HomeMy WebLinkAboutReso 82-18 - Approving Administrative Services Agreement with CA Western States Life Insurance Company '
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� RESOLUTION NO. ��, ��y _
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF REDDING
APPROVING ADMINISTRATIVE SERVICES AGREEMENT WITH CALIFORNIA
WESTERN STATES LIFE INSURANCE COMPANY.
WHEREAS, the City of Redding has adopted its own inedical
and. dental insurance plan, and
WHEREAS,• the City of Redding has requested Cal-West to
furnish administrative assistance 'under the plan, and to act as
claims administrator under the plan, and in such capacity to pro-
cess pay claims and disburse claims payment thereunder, �
NOW, THEREFORE, BE IT RESOLVED that the City Council of
the City of Redding hereby approves the Administrative Services
Agreement, dated January 1, 1982 , between the City of Redding and
the California Western States Life Znsurance Company.
I HEREBY CERTIFY that the foregoing Resolution was in-
troduced and read at a regular meeting of the City Council of the
City of Redding on the �St day of February . , 1982, and was duly
' adopted at said meeting by the following vote:
AYES: COUNCILMEN: FU1t0�, Gard, Kirkpatrick, and Demsher
� NOES : COUNCILMEN: NOIIE
ABSENT: ._COUNCILMEN: PUgh �� •.
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AT7'EST.:=�,; �.
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' -' '� �� Vice Mayor of ,the City of Redding
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-ETHEL A: RICHTER, City Clerk
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FORM APPROVED t
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RAN ALL A. AYS, �C ty ttorney �
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` ADMINISTRATIVE SERVICES AGREEMENT
THIS AGREEMENT, made and entered into as of lst day ,
of January, 1982, by and between CITY OF REDDING ("Organi- • . ..
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zation") , a California Municipality, and CnLIFORNIA- "
WESTERN STATES LIFE INSURANCE COMPANY ("Cal-41est") ; a • �
' California insurance corporation.
W I T N E S S E T H:
WHEREAS, the Organization has adopted its own Medical � ,
and Dental Plan of Insurance ("Plan") , a copy of which is '
� attached hereto as Exhibit "A, " for its eligible employees
and retired employees and for the eligible 3ependents of ,
such employees and retired employees; and �
� WHEREAS, the Organization ha3 requested Cal-West to
furnish administrative assistance under the Plan and to
act as claims administrator under the Plan and in such
capacity to process, pay claims, and disburse claims payments
thereunder:
_ NOW, THEREFORE, in consideration of the mutual promises
and covenants contained herein, .it is hereby agreed as follows:
� Section 1. Claims }�dministration.
(a) Upon receipt of a written claim for benefits under
- the Plan, Cal-West shall process such claim which shall include
the following:
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1) The determination as to whether or not tlie
claim has been properly filed; -�
. 2) The amount, if any, .which is due and payable_ � ,
with respect thereto.
(b) Cal-S4est on behalf and as agent of the Organization
shall disburse claim payments which Cal-West determines to '
be duein accordance with the provisions of the Plan to the • •
' person or assignee entitled thereto, in the manner provided
in Section 2 of this Agreement. , .
(c) in determining any person' s right to benefits under
the Plan, Cal-i�est shall rely on eligibility information
furnished by the Organization, . and the Organization shall � •
hold Cal-West harmless for any inaccuracy in such information.
The Orqanization shall advise Ca1-West on a monthly basis on
or about the first of each month, in a form acceptable to ,
Cal-West, with respect to the persons eligible for benefits -
� under the Plan, the effective date or the terminatioz date "
(as the case may be) of their eligibility and the extent of the
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benefits to which they are entitled. The Organization shall
furnish Cal-West with such other information as may reasonably
be required for the proper administration of the Plan. .
(d) Proofs of claim satisfactory .to Cal-West in accord-
ance with Cal-West' s standard practices, must be furnished to
Cal-West not later than fifteen (15) months from the date on '
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which the health care service was received: .
