limitations; which would allow you to work at your own occupation or a reasonable occupation (if you are receiving benefits for being unable to work any reasonable occupation) and provided that a physician agrees that such changes, adaptive devices or equipment suit your particular medical limitations.  The date you refuse any treatment recommended by your attending physician that, in Aetna’s opinion, would cure, correct or limit your disability.  The date your condition would permit you to:  Work; or  Increase the hours you work; or  Increase the number or type of duties you perform in your own occupation but you refuse to do so.  The date of your death.  The day after Aetna determines that you can participate in an approved rehabilitation program and you refuse to do so. CONFIDENTIAL AETNA 0084 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 10 of 30 GR-9N 9 Limitations Which Apply to Long Term Disability Coverage (GR-9N 06-030 01) You will no longer be considered as disabled and eligible for long term monthly benefits after benefits have been payable for 24 months if it is determined that your disability is primarily caused by:  A mental health or psychiatric condition, including physical manifestations of these conditions, but excluding conditions with demonstrable, structural brain damage; or  Alcohol and/or drug abuse. There are 2 exceptions to the above limitations if you are confined as an inpatient in a hospital or treatment facility for treatment of that condition at the end of such 24 months.  If the inpatient confinement lasts less than 30 days, the disability will cease when you are no longer confined.  If the inpatient confinement lasts 30 days or more, the disability may continue until 90 days after the date you have not been so continuously confined. Important Note The rules under If You Become Disabled Again do not apply beyond 24 months to disabilities subject to this Limitations Which Apply to Long Term Disability Coverage section. If You Become Disabled Again (Successive Disabilities) (GR-9N 06-035 01) Once you are no longer disabled and your monthly benefit payments have ended, any new disabilities will be treated separately. However, 2 or more separate disabilities due to the same or related causes will be deemed to be one disability and only one Elimination Period will apply if your disability occurs again within 6 months or less of continuous active work from when the prior disability ended. Aetna will resume its payments to you if your coverage has remained continuously in effect for the period of your temporary recovery. You will not need to satisfy a new Elimination Period. If:  Your disability ended;  Benefits were not payable because you did not meet the elimination period; and  Your disability due to the same or related cause occurs again after less than 15 days of continuous active work from when the prior disability ended. you will only need to satisfy the remainder of the elimination period in order to be considered eligible for benefits payments. The first disability will not be included if it began while you were not covered under this LTD plan. If you become eligible for coverage under any other group long term disability benefits plan carried or sponsored by your employer, this If You Become Disabled Again section will no longer apply to you. Pre-existing Conditions (GR-9N 06-045 01) A pre-existing condition is an illness, injury or pregnancy-related condition for which, during the 3 months before your coverage or increase in coverage became effective:  You were diagnosed or treated; or  You received diagnostic or treatment services; or  You took drugs that were prescribed or recommended by a physician. The plan does not pay benefits for a disability that is caused, or contributed to, by a pre-existing condition, if the disability starts within the first 12 months after your coverage goes into effect. CONFIDENTIAL AETNA 0085 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 11 of 30 GR-9N 10 Special Rules As To An Increase in Coverage If your disability is caused by a pre-existing condition, your monthly benefit will be based on the amount of the Scheduled monthly benefit that has been in effect for at least 12 months under this plan or any other prior coverage. You will not be eligible for any benefit increase if the disability starts within the first 12 months after you increase in coverage goes into effect. Approved Rehabilitation Program (GR-9N 06-050-01) Aetna has the right to evaluate you for participation in an approved rehabilitation program. If, in Aetna's judgment, you are able to participate, Aetna may, in its sole discretion require you to participate in an approved rehabilitation program. Benefits Available to You When You Participate in an Approved Rehabilitation Program The plan will pay for all of the services and supplies (including but not limited to, those for workplace modifications), approved in advance by Aetna, you need in connection with participation in the program, except those for which you can be reimbursed by another payer, including government benefits programs. During your active participation in an Aetna approved rehabilitation program, Aetna will increase the monthly benefit payable. A 10% increase in the monthly benefit payable (after all applicable reductions for other income benefits) will be paid for up to six consecutive months for each disability, up to a maximum monthly increase of $500. Other Income Benefits (GR-9N 06-055 01 TN) (GR-9N 06-060 01) Important Note Please read this section carefully. It explains how and when other income benefits reduce your monthly LTD benefit. It is your responsibility to enroll or apply for benefits from other sources if you are eligible. See the Aetna Requires Proof of Other Income section for more information. Other income benefits can affect the monthly benefit described in the long term disability coverage section. When calculating the benefit payable, other income benefits that you, your spouse, your children or your dependents are eligible for because of your disability or retirement are taken into consideration. The other income benefits considered when your benefits payable are calculated are:  50% of any award given under The Jones Act or The Maritime Doctrine of Maintenance, Wages and Cure.  Disability, retirement or unemployment benefits required or provided for by government law. This includes (but is not limited to):  Unemployment compensation benefits.  