Medical Reimbursement Plan

MEDICAL REIMBURSEMENT PLAN FOR EMPLOYEES OF [CompanyName] A [State] Corporation SUMMARY PLAN DESCRIPTION THIS PLAN SUMMARY IS INTENDED TO BE A SUMMARY OF MANY OF THE PLAN PROVISIONS BUT IS NOT A COMPLETE RESTATEMENT OF THE PLAN. THE COMPLETE PLAN IS AVAILABLE FOR YOUR REVIEW WHICH THE EMPLOYER ENCOURAGES SINCE THE PROVISIONS OF THE PLAN ON ALL MATTERS WILL BE CONTROLLING. 1. Name of Plan: This Plan is known as the Medical Reimbursement Plan of [Company Name], a [State] Corporation. 2. Name, Address and Telephone Number of Employer: [Street Address] [City], [State] [Zip] [Phone number] 3. Employer Identification Number: Your Employer is the Plan Sponsor and the Identification Number assigned to your Employer by the Internal Revenue Service is ##-#######. Your plan number is 001. 4. Type of Plan: This is a single employer Employee Welfare Plan through which your employer provides eligible employees with partial or complete reimbursement for medical expenses they incur. 5. Plan Administration: The Board of Directors of your Employer is the Plan Administrator and the business address and telephone number of your Employer is stated above. 6. Agent for Service of Legal Process: The person designated as agent for the service of legal process is: [Name of plan administrator] [Street Address] [City], [State] [Zip] In addition, service of legal process may be made upon the Plan Administrator. 7. Eligibility: All active full-time employees who have attained twenty-five (25) years of age and who have completed one (1) or more Years of Service are eligible for medical reimbursement under this Plan. Certain employees who are covered by a collective bargaining agreement may not be covered under this Plan. 8. Plan Benefits: This Plan provides for the reimbursement for the medical expenses incurred by an eligible for the medical care of such eligible employee, his or her spouse and dependents (as defined in Section 152 of the Internal Revenue Code) for whom such eligible employee furnishes over one-half (1/2) of their support. Expenses for medical care shall include all amounts paid for hospital bills and co-payments, doctor bills and co-payments, dental expenses, drugs and premiums on accident or health insurance, including hospitalization, surgical, and medical insurance. 9. Funding: The cost of this Plan is met through Employer contributions. 10. Plan Year: The year for purposes of maintaining plan records ends on December 31. 11. Limitation on Benefits: (a) The reimbursement provided under this Plan shall be made only in the event and to the extent that such reimbursement is not provided for under any insurance policy or policies, whether owned by you or your Employer, under any other health or accident plan, or under any other recovery providing for reimbursement or payment in whole or in part. (b) A Plan Administrator may change or eliminate benefits under the Plan and may terminate the entire plan or any portion of it. Your individual coverage terminates when you leave active service, when you are no longer in an eligible class or when the Plan Administrator terminates the Plan, whichever occurs first. 12. Claim Procedure: (a) To obtain reimbursement for medical expenses, an eligible employee must submit within 60 days after the end of each calendar quarter a request for reimbursement for medical expenses incurred by him or her during the preceding quarter, together with such evidence of payment of such expenses. (b) Reimbursement shall be made to the eligible employee in the same taxable year of the Employer as the year of employee payment. 13. Statement of ERISA Rights: As a participant in this plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: (a) Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as work sites and union halls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all documents filed by the plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions. (b) Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The administrator may make a reasonable charge for the copies. (c) Receive a summary of the plan’s annual financial report if the plan covers 100 or more participants. The Plan Administrator is required by law to furnish each participant with a copy of this summary financial report. In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants. 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. If your claim for a welfare benefit is denied in whole or in part, you may receive a written explanation of the reason for the denial. You have the right to have the plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the plan and do not receive them within thirty (30) days, you may file suit in a federal court. In such case, the court may require the Plan Administrator to provide the materials and pay you up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the 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. If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U.S. Labor-Management Services Administration Department of Labor. ____________________________________ Plan Administrator