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(e) Cal-West shall take all reasonable steps to process, . .
pay claims, and to disburse claim payments expeditiously. All , .
claims processing shall be consis•cent and in accord with •
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applicable laws, regulations, and general insurance industry •�
practice. , .
Section 2. Payment of CTaims.
(a) The Organization shall establish such accounts ,
with Lloyds Bank California as may be required and shall -
maintain in such accounts amounts which will" be sufficient at
� all times to pay claims under the Plan.
(b) Cal-West shall •pay claims under. the Plan by disburse-
ments through such accounts with Lloyds Bank California. The �
Organization, by execution of this Aqreement, authorizes Cal- �
West to effect such disbursements for the purpose of paying
claims under the Plan. _
� - - (c) In� the event Ca1=West inadvertently pays any person �
less than the amount to which he or she is entitled under the .
Plan, Cal-West will, upon discovery, promptly adjust the �
payment. In the event of an overpayment, Cal-West shall make
a reasonable and diligent effort to recover the overpayment
to the credit of the Organization.
(d) . The determination of whether any eligible claimant
is entitled to benefits=under the Plan and the extent to
which he or she is entitled .shall rest with Cal-West. Any ..
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application for benefits shall be submitted to Cal-West in
writing on the prescribed form. in the event that any
application for benefits is denied in whole or in part, .
Cal-West shall notify the applicant in writing of the right
to a review of the denial. Such written notice shall set
forth, in a manner calculated to be understood by the
applicant, specific reasons for the denial, specific refer- �;
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ences to the Plan provisions on which the denial was based,
a description of any information or material necessary to
perfect the application, an explanation of why such material ,
is .necessary and an explanation of the Plan' s review procedure. � :
. Such written notice shall be given to the applicant �aithin 90
days after Cal-West receives the application, unleas speci.al
circumstances require an extension of tine for processing ' '�
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the application. Zn no event shall such an extension exceed �;
a period of 90 days from the end of the initial 90-day period.
If such an extension is required, written notice thereof shall �
be furnished to the applicant before the end of the initial ''
• 90=day period or the application shall be deemed to have been i
denied. Such notice shall indicate the special circumstances
requiring an extension of time and the date by which the Company '
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expects to �render a decision. � . �t
(e) Cal-West will conduct claim audits periodically, but :
no less than annually, to verify the accuracy of payments,
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adequacy of proof of claim and eligibility of claimants for .
benefits. '
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Secticn 3. A. S. G. Fee. � • •
(a) The charge for services performed by Cal-West -
under this Agreement shall be $5. 21 per employee per month.
In addition, Cal-West shall be reimbursed for costs actually
. lincurred in printing drafts, booklets and all forms (other .
than those normally furnished by Cal-West). approved by the
Orqanization. Such printing costs shall be billed and paid -
in accord with the same procedure as set forth in Section 3. (b) ,
below. �
- (b) On or about the first day of each month, Cal-West .
: shall submit to the Organization a statement showing the A.S.O.
. Fee for the preceding month determined on the basis set forth
in Subsection (a) of this Section 3. Simultaneous. with sub- � �.
mission of such statement, Cal-West shall withdraw funds in
the amount of such statement from the accounts referred to in '
Section 2. (a) .
. (c) Cal-West may change the A.S.O. Fee on the first
. anniversary of this Agreement' s effective date or on the first •
day of any calendar month thereafter, by giving written notice
of such change at least sixty (60) days prior thereto, provided :
that Cal-West shall not have the right to make such change in
the A.S.O. Fee more than once in any twelve consecutive months �'
if no modification of this Agreement is involved. Such change
shall become effective on such anniversary date, or on such
first day of the calendar month, and shall form a part of this '
Agreement unless the Organization notifies Cal-West at least
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thirty (30) .days prior to the effective date of chanqe in the
A.S.O. Fee of its intention to terminate this Agreement as of
such date. . ' �
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Section 4. Duties of Cal-West. -
Cal-West shall have the following duties: �
(a) Preparation and delivery of claim forms and Plan
booklets describing the benefits and coaditions of the plans _
to the Organization.
: (b) Written notification to claimants of rejected claims ..
and of the specific reason for the rejection, and of the right .