Temporary or permanent, partial or total, disability benefits under any workers' compensation law or similar law meant to compensate a worker for:  Loss of past and future wages;  Impaired earning capacity;  A lessened ability to compete for jobs;  Any permanent impairment; and  Any loss of bodily function or capacity.  Automobile no-fault wage replacement benefits required by law.  Benefits under the Federal Social Security Act, Railroad Retirement Act, Canada Pension Plan and Quebec Pension Plan.  Veteran's benefits. CONFIDENTIAL AETNA 0086 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 12 of 30 GR-9N 11  Statutory disability benefits  Disability or unemployment benefits payable by either insured and uninsured plans:  As a result of employment by or association with your employer; or  As a result of your membership in, or association with, any group, association, union or other organization. This includes both plans that are insured and those that are not.  Unreduced retirement benefits for which you are (or may become) eligible under a group pension plan at age 62 or the plan's normal retirement age, whichever comes later. This applies only to the amount of the benefit that was paid by an employer.  Retirement benefits you elect and receive under any group pension plan. This applies only to the amount of the benefit that was paid by an employer.  Disability payments for lost wages or time from work from underinsured motorist (UIM), uninsured motorist coverage (UM), liability insurance or other sources for a disability caused by a third party. "Other sources" include (but are not limited to) damages or a settlement received through legal action.  Disability benefits from an accumulated sick time or salary continuation program, provided they are part of an established group plan maintained by your Employer for the benefit of its employees. What Happens When Other Income Benefits Increase (GR-9N 06-070-01) An increase in other income benefits that you are eligible for may affect your benefit payable under this coverage. If your other income benefits increase as the result of one of the following situations, the increased amount will be considered when calculating your benefits payable:  The number of people in your family changes;  Your benefit level is adjusted or corrected; or  The severity of your disability changes. This may result in a reduction in benefits payable. A cost of living increase in other income benefits you receive from a governmental source (including, but not limited, to benefits under the Federal Social Security Act) will not reduce your benefits payable. A cost of living increase in other income benefits you receive from a non-governmental source will not affect your benefits payable to the extent that the increase is based on the annual average increase in the Consumer Price Index. Other Income Benefits That Do Not Reduce Monthly Benefits (GR-9N 06-065 02) Income from certain sources will not reduce your monthly disability benefits under this plan. Your benefits under the long term disability coverage will not be reduced by the amount of benefits you were receiving from the following sources, if you were receiving the income before you became disabled:  Military and other government service pensions;  Retirement benefits from a former employer;  Veteran's benefits for service-related disabilities;  Individual disability income policies; and  Retirement Federal Social Security Act. CONFIDENTIAL AETNA 0087 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 13 of 30 GR-9N 12 The amount of income or other benefits from the following sources will not reduce your disability benefits:  Profit sharing plans;  Thrift or savings plans;  401(k) plans;  Keogh plans;  Employee stock option plans;  403 (b) Tax-sheltered annuity plans;  457 deferred compensation plans;  Severance pay;  Individual disability income policies;  Individual retirement accounts (IRAs); or  Mortgage or credit disability income plans. How Aetna Applies Other Income Benefits (GR-9N 06-075 02-TN) Long Term Disability Any Lump sum or periodic payments you receive from any other income benefit are prorated on a monthly basis over the period of time for which the payment was made. If a period of time is not indicated, Aetna will prorate the payments over a reasonable period of time. Aetna will take into account the expected duration of your disability payments and other relevant factors. The part of a lump sum or periodic payment that you receive for income lost as a result of your disability will be counted as an other income benefit. If the portion attributable to lost income is not specifically allotted or identified, you must provide proof to Aetna as to what part is attributable to lost income. If you do not provide acceptable proof, Aetna will consider 50% to be payable for your disability. Any of these other income benefit payments that date back to a prior date may be allocated on a retroactive basis. If the other income benefits are automobile no-fault wage replacement benefits or disability payments which result from a disability caused by a third party, the applicable period of time will start from the date of the accident. Estimate of Other Income Benefits Aetna will estimate other income benefits for which you appear to be eligible, unless you sign and return a reimbursement agreement to Aetna. The reimbursement agreement includes your promise to repay Aetna for any overpayment of benefits made to you as a result of your receipt of other income benefits. If other income benefits are estimated, your monthly benefit will be adjusted when Aetna receives proof:  Of the exact amount paid or awarded; or  That benefits have been denied after review at the highest administrative level. If estimating your other income benefits results in an underpayment, Aetna will pay you the difference between the underpayment and the benefit payable. If there is an overpayment, you must repay Aetna the difference between all overpayments and the benefit payable. If Aetna must take legal action to recover such overpayment, you also must pay Aetna's reasonable attorneys fees and court costs, if Aetna prevails. Aetna Requires Proof of Other Income (GR-9N-06-080 01) Aetna may require proof:  That you, your spouse, child or dependent has applied for all other income benefits that you or they are or may be eligible to receive because of your disability, and has made a timely appeal of any denial of benefits through the highest administrative level. "Timely appeal" means making the appeal in the time required, but never more than 60 days after the latest denial.  