SECTION XIV: DEFINITIONS

These are some of the terms used in your booklet. Some other terms are described where they are used. PLEASE READ THEM CAREFULLY. They can help you to better understand what your benefits are.

Board means the Board of Trustees established by the Trust Agreement.

Calendar year means the twelve-month period beginning January 1 and ending December 31.

Convalescent Hospital or Skilled Nursing Facility means an institution which:

1. is regularly engaged in providing skilled nursing care for sick and injured persons under 24-hour supervision of a Physician or a graduate Registered Nurse (R.N.);
2. has available at all times the services of a Physician who is a staff member of a general Hospital;
3. has on duty 24 hours a day a graduate Registered Nurse (R.N.), Licensed Vocational Nurse (L.V.N.) or skilled practical nurse;
4. has a graduate Registered Nurse (R.N.) on duty at least 7 hours per day;
5. maintains a daily medical record for each patient; and
6. complies with all licensing and other legal requirements.

Convalescent Hospital does not mean any institution, or part thereof (other than incidentally), which is a place for rest, a place for Custodial Care, a place for the aged, a place for drug addicts, a place for alcoholics, a hotel, or a similar institution.

Covered Charge(s) or Covered Expense(s) means only those charges which are Reasonable and Customary and which are incurred as a result of a Medical Necessity for conditions that are covered under this Plan. It shall also mean only those charges incurred by a Covered Person while eligible for benefits under this Plan.

Covered Employee or Employee means a member performing work under a Collective Bargaining Agreement with IBEW Local 6 which requires contributions to this Plan. Or an employee for whom contributions are made to this Plan pursuant to a subscription agreement approved by the Board of Trustees.

Covered Employment means work performed under a Collective Bargaining Agreement with a Local Union of IBEW which requires contributions to this Plan.

Covered Person or Participant means each eligible Employee or Retiree and each of his or her Dependents, if any.

Custodial Care means treatment, services or confinement which could be rendered safely and reasonably by a person not medically skilled, and which are designed mainly to help the patient with activities of daily life. Custodial Care includes personal care, homemaking services, moving the patient, acting as companion or sitter, or supervising medication which can usually be self-administered.

Hospital means an institution which:

1. is primarily engaged in providing, by or under the supervision of Physicians, inpatient diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation of injured, disabled or sick persons;
2. maintains clinical records on all patients;
3. has bylaws in effect with respect to its staff of Physicians;
4. has a requirement that every patient be under the care of a Physician;
5. provides 24-hour nursing service rendered or supervised by a registered professional nurse;
6. has in effect a Hospital utilization review plan;
7. is licensed pursuant to any state or agency of the state responsible for licensing Hospitals; and
8. has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.

The term “Hospital” does not include an institution, or that part of an institution, used mainly for: (1) nursing care; (2) rest care; (3) convalescent care; (4) care of the aged; (5) Custodial Care; or (6) educational services.

Illness means a bodily disorder, infection, or disease and all related symptoms and recurrent conditions resulting from the same causes.

Injury means physical harm sustained to the body as the direct result of an accident, affected solely through external means, and all related symptoms and recurrent conditions resulting from the same accident.

Medically Necessary the treatment must be ordered by a Physician or other Licensed or Certified Health Care Provider to diagnose or treat an Injury or Illness and be:

1. generally recognized as effective and essential to the treatment of the Injury or Illness for which it is ordered;
2. appropriate for the symptoms and consistent with the diagnosis;
3. the appropriate level of care, and which:
   1. is provided in the most appropriate setting, based on the diagnosis and condition;
   2. could not have been omitted without an adverse effect on the Covered Person’s condition or the quality of medical care; and
   3. based on generally recognized and accepted standards of medical practice in the United States;
      1. is not considered Experimental, Investigatory, or primarily limited to research in its application to the Injury or Illness;
      2. is not primarily for scholastic, educational, vocational or developmental training;
      3. not primarily for the conform, convenience or administrative ease of the Physician or other health care provider, or the member or his or her family or care taker; and
      4. is not Custodial Care.

Medicare means the benefits provided under Title XVIII of the Social Security Amendments of 1965.

Other Licensed or Certified Health Care Provider means Physician's assistant, nurse practitioners or midwife, or nurse midwife, who provides medical care within the scope of his or her license or certificate.

Physician means a duly licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) authorized to perform medical or surgical service within the lawful scope of his or her practice, and shall also include any other health care provider or allied practitioner as mandated by State Law.

Plan. The term “Plan” is used interchangeably with the term “Trust Fund” throughout this document and means the San Francisco Electrical Workers Health & Welfare Trust.

Plan Office means the administrative office of the San Francisco Electrical Workers Health & Welfare Plan in San Francisco, California.

Prescription Drugs means any article that may be lawfully dispensed, as provided under the Federal Food, Drug and Cosmetic Act including any amendments thereto, only upon a written or oral prescription of a Physician or Dentist licensed by law to administer it.

Reasonable and Customary means the charges which fall within the common range of fees billed by a majority of health care providers for a covered procedure in a given geographic region, or which is justified based on the complexity or the severity of treatment for a specific case, as determined from time to time by the Board of Trustees. The term “region” means a county or such greater area that is necessary to obtain a representative cross-section of the usual charges made. Currently the Plan uses Medical Data Research (“MDR”) at the 90th percentile to determine what is Reasonable and Customary. This means that the acceptable limit will not exceed the amounts normally charged by 90% of the Physicians in a geographical area.

Trust Agreement means the Trust Agreement establishing the San Francisco Electrical Workers Health & Welfare Plan and any modification, amendment, extension or renewal thereof.

Union means the International Brotherhood of Electrical Workers, Local 6 that has entered into a Collective Bargaining Agreement with an Employer, the terms of which require such Employer to make contributions to the San Francisco Electrical Workers Health and Welfare Plan on behalf of eligible Employees, Retirees and their Dependents.

For Further Information Call or Write:

SAN FRANCISCO ELECTRICAL WORKERS
HEALTH & WELFARE TRUST

720 Market Street, Suite 700
San Francisco, CA 94102-2509
(415) 263-3670
Fax: (415) 263-3672

Plan Manager
Judith Fisher
EISB, Inc.

Legal Counsel
David F. Crutcher
Attorney at Law
1000 4th Street, Suite 390
San Rafael, CA 94901

Peter W. Saltzman
Leonard Carder LLP
1330 Broadway, Suite 1450
Oakland, CA 94612

Plan Consultant
Sid Kaufmann
Kaufmann & Goble Associates
10 Almaden Blvd.
San Jose, CA 95113-2226