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to a review thereof in accord with Section 5.
� (c) Advising and aiding claimants �uith. respect to require-
ments for additional information and proper completion of- claian
forms. .
(d� Discussion of claims, where applicable, with
. _. physicians, attorneys, providers of services, and other repre-
sentatives. � -
� • (e) Obtaininq and furnishing, as necessary, information r
regarding coordination of benefits.
(E) Certifying, upon request, to vendors of health care
services as to a person' s eligibility for benefits under the
Plan and the details of such benefits. ' '
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Section 5. Review of Denied Claims. ' :
(a) Cal-West shall have the authority to act with respect
to any appeal from a denial of benefits. �.
(b) Any person whose application. for benefits is denied '
in whole or in part (or such person' s duly authorized represen- :
tative) may appeal from the denial by submitting to Cal-West a
request for a review of such application within six months after
receiyinq written notice ,of the denial. Cal-West shall give the �
applicant or such representative an opportunity to review per-
tinent documents (except legally privileged materials) in prepar-
ing such request for review and to submit issues and comments in
writing. The request for review shall be in writing and shall
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be addressed to Cal-West. The request for review shall set • ,
. forth all of the grounds on which it is based, all facts in :
support of the request and any other matters which the applicant
deems pertinent. Cal-West may require the applicant to submit
such additional facts, documents or 'other material as it may deem
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� necessary or appropriate in makinq its review. �
. (c) Cal-West shall act upon each request for review within '
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60 days after receipt thereof, unless special circumstances
require an extension of time. for processinq, but in no event ,
shall the decision on review be rendered more than 120 days �
after Cal-West receives the request for review. If such an
_ extension is required, w:itten notice thereof shall be furnisRed
to the. applicant before the end of the initial 60-day period.
Cal-West shall give prompt, written notice of its decision to •
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th� applicant. In the event that Cal-West confirms the denial
of the application for benefits in whole or in part, such .
notice shall set forth, in a manner calculated to be under- �
stood by the applicant, the specific reasons for such denial
and specific references to the Plan provisions on which the
decision is based.
(d) No legal or equitable action under the Plan shall be ,
brought unless and until the claimant (i) has submitted a . -
written application for benefits in accordance with Section 2. .
' and such application has been denied, and (ii) has filed a
. written request for a review of the application in accordance ,
• with this section which has been denied; provided, however, an
- _ action. may be brought if Cal-West has failed to act on the claim
within the prescribed time. . ' • �
Section 6. Experience Reports.
(a) Annually, Ca1-West will furnish to the Organization
an analysis of the experience of the Plan which shall include:
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( i) An estimate of incurred but unreported claims;
(ii) Claim payments. �
(b) Monthly, Cal-West will furnish to the Organization a
report of claims payments.
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Section 7. Information Reports. .
Cal-4lest shall prepare .for the Organization information
reports in connection with claim payments under the P.lan to
provfders of health care services pursuant to Section 6041 ,
of the Internal Revenue Code. The Orqanization hereby ..
appoints Cal-West to prepare in the name of the Organization
. such information reports to be furnished such providers and
the Internal .Revenue Service as required under the applicable '.
law, regulations and rulings. � •
Section 8. Record Retention and Review. •
Cal-West shall maintain all records (or appropriate .
microfilm thereof) used to perform its services for six (6)
.,
years following the year in which the services were performed.
Such records may be reviewed and audited by the Organization
at any time during the normal business hours of Cal-West. ,
In the event of termination of this Agreement, any such records
in possession of Cal-West shall be forwarded to the Organization
as soon as there is no further need for them in connection with •
the services contemplated by this Agreement. In the event of �
such a termination, Cal-West shall be permitted to retain '
copies of such records as may be necessary. under applicable
laws, regulations, or industry practices. y
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Section 9. Privilege of Obtaining an individual Insurance
Po�icy Un e�-r Certain Conditions.
(a) Cal-West will, while this Agreement is in effect and _
- subject to the conditions hereinafter. stated, make an individual '
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polioy available to any member or dependent of a member, -
when applicable, of the Organization whose coverage under
the Plan terminates by reason of termination of that
member' s employment or of that member' s transfer out of .
the classes eligible for such covErage, if the terms of the .