That the person applying for other income benefits has furnished the necessary proof needed to obtain other income benefits, which include, but is not limited to, workers' compensation benefits;  That the person has not waived (given up his or her right to) any other income benefits without Aetna's written consent; CONFIDENTIAL AETNA 0088 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 14 of 30 GR-9N 13  That the person has sent Aetna copies of documents showing the effective dates and amounts of other income benefits.  Of income you receive from any work for pay or profit. If you apply for Social Security benefits and are denied, you must request reconsideration within 60 days after the denial unless Aetna states, in writing, that you are not required to do so. If the reconsideration is denied, you must apply for a hearing before an administrative law judge within 60 days of the denial, unless Aetna waives this requirement. You do not have to apply for:  Retirement benefits paid only on a reduced basis; or  Disability benefits under a group life insurance plan, if the disability benefits would reduce the amount of your group life insurance. However, if you apply for and receive these benefits, they will be considered as other income benefits and you must provide proof to Aetna, if requested. If you do not provide the proof that Aetna may require, Aetna has the right to suspend or adjust this plan's benefits by the estimated amount of the other income benefits. Exclusions That Apply to Long Term Disability (GR-9N 28-010 02 TN) Long term disability coverage does not cover any disability on any day that you are confined in a penal or correctional institution for conviction of a criminal act or other public offense. You will not be considered to be disabled, and no benefits will be payable. Long term disability coverage also does not cover any disability that:  Is due to insurrection, rebellion, or taking part in a riot or civil commotion.  Is due to intentionally self-inflicted injury (while sane or insane).  Is due to war or any act of war (declared or not declared).  Results from your commission of, or attempting to commit a criminal act.  Results from a motor vehicle accident caused by operating the vehicle while you are under the influence of alcohol. A motor vehicle accident will be deemed to be caused by the use of alcohol if it is determined that at the time of the accident you were :  Operating the motor vehicle while under the influence of alcohol at a level which meets or exceeds the level at which intoxication would be presumed under the laws of the state where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person's blood alcohol level meets or exceeds .08 grams per deciliter. How Prior Coverage Affects Coverage Under This Plan (GR-9N 06-085 02) If the coverage of any person under this plan replaces any prior coverage of the person, the following will apply. "Prior Coverage" is any plan of group LTD coverage that has been replaced by coverage under part or all of this plan. It must have been sponsored by your Employer who is participating in this plan. The replacement can be complete or in part for the eligible class to which you belong. Any such plan is prior coverage if provided by another group insurance plan. CONFIDENTIAL AETNA 0089 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 15 of 30 GR-9N 14 Your coverage under this Plan replaces and supersedes any prior coverage. It will be in exchange for everything under such prior coverage, except that no benefit will be payable under this plan as to a particular period of disability if:  You are receiving, or eligible to receive, benefits for that disability under the prior coverage; or  In the absence of coverage under this plan, you would have been eligible to receive benefits for that disability under the prior coverage. Same or Related Causes of Disability Any disability that began before you were covered under this LTD plan will not be included for purposes of the If You Become Disabled Again (Successive Disabilities) section of this plan. However, if you meet all of the following conditions, the elimination period under this plan will apply to the extent it would have applied under the terms of the prior coverage had it remained in force:  You had prior coverage on the day before LTD coverage took effect; and  You became covered for this LTD plan on the date it takes effect; and  While you are insured under this plan, a disability starts that is due to the same illness, injury or disabling pregnancy related condition for which you received or were eligible to receive benefits under the prior coverage; and  There are no benefits available under the terms of the prior coverage for this disability due to the same illness, injury or disabling pregnancy related condition, the Elimination Period under this plan will apply to the extent it would have applied under the terms of the prior coverage had it remained in force. Where the above paragraph applies, the amount of monthly benefit and the maximum period for which benefits will be payable, as to a disability due to the same or related causes, will be as provided in this LTD plan. Pre-existing Conditions As stated earlier, no benefits will be payable, as to a disability caused by a pre-existing condition. However if:  You had prior coverage on the day before LTD coverage took effect; and  You became covered for this LTD plan on the date it takes effect; a benefit may be payable if a continuous period of coverage under the prior coverage and this LTD plan are equal to the lesser of:  12 months and;  Any period of limitation as to a pre-existing condition remaining under the prior coverage. Where the exclusion no longer applies, the amount of monthly benefit and the maximum period for which benefits will be payable, as to a disability caused by such pre-existing condition, will be as provided in this LTD plan, subject to the Special Rules As To An Increase in Coverage section. In no event will:  A benefit be payable as to a disability caused by a pre-existing condition, if the disability is excluded by any other terms of this LTD plan.  