Plan provide for the privilege of obtaining individual insur- �
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ance coverage for the member under such circumstances. The
�individual insurance policy will be renewable at the option �
of Cal-West and will afford co�erage subject to the conditions
below. The member may, without furnishinq evidence of insur-
ability, obtain the individual insurance policy by makinq
written application and the first premium payment therefor .to ' ,
Cal-West at its Home Office not later than thirty-one (31) .
days from the date of such termination of coverage. The �
availability of the individual insurance policy, the coveraqe •
thereunder, the person or persons covered under the policy, '
• the initial premium payable under the policy, the form and
all terms and conditions thereof shall be consistent with
rules of Cal-�4est which pertain to insurance obtainable by �
persons terminating coverage under Cal-West group insurance ;
policies, and which are in effect at the time the application • ,
for such individual policy is made to Cal-West.
(b) The Plan itself (Exhibit "A") shall govern and
. determine the terms and conditions under which any person
may be eligible for such individual insurance policy.
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Section 10. Other Duties. ,
Cal-West shall perform such other duties and prepare �
such reports and statistical material as may be mutually
agreed upon bythe Organization and Cal-Wes�.: Such agree- _
ment with respect to such duties, reports and material .
and the additional charge therefor, if any, shall be in
writing and signed by the parties. •
Section 11. Nature .and Construction of the
Agreement; Legal Actions. •
� (a) It is mutually recognized that Cal-West in perform-
' ing .its obliqations under this Agreement is acting only as an
agent of the Organization. It is understood that the Organi- .
zation retains all authority and responsibility for the Plan �
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itself and its operation and that Cal-West is enpowered to �
act on behalf of the Organization in connection with the Plan
.. only as expressly stated in this Agreement or as mutually ;
agreed to in writing by the parties. .
� (b) The Organization agrees to hold Cal-West and its '
directors, officers and employees harmless from any and all -
damages, losses, . claims, lawsuits, settlements, judgments, ��c
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costs, penalties and expenses, including attorney' s fees, •
resulting from, or arising out of, or in connectirn with �any �
function of Cal-West under this Agreement; unless the cause �
of liability therefor was the criminal conduct, fraud, or .
willful misconduct or negligent act or omission on the part
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of Cal-West or any of its directors, officers or employees;
Cal-West agrees to hold the Organization, and its applicable
representatives, harmless from any and all namages, losses, .
clai.ms, lawsuits, settlements, judgments, costs, penalties.
and expenses,. including attorney's fees caused by any such
criminal conduct, fraud, willful misconduct, or negligent
act or omission. -
(c) The defense of any legal or equitable action �
instituted on a claim for benefits under the Plan shall not
be an obligation of Cal-West, imless Cal-West is named as ,
a party defendant in such action. In such event, Cal-4lest
shall be responsible and shall control its separate defense.
Cal-West shall, to the extent possible, cooperate with the .
Organization by furnishing such evidence as it has available
in connection with the defense of any such action.
(d) Cal-West shall not be considered to have failed to
perform its obligations under this Agreement if any delay or
� nonperformance is due to the Organization' s failure to promptly
discharge its obligations under this Agreement.
Section 12. Modification of Agreement..
This Agreement may be changed only by an amendment �
hereto signed by all the parties hereto.
Section 13. Modification of the Plan.
Upon request of the Organization and receipt of any
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required information, Cal-�9est will furnish to the Organization
an estimate of the benefit cost of any proposed modiPicatinn or .
extension of the Plan. in connection therewith, Cal-West will
notify the Orqanization of any changes in the A.S.O. Fee which
would be required if the Plan were so modified or extepded. .
Any change in the Plan (including termination) by the Organi- �
zation shall be communicated to Cal-West in writing at least •
thirty (30) days prior to its effective date. .
Section 14. Termination of Agreemen�.. ,
(a) This Agreement shall terminate upon the first to
occur of the following:
(i) The expiration of thirty-one (31) days after . .-
written notice has been given by either party to the other; �
;'
(ii) The date specified in a written notice given �
by Cal-West to the other party hereto of its intent to ter-
� minate this Agreement because of the Orqanization' s failure
to remit to Cal-West charges for services; �
(iii) Termination of the Plan;
(iv) Modification of the Plan, but such modification
of the Plan shall not operate to terminate this Agreement (A) if
this Agreement is chanqed to make such modified plan the Plan �
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under this Agreement, or (B) while this Agreement is being
continued .by mutual agreement between the parties hereto prior .
to such change therein. �
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(b) In the event of termination of this Agreement, Cal- ,
West shall continue to furnish claim payment services as to
those claims for which it has received complete information
prior to the termination date at the same charges as were
. then in effect under this Agreement unless the Organization
notifies Cal-West in writing at the tune of such termination
that such services are not required by the Organization.
Section 15. Miscellaneous Provis'ions. -
If any taxes or other charges .(specifically including but '
not limi.ted . to premium taxes) are assessed against Cal-West
with respect to any claim payments under the Plan, the Orqani-
zation shall, within thirty (30) days of receipt of notice
thereof from Cal-West, re unburse Cal-West for the amount of such . .
taxes or other charges together with any penalties and inter-
eat, unless the Orqanization, at its own cost and expense, elects
to contest, in the name of Cal-West, the propriety of such assess-
ment; and in such event, the Organization further agrees that .. �
it will promptly reimburse the amount of such taxes or other �
charges together with any penalty and interest to Cal-west in
the event it is finally determined that such taxes or charges
are due. �
CIT RED ING
ATTEST:
Title: Vice �4ayor of the City of Redding
/s/ Ethel A. Richter .
Ethe A. Richter, City C erk CALIFORNIA-WESTEFtN STATES
� . LIFE INSURANCE COMPANY ,
FORM APPROVED: � / /� � / � _
� BY:.�r��f�GL�� • /c�l:CG�tLt!�� �
� /s/ Randall A. Hays � Title: ,.::fCucp�Y�ct,��-<<�...,�
� Randall A. Hays, City Attorney /a3 S� ,
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CITY OF REDDIP� G � .
� . EMPLOYEE SELF - Fl{ iVDED .
� MEDICAL AiJD DENTA .L PLAN -
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� ��crtve JaNuwtv I. 19ffi . . �.
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, ° OEFINITIONS . -.__._._. . . _..._ _ ...... _.__..--.. ....:.... ...___ _.-.--
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"Basic Salary" means the Insured's regular rate of compensation, exclusive
of overtime pay, commissions, banuses , expense allowances and other types
of allowances.
. "Complication of pregnancy" means any condition arising from pregnancy re-
quiring medical treatment except for a normal pregnancy terminating in a
normal delivery or an elective maternity procedure which is not medically
necessary. •
°Convalescent hospital" means a place (including a separate part of a hos-
� pital ) which (a) regularly provides room and board for persons convalescing
from inJury or sickness, (b) has nurses on duty 24 hours a day under medicai
supervision, (c) has a doctor available at all times , (d) maintains a daily
ctinical record for each patient, (e) is not, other than incidentally, a
place for rest, the aged, drug addicts, or alcoholics, and (f) is licensed
a�d accredited as a convalescent hospital by the state in which it is • � ��
• located. �
' _ °Covered Charges" means (1 ) charges payable .under the Major Expense Benefit
of this Policy, subject to the Exclusions ard Limitations section, (2) charges
determined by City of Redding not to be in excess of the fees and prices
generally charged in the community for the services and supplies fur�ished,
� and (3) charges for services and supplies determined by City of Redding to
be generally furnished for the treatment of the injury or sickness being .
treated. -
°Covered Person" means the Insured or any dependent with respect to whom he
ts covered under this Policy.
°Custodial care" means care provided primarily for the maintenance of the
patient or which is designed essentially to assist the patient in meeting
his activities of daily living and which is not primaril,y provided for its
therapeutic value in the treatment of a sickness or accidental bodilyinjury.