A condition will be considered to be a pre-existing condition under this LTD plan if it was not a pre-existing condition under the prior coverage. CONFIDENTIAL AETNA 0090 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 16 of 30 GR-9N 15 Additional Benefits (GR-9N 06-095 01) Survivor Benefit (GR-9N 06-090 01) If you die while disabled, a single, lump sum benefit will be paid under this provision if:  There is an eligible survivor as defined below; and  A monthly benefit was payable under this plan. The benefit amount will be 3 times the monthly benefit, not reduced by other income benefits, for which you were eligible in the full month just before the month in which you die. If you die before you are eligible for one full monthly benefit, however, the benefit will be 3 times the monthly benefit, not reduced by other income benefits for which you would have been eligible if you had not died, for the first full month after the month in which you die. An eligible survivor is:  Your legally married spouse at the date of your death.  If there is no such spouse, your biological or legally adopted child who, when you die:  is not married; and  is depending on you for support; and  is under age 25. This age limit will not apply if the child is not capable of self-sustaining employment because of mental or physical handicap which existed prior to age 25. How the Survivor Benefit Will Be Paid The benefit will be paid to your eligible surviving spouse, if any. Otherwise, it will be paid in equal shares to your eligible surviving children. If monthly benefit payments are made in amounts greater than the monthly benefits that you are entitled to receive, Aetna has the right to first apply the survivor benefit to any such overpayment. Aetna may pay the benefit to anyone who, in Aetna's opinion, is caring for and supporting the eligible survivor; or if proper claim is made, Aetna may pay the benefit to an eligible survivor's legally appointed guardian or committee. When Coverage Ends (GR-9N-30-015-04) Coverage under your plan can end for a variety of reasons. In this section, you will find details on how and why coverage ends, and how you may still be able to continue coverage. When Coverage Ends For Employees (GR-9N-30-005-02 TN) Your coverage under the plan will end if:  The plan is discontinued;  You voluntarily stop your coverage;  The group policy ends;  You are no longer eligible for coverage;  You do not make any required contributions;  You become covered under another plan offered by your employer; CONFIDENTIAL AETNA 0091 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 17 of 30 GR-9N 16  Your employment stops for any reason, including job elimination or being placed on severance. This will be the date you stop active work. However, if premium payments are made on your behalf, Aetna may deem your employment to continue, for purposes of remaining eligible for coverage under this Plan, as described below:  If you are not actively at work due to illness or injury, your coverage may continue, until stopped by your employer, but not beyond 12 months from the start of the absence.  If you are not actively at work due to temporary lay-off or leave of absence, your coverage will stop on the last full day you are actively at work before the start of the lay-off or leave of absence. It is your employer’s responsibility to let Aetna know when your employment ends. The limits above may be extended only if Aetna and your employer agree, in writing, to extend them. Reinstating Coverage (GR-9N 30-005 02) If your long term disability coverage ends, you may reinstate the coverage you previously had in effect subject to the rules described in the When your Coverage Begins section. However, if your coverage ends because you stop active work, you may reinstate the coverage you previously had in effect without having to complete a new eligibility probationary period, if you return to active work in an Eligible Class within 24 months of the date your coverage ended. In addition, if you return to work in an Eligible Class within 6 months of the date your coverage ended, the pre- existing condition rule applies to the extent the rule would have applied if your coverage had not ended. For the above exceptions to apply, you must request to reinstate contributory coverage within 31 days of your return to active work. Extension of Benefits (GR-9N 31-020-01 TN) Coverage for Long Term Disability Benefits If your long term disability coverage ends during a period of total disability which began while you had coverage, any long term disability benefits will be continued until your benefit eligibility ends. CONFIDENTIAL AETNA 0092 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 18 of 30 GR-9N 17 General Provisions (GR-9N-32-005-02-TN) Physical Examinations (GR-9N-32-005-02-TN) Aetna will have the right and opportunity to have a physician of its choice examine any person who is requesting certification or benefits for new and ongoing claims. Multiple exams, evaluations and functional capacity exams may be required during your disability for an ongoing claim This will be done at all reasonable times while certification or a claim for benefits is pending or under review. This will be done at no cost to you. Legal Action No legal action can be brought to recover payment under any benefit after 2 years from the final decision date of your last appeal decision, but not later than 3 years from the date your eligibility for disability benefit was first denied. Aetna will not try to reduce or deny a benefit payment on the grounds that a condition existed before your coverage went into effect, if the loss occurs more than 2 years from the date coverage commenced. This will not apply to conditions excluded from coverage on the date of the loss. Confidentiality Information contained in your medical records and information received from any provider incident to the provider patient relationship shall be kept confidential in accordance with applicable law. Information may be used or disclosed by Aetna when necessary for the operation of the plan and administration of this Booklet-Certificate, or other activities, as permitted by applicable law. You can obtain a copy of Aetna’s Notice of Information Practices at www.aetna.com. Additional Provisions The following additional provisions apply to your coverage:  You cannot receive multiple coverage under the plan because you are connected with more than one employer.  In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will be used to determine the coverage in force.  This document describes the main features of the plan. Additional provisions are described elsewhere in the group policy. If you have any questions about the terms of the plan or about the proper payment of benefits, contact your employer or Aetna.  