� Custodial care includes, but is not limited to, help in walking, bathing,
dressing, feeding, preparation of special diets, and supervision over self- '
administration of inedications not requiring constant attention of trained
medical personnel .
°Dentist" means a doctor of dentistry or any of the following to the extent
they are authorized by law to perform a particular dental service covered '
. under the terms of this Policy: doctor of inedicine or doctor of osteopathy.
°Dependent" means only the Insured's unmarried child from birth to 19 years of
age, and the Insured's spouse. Nowever, any individual eligible to be an
Insured under this Policy or any indi 'vidual in full-time mititary', naval , or
air service shall not be considered a dependent. The word "child" includes a ;
• . recognized natural child or step child or legally adopted child, who is eco-
nomically dependent on the Insured. An vnmarried child who is 19 years of age �
or over but under 24 years of•age and in full-time attendance at a school or
tollege shall also b'e .included as a dependent under this definition.
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' '% '''�' ' .` " D FINITIONS - (Continuedj v �
With respect to thc_,!:*•.fe .l--�rance Benefit for each Dependent, the age
. limits for a child are 14 aays of age or over but. under 19 years of age,
and 19 years of age or over but under 21 years of age if in full-time
attendance at a school or college.
In addition, any insured child who, upon attaining any limiting age spec-
ified in this definition, is incapable of self-sustaining employment .due �
to mental retardation or physical handicap, shall continue to be considered
a dependent under this definition with respect to all benefits except the
Life Insurance Benefit for each Dependent (if included herein) , provided
that proof of such incapacity is provided within 31 days following Lhe date
� such child attains the limiting age. City of Redding has the right to
require proof of the continuation of the incapacity at any time, but not ' . .
more frequently than annually after the 2-year period following the child's
attainment of the limiting age. .
"Doctor" means any of the following to the extent they are authorized by
law to perform a particular service which is covered under this Policy:
doctor of inedicine, doctor of osteopathy, doctor of dentistry, doctor of
. podiatry, doctor of optometry, doctor of chiropractic, psychologist, and.
upon referral by a physician and surgeon, licensed clinical . social worker
• . or physical therapist.
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°Orugs and medicines" means only those drugs .and medicines lawfully obtain-.
able only on the prescription of a doctor, the generic formulas of which are
approved by the Food and Drug Administration.
°Employee" means an individual who works at least 20 hours per week for the �
� City of Redding but does not include any. individual employed on a seasonal.
or temporary basis. ,
°Nome Health Care Agency" means. a public or private agency or organization :
licensed by the state in which it is located. _
°Home Health Care Services" consists of, but sha11 not be limited to, (1 )
part-time or intermittent skilled nursing services provided by a registered
nurse or licensed vocational nurse, (2) part-time or intermittent home health
' , aide services which provide supportive services in the home under the super-
vision of a registered nurse or a physical speech or occupational therapist,
(3) physical , occupational or speech therapy and (4) medical supplies, drugs
and medicines prescribed by a physician and related pharr�aceutical services
and laboratory services to the extent such charges or costs would have been -
covered under this Policy if the Covered Person had remained in the
hospital . , �
"Hospital" means an institution constituted and operated pursuant to law,
primarily engaged in providing, on an inpatient basis, diagnostic and thera- •
peutic facilities located therein or in facilities controlled by such insti- .
tution, for� the surgical and medical dia9rosis, treatment and care of injured
• and sick persons by or under the supervision of a staff of one or more doctors, .
and cootinuous}y provides 24 hour a day service by nurses. Nospital shall •
also include a specialized or� private facility, or portions thereof, specif- �
ically designed to provide modalities of treatment for alcoholism, such as �
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� a•, ���.� • � �EFINITIONS - (Continued) v '' ' .
°Conditioned reflex" therapy for detoxification, which is appropriately •
licensed by the state and accredited under the Hospital Accreditation
Program of the Joint Commission on Accreditation of Ilospitals. Hospital
shall not include an institution, or part thereof which is other than
incidentally, a nursing home, a convalescent hospital , a place for rest, �
the a9ed, drug addicts , or facilities such as alcoholic recovery homes, .
� residential treatment centers or halfway houses. :
"Insured" means an employee or retired employee insured under this Policy.
°Intensive Care Unit" means a room of a hospital primarily designated and •
atcredited as an intensive care unit or cardiac unit wherein the Covered �
Person is continually monitored by. appropriate equipment and such equip-
. ment is continually monitored by appropriate personnel .
°Nurse" means a Registered Nurse or Litensed Vocational Nurse who does not "
- ordinarily reside in the Covered Person's home and who is not related to
the Covered Person by bload or marriage.
°Retired employee" means only an Active Employee� who has retired under the ,
Public Employees' Retirement System.
°Totally disabled" or "total disability" means disability resulting from
accidental bodily injury or sickness which prevents the Covered Person from
engaging, for compensation or profit, in any busine'ss or occupation for which '
he is or becomes qualified by educatio�, training or experience.
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SCHEDULE OF BENEFITS
The following schedule outlines the benefits provided in this Policy. For �
a detailed description see the following pages. �
EIIGIBILITY PERI00 . .�
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The first day of the Policy month coincident with or next following the date
the employee has completed one month of continuous serv.ice for the. City of -
Redding. This is applicable to present and new employees.
- �MEDICAL EXPENSE BENEFITS FOR EACH COVERED PERSON �
Each Covered Person ,
Hospital Benefit: (Maximum may be reinstated)
Ddily Room and Board - �
Limited to the hospital 's 3-Bed Ward Rate. =
� Intensive care unit, to a maximum of 20 days - ,-
Up to a maximum per day of . . . . . . . . . E 100.00
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- MEDICAL EXPENSE BEYf�I7� -•1{Continued) . �
. Each Covered Person �
Hospital Benefit: (Cantinued) �
Total number of days covered . .. . . . 70
Other Hospital Services, limited to the first 70� �
, days of hospital confinement - Up to maximum of. .8 1 .000.00 `
Ambulance Service - Up to a maximum of. . . . . . .8 , 75.00
Continued Coverage While in a Convalescent Hospital :
� The limits on payment shown above will include
confinement in a convalescent hospital except .
that (a) with respect to the number of days
covered, each day of such confinement will count �
" as 1/2 day of hospital confinement and (b) the •'
room and board maximum will be 525.00 per day. .'
Surgical Benefit: (Maximum may be reinstated). '
Factor. . . . . . . . . . . . . . . .E 5.00 ' �
, The maximum amount payable to the Principal Surgeo� � �
for any operation shall equal the Factor times .
. the Unit Yalue set opposite the specific oper-
• ation in the Schedule of Operations. This benefit � �
- also pays charges for Assistant Surgeon and ' � ;
Mesthesiologist as provided in 'the RVS, except -
that payment for administration of anesthetics, �
when billed by a hospital� or nurse anesthetist,
, : � shall not exceed 15% of the amount otherwise •
payable to the Principal Surgeon. : � : i
Amounts payable for a11 operations:
, Principal Surgeon - Up to a maximum of. . . . . .E 1 ,600.00 .
Assistant Surgeon - Up to a maximum of. . . . . .S 320.00 , . ;
, Anesthesiologi.st - Up to a maximum of , . . . . .E . 400.00 '
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Medical Care Benefit: (Active and Retired Employees) ,
Home calls - .Up to a maximum per call of. .. . . :_.$..__ . ' . .. 5.00 •
Office calls - Up to a maximum per call of. . . . .E 3.00
" . ""' � '�Hospital calls - Up to a maximum-per call of, . , ,$ 5.00 !
� Amount payable during each calendar year - ' '
' Up to a maximum of. , , , . . , , , . .a 250.00 �
Initial number of home and office ca11s due to any • �
one 5ickness that are not covered . . . . . . . . 2.