Your employer hopes to continue the plan indefinitely but, as with all group plans, the plan may be changed or discontinued with respect to your coverage. Assignments (GR-9N-32-005-01) (GR-9N-32-005-02-TN) Coverage may be assigned only with the written consent of Aetna. Misstatements (GR-9N-32-005-03-TN) If any fact as to the Policyholder or you is found to have been misstated, a fair change in premiums may be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in determining whether coverage is or remains in force and its amount. All statements made by the Policyholder or you shall be deemed representations and not warranties. No written statement made by you shall be used by Aetna in a contest unless a copy of the statement is or has been furnished to CONFIDENTIAL AETNA 0093 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 19 of 30 GR-9N 18 you or your beneficiary, or the person making the claim. Aetna’s failure to implement or insist upon compliance with any provision of this policy at any given time or times, shall not constitute a waiver of Aetna’s right to implement or insist upon compliance with that provision at any other time or times. This includes, but is not limited to, the payment of premiums. This applies whether or not the circumstances are the same. Incontestability (GR-9N-32-005-02-TN) During the first two years that your insurance is in force, any statement that you have made may be used by Aetna in contesting the validity of that coverage. This also applies to any increase in your coverage for the two years that follow the effective date of that increase, if evidence of good health was required in order for the increase to take effect. Once coverage (including any increases in coverage) has been continuously in effect for two years, the validity of your insurance (or increase in coverage) under this plan shall not be contested by Aetna unless your statement was in writing on a form signed by you and was fraudulently made in order to obtain that coverage or increase. Aetna may also contest the validity of your insurance at any time under this plan for non-payment of premiums when due. Subrogation (GR-9N-32-010-02 TN) As used herein, the term “Third Party,” means any party that is, or may be, or is claimed to be responsible for illness or injuries to you that caused your disability. Such illness or injuries are referred to as “Third Party Injuries.” “Third Party” includes any party responsible for payment of benefits for loss of time or wages as a result of Third Party Injuries. By accepting benefits under this plan, you specifically acknowledge Aetna’s right of subrogation. When this plan pays benefits for disabilities incurred due to Third Party Injuries, Aetna shall be subrogated to your right of recovery against any party to the extent of all benefits provided by this plan. Aetna will notify the covered person or the covered person’s representative of its interest and maintain contact throughout the process. By accepting benefits under this plan, you or your representatives further agree to:  Notify Aetna within 45 days and in writing when notice is given to any party, including an insurance company or attorney, of the intention to investigate or pursue a claim to recover damages or obtain compensation due to Third Party Injuries sustained by you;  Cooperate with Aetna and do whatever is necessary to secure Aetna’s rights of subrogation and recovery under this Booklet-Certificate;  Give Aetna a first-priority lien on any recovery, settlement, or judgment or other source of compensation which may be had from any party to the extent of the full cost of all benefits associated with Third Party Injuries provided by this plan;  Pay, as the first priority, from any recovery, settlement judgment, or other source of compensation, any and all amounts due Aetna as recovery of the full cost of all benefits associated with Third Party Injuries paid by this plan(regardless of whether such payment will result in a recovery to the covered person which is insufficient to make the covered person whole or to compensate the covered person in part or in whole for the damages sustained), unless otherwise agreed to by Aetna in writing; and  Do nothing to prejudice Aetna’s rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of all benefits paid by the plan;  Serve as a constructive trustee for the benefits of this plan over any settlement or recovery funds received as a result of Third Party Injuries. CONFIDENTIAL AETNA 0094 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 20 of 30 GR-9N 19 Aetna may recover full cost of all benefits paid by this plan under this Booklet-Certificate without regard to any claim of fault on your part, whether by comparative negligence or otherwise. Recovery of Overpayments Long Term Disability Coverage If payments are made in amounts greater than the benefits that you are entitled to receive, Aetna has the right to do any one or all of the following:  Require you to return the overpayment on request;  Stop payment of benefits until the overpayment is recovered;  Take any legal action needed to recover the overpayment; and  Place a lien, if not prohibited by law, in the amount of the overpayment on the proceeds of any other income, whether on a periodic or lump sum basis. If the overpayment:  Occurs as a result of your receipt of “other income benefits" for the same period for which you have received a benefit under this plan; and  To obtain such “other income benefits", advocate or legal fees were incurred; This Plan will exclude from the amount to be recovered, such advocate or legal fees; provided you return the overpayment to the plan within 30 days of the plan's written request for the overpayment. If you do not return the overpayment to this plan within such 30 days, such fees will not be excluded; you will remain responsible for repayment of the total overpaid amount. Examples of “other income benefits” are:  Workers' compensation.  Federal Social Security benefits.  Disability payments made by, or on behalf of, a third party as a result of any person's action or inaction. Reporting of Claims (GR-9N-32-020-01) You are required to submit a claim to Aetna in writing. Claim forms may be obtained from Aetna. Follow the procedure chosen by your Employer to report a disability claim to Aetna. If the procedure requires that claim forms be submitted, you may obtain them from your employer or Aetna. Your claim must give proof of the nature and extent of the loss. You must furnish true and correct information as Aetna may reasonably request. At any time, Aetna may require copies of documents to support your claim, including data about employment. You must also provide Aetna with authorizations to allow it to investigate your claim and your eligibility for and the amount of work earnings and other income benefits. In addition to the above: if you must be out of work because you are disabled, a claim for a Long Term Disability Benefit should be made right away. Do not wait until you go back to work. This may delay payment of benefits. At any time, Aetna may require copies of documents to support your claim, including data about employment and any other income benefits. The deadline for filing a long term disability claim is 90 days after the end of the elimination period, if any. If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims will not be covered if they are filed more than one year after the deadline. CONFIDENTIAL AETNA 0095 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 21 of 30 GR-9N 20 Payment of Benefits (GR-9N-32-025-04) Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must be provided for all benefits. Long Term Disability benefits will be paid at the end of each calendar month during the period for which benefits are payable. Long Term Disability benefits for a period less than a month will be prorated. This will be done on the basis of the ratio, to 30 days, of the days of eligibility for benefits during the month. Any unpaid balance (at the end of Aetna's liability as to Long Term Disability) will be paid within 30 days of receipt by Aetna of the due written proof. Aetna may pay up to $1,000 of any other benefit to any of your relatives whom it believes are fairly entitled to it. This can be done if the benefit is payable to you and you are a minor or not able to give a valid release. It can also be done if a benefit is payable to your estate. Contract Not a Substitute for Workers’ Compensation Insurance (GR-9N-32-030-01) The group policy is not in lieu of and does not affect workers' compensation benefits. However, any workers' compensation benefits are considered other income benefits. Contacting Aetna (GR-9N 32-005-05-NE) If you have questions, comments or concerns about your benefits or coverage, or if you are required to submit information to Aetna, you may contact Aetna’s Home Office at: Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT 06156 You may visit Aetna’s web site at www.aetna.com. CONFIDENTIAL AETNA 0096 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 22 of 30 GR-9N 21 Glossary (GR-9N-34-005-01 TN) In this section, you will find definitions for the words and phrases that appear in bold type throughout the text of this Booklet-Certificate. A (GR-9N-34-005-05) Active at Work; Actively at Work; Active Work (GR-9N-34-005-02) You will be considered to be active at work, actively at work or performing active work on any of your employer’s scheduled work days if, on that day, you are performing the regular duties of your job on a full time basis for the number of hours you are normally scheduled to work. In addition, you will be considered to be actively at work on the following days:  any day which is not one of your employer’s scheduled work days if you were actively at work on the preceding scheduled work day; or  a normal vacation day. Adjusted Predisability Earnings Your predisability earnings, plus any increase made on each January 1. The first increase will be made on the January 1 following a 12-month period of disability. On each January 1, the increase made will equal the percentage increase in the Consumer Price Index, rounded to the nearest tenth; to a maximum of 10%. Aetna Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna. Approved Rehabilitation Program A written program, approved by Aetna, that provides for services and supplies which are intended to enable you to return to work. The program may include, but is not limited to:  Vocational testing;  Vocational training;  Alternative treatment plans such as:  Support groups;  Physical therapy;  Occupational therapy; and  Speech therapy;  Workplace modification to the extent not otherwise provided;  Part time employment; and  Job placement. A rehabilitation program will no longer be an approved rehabilitation program on the date Aetna withdraws, in writing, its approval of the program. C (GR-9N-34-015-02-TN) Consumer Price Index The Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W), is published by the United States Department of Labor. If the CPI-W is discontinued or changed, Aetna reserves the right to use a comparable index. CONFIDENTIAL AETNA 0097 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 23 of 30 GR-9N 22 E (GR-9N 34-025 04) Effective Treatment of Alcoholism or Drug Abuse This means a program of alcoholism or substance abuse therapy that is prescribed and supervised by a physician and either:  Has a follow-up therapy program directed by a physician on at least a monthly basis; or  Includes meetings at least twice a month with organizations devoted to the treatment of alcoholism or drug abuse. Detoxification and maintenance care are not effective treatment. H (GR-9N 34-040 02) Hospital An institution that:  Is primarily engaged in providing, on its premises, inpatient medical, surgical and diagnostic services;  Is supervised by a staff of physicians;  Provides twenty-four (24) hour-a-day R.N. service,  Charges patients for its services;  Is operating in accordance with the laws of the jurisdiction in which it is located; and  Does not meet all of the requirements above, but does meet the requirements of the jurisdiction in which it operates for licensing as a hospital and is accredited as a hospital by the Joint Commission on the Accreditation of Healthcare Organizations. In no event does hospital include a convalescent nursing home or any institution or part of one which is used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care facility, intermediate care facility, skilled nursing facility, hospice, rehabilitative hospital or facility primarily for rehabilitative or custodial services. I (GR-9N 34-045 02) Illness A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to the findings set the condition apart as an abnormal entity differing from other normal or pathological body states. Injury An accidental bodily injury that is the sole and direct result of:  An unexpected or reasonably unforeseen occurrence or event; or  The reasonable unforeseeable consequences of a voluntary act by the person.  An act or event must be definite as to time and place. CONFIDENTIAL AETNA 0098 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 24 of 30 GR-9N 23 M (GR-9N 34-065 03 TN) Material Duties Duties that:  Are normally needed for the performance of your own occupation; and  Cannot be reasonably left out or changed. However, to be at work more than 40 hours per week is not a material duty. O (GR-9N-34-075-01 TN) Own Occupation The occupation that you are routinely performing when your period of disability begins. Your occupation will be viewed as it is normally performed in the national economy instead of how it is performed:  For your specific employer; or  At your location or work site; and  Without regard to your specific reporting relationship. P (GR-9N-34-080-09 TN) Physician (GR-9N-34-080-09 TN) A duly licensed member of a medical profession who:  Has an M.D. or D.O. degree;  Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the individual practices; and  Provides medical services which are within the scope of his or her license or certificate. This also includes a health professional who:  Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or she practices;  Provides medical services which are within the scope of his or her license or certificate; and  Under applicable insurance law is considered a "physician" for purposes of this coverage. For the purposes of Long Term Disability coverage, regular care of a physician means you are attended by a physician who:  Is not you or related to you;  Has the medical training and clinical expertise suitable to treat your disabling condition;  Specializes in psychiatry, if your disability is caused, to any extent, by a mental health or psychiatric condition; and  Whose treatment is:  Consistent with the diagnosis of the disabling condition;  According to guidelines established by medical, research and rehabilitative organizations; and  Administered as often as needed. CONFIDENTIAL AETNA 0099 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 25 of 30 GR-9N 24 Predisability Earnings This is the amount of salary or wages you received from an employer participating in this plan for the last full calendar year before a period of disability started. If you were not employed for all of the last full calendar year, it will be the average monthly salary or wages for the last 12 months before the period of disability started. If you were not employed for all of the last 12 months, it will be the average monthly salary or wages for the months employed. Included in salary or wages are:  Commissions, awards and bonuses averaged over the last 12 months of actual employment or such shorter period if actual employment was for fewer than 12 months.   Shift Differential pay.  Contributions you make through a salary reduction agreement with your Employer to any of the following:  An Internal Revenue Code (IRC) Section 125 plan for your fringe benefits.  An IRC 401(k), 403(b), or 457 deferred compensation arrangement.  An executive nonqualified deferred compensation agreement. Salary or wages do not include:  Overtime pay.  Contributions made by your Employer to any deferred compensation arrangement or pension plan.  Extra compensation such as payments for revenue sharing, housing allowances, stipends, relocation incentives or buyouts of unused vacations, professional fees, non-qualified income. A retroactive change in your rate of earnings will not result in a retroactive change in coverage. R (GR-9N-34-090-01 TN) Reasonable Occupation This is any gainful activity:  For which you are, or may reasonably become, fitted by education, training, or experience; and  Which results in, or can be expected to result in, an income of more than 60% of your adjusted predisability earnings. T (GR-9N 34-100-02) Treatment Facility This is an institution (or distinct part thereof) that is for the treatment of alcoholism or drug abuse and which meets fully every one of the following tests:  It is primarily engaged in providing on a full-time inpatient basis, a program for diagnosis, evaluation, and treatment of alcoholism or drug abuse.  It provides all medical detoxification services on the premises, 24 hours a day.  It provides all normal infirmary-level medical services required during the treatment period, whether or not related to the alcoholism or drug abuse, on a 24 hour daily basis. Also, it provides, or has an agreement with a hospital in the area to provide, any other medical services that may be required during the treatment period.  On a continuous 24 hour daily basis, it is under the supervision of a staff of physicians, and provides skilled nursing services by licensed nursing personnel under the direction of a full-time registered graduate nurse.  It prepares and maintains a written individual plan of treatment for each patient based on a diagnostic assessment of the patient's medical, psychological and social needs with documentation that the plan is under the supervision of a physician.  It meets any applicable licensing standards established by the jurisdiction in which it is located. CONFIDENTIAL AETNA 0100 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 26 of 30 Confidentiality Notice Aetna considers personal information to be confidential and has policies and procedures in place to protect it against unlawful use and disclosure. By "personal information," we mean information that relates to a member's physical or mental health or condition, the provision of health care to the member, or payment for the provision of health care or disability or life benefits to the member. Personal information does not include publicly available information or information that is available or reported in a summarized or aggregate fashion but does not identify the member. When necessary or appropriate for your care or treatment, the operation of our health, disability or life insurance plans, or other related activities, we use personal information internally, share it with our affiliates, and disclose it to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers), payors (health care provider organizations, employers who sponsor self-funded health plans or who share responsibility for the payment of benefits, and others who may be financially responsible for payment for the services or benefits you receive under your plan), other insurers, third party administrators, vendors, consultants, government authorities, and their respective agents. These parties are required to keep personal information confidential as provided by applicable law. Some of the ways in which personal information is used include claim payment; utilization review and management; coordination of care and benefits; preventive health, early detection, vocational rehabilitation and disease and case management; quality assessment and improvement activities; auditing and anti-fraud activities; performance measurement and outcomes assessment; health, disability and life claims analysis and reporting; health services, disability and life research; data and information systems management; compliance with legal and regulatory requirements; formulary management; litigation proceedings; transfer of policies or contracts to and from other insurers, HMOs and third party administrators; underwriting activities; and due diligence activities in connection with the purchase or sale of some or all of our business. We consider these activities key for the operation of our health, disability and life plans. To the extent permitted by law, we use and disclose personal information as provided above without member consent. However, we recognize that many members do not want to receive unsolicited marketing materials unrelated to their health, disability and life benefits. We do not disclose personal information for these marketing purposes unless the member consents. We also have policies addressing circumstances in which members are unable to give consent. To obtain a copy of our Notice of Information Practices, which describes in greater detail our practices concerning use and disclosure of personal information, please call 1-866-825-6944 or visit our Internet site at www.aetna.com. CONFIDENTIAL AETNA 0101 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 27 of 30 Additional Information Provided by Autozone, Inc. The following information is provided to you in accordance with the Employee Retirement Income Security Act of 1974 (ERISA). It is not a part of your booklet-certificate. Your Plan Administrator has determined that this information together with the information contained in your booklet-certificate is the Summary Plan Description required by ERISA. In furnishing this information, Aetna is acting on behalf of your Plan Administrator who remains responsible for complying with the ERISA reporting rules and regulations on a timely and accurate basis. Name of Plan: Long-Term Disability Employer Identification Number: 62-1482048 Plan Number: 502 Type of Plan: Welfare Benefit Type of Administration: Group Insurance Policy with: Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT 06156 Plan Administrator: Senior Vice President of Human Resources AutoZone Parts, Inc. 123 South Front Street Memphis, TN 38103 Telephone Number: (901) 495-7223 Agent For Service of Legal Process: CT Corporation System AutoZone Parts, Inc. 800 South Gray Street, Suite 2021 Knoxville, TN 37929 Service of legal process may also be made upon the Plan Administrator End of Plan Year: December 31 Source of Contributions: Employer/ Employee Procedure for Amending the Plan: The Employer may amend the Plan from time to time by a written instrument signed by Plan Administrator. CONFIDENTIAL AETNA 0102 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 28 of 30 ERISA Rights As a participant in the group insurance plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974. ERISA provides that all plan participants shall be entitled to: Receive Information about Your Plan and Benefits Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts, collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) that is filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, collective bargaining agreements, and copies of the latest annual report (Form 5500 Series), and an updated Summary Plan Description. The 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. 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 your interest and that of other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain 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 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 up to $ 110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the 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 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, you should contact:  the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory; or  the Division of Technical Assistance and Inquiries, Employee Benefits Security 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 Employee Benefits Security Administration. CONFIDENTIAL AETNA 0103 Case 2:16-cv-06512-GJP Document 4-3 Filed 12/27/16 Page 29 of 30 Continuation of Coverage During an Approved Leave of Absence Granted to Comply With Federal Law This continuation of coverage section applies only for the period of any approved family or medical leave (approved FMLA leave) required by Family and Medical Leave Act of 1993 (FMLA). If your Employer grants you an approved leave for a period in excess of the period required by FMLA, any continuation of coverage during that excess period will be subject to prior written agreement between Aetna and your Employer. If your Employer grants you an approved FMLA leave in accordance with FMLA, your Employer may allow you to continue coverage for which you are covered under the group contract on the day before the approved FMLA leave starts. At the time you request FMLA leave, you must agree to make any contributions required by your Employer to continue coverage. Your Employer must continue to make premium payments. Coverage will not be continued beyond the first to occur of:  The date you are required to make any contribution and you fail to do so.  The date your Employer determines your approved FMLA leave is terminated.  The date the coverage involved discontinues as to your eligible class. If you return to work for your Employer following the date your Employer determines the approved FMLA leave is terminated, your coverage under the group contract will be in force as though you had continued in active employment rather than going on an approved FMLA leave provided you make request for such coverage within 31 days of the date your Employer determines the approved FMLA leave to be terminated. If you do not make such request within 31 days, coverage will again be effective under the group contract only if and when Aetna gives its written consent. 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