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Medical Care Benefit: (Dependents Only) '�
� . Home calls - Up to a maximum per call of. . . . . .E 0.00
Office calls - Up to a maximum per call of. . . . .$ 0.00
Hospital calls - Up to a maximum per call of. . . .$ 3.00 .i
Amount payable during each calendar year - �
Up to maximum of. . . . . . . . . . . . . . . . .E 210.00
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� � ,. SC}IE`�LE OF BENEFITS - (Continued) � • •
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, MEDICAL EXPENSE BENEFITS - (Continued) � � "
Each Covered Person
Diagnostic l(-Ray and Laboratory Examination Benefit : ,
For each accident - Up to a maximum of. . . . . . .S 150.00
For each sickness - Up to a maxinum of. . . . . . .S 150.00
Accident .Expense Benefit: �
For each accident - Up to a maximum of. . . . . . .$ 300.00
Mafor Expense 8enefit: �
Maximum amount for al.t sickness and injuries. . . .b 1 ,000,000.00* ,
Maximum amount for mental or. psychoneurotic
disorders: �
a. Payment for treatment of such conditions � ' . �
� when confined in a hospital as a registered � •
bed patient is limited to a maximum of �
�10,000 during any 12-month period. ',�
b. Payment for treatment of such conditions . .
when not confined in a hospital as a � • ' .
registered bed patient is limited to (1 ) a
maximum of 51 ,000.00 during any 12-month
� ' period and (2) Covered Charges up to $40.00
' ' per day will be payable at 50%. ' '. � '
' t. No more than $25,000 shall be paid for all •�
such treatment with respect to a Covered '
Person during such Covered Person'.s lifetime. ,
Allowable daily charge for hospital roam and board- �
. Limited to the hospital 's daily charge for a semi- � .'
private room. �
. Allowable daily charge for intensive care unit••2-1/2 '
times the hospital ' s daily charge for a semiprivate .
room. � -
Cash Deductible each calendar year. . . . . . . . .E 100.00 �
Percentage of Covered Charges payable . . . . . ' 80%
Maximum payable for pre-existing condition. . . . .$ 1 ,000.00 �
' '(Up to 81 ,000 automat9cally restored each calendar
year, except with respect to mental or. psychoneurotic
disorders. )
The Cash Deductible is limited to $300.00 per family '�
each calendar year. , " �
After a family has incurred Covered Charges of $15,000.00 in any calendar
year under the Major Expense Benefit in excess of the Cash Deductible and �
any other Medical Expense Denefits provided in this Policy, the percentage .
applied will be 100N of Covered Charges incurred during the balance of the ,
calendar year for all family members; however, this does not waive the
�equirement for a Cash Oeductible for each member of the family. This does
not apply to Covered Charges for trcatment of any mental or nervous condition
when not hospital confined or Dental Charges. .
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DENTAL EXPENSE BENEFIT (Not Applicable to Retired Emptoyees or their Dependc�ts)
Each Covered Person
Preventive-Restorative Procedures � • ,
Percentage.. of Dental Charges payable . . . . . . : . 80% •
Replacement Procedures : `•'
Percentage of Dental Charges payable . . . . . . . 80�
Cash Deductible - per calendar year. . . . . .b 25.00 :
Benefit Waiting Period - Dental Charges for�the ' . ,
Insured are covered after he has been insured ' ,
under this benefit for 6 months. Such Dental •
Charges for a dependent are covered after any
one dependent, has been insured under this �'
benefit for 6 months. ��
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Maximum Amount Payable:
� For Dental Charges during any calendar year. . . . .S 1 ;000.00 '
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� SCHEDULE OF BEIJEFITS - (Continued) '
CLASSIFICATION CHANGE �
For an Insured eligible for increased benefits due to a change in classifi-.
cation, the effective date of such increased benefits shall be the first day
. of the Policy month coincident with or next following the date of such re-
classification. However, if the Insured is not actively at work on the
- effective date, he- shall not be covered for increased benefits until the date
he returns ta active work. . „
If the Insured's benefits are to be reduced due to a change in classification,
he shalt be covered for the reduced benefits� fram the date of such change in
classification.
BASIC SALARY CHAPlGE , � �
Changes in the amount of benefits due to change in salary of the Insured (other
.. than salary change due to a change i� classification) will be made once each
year on July 1 based on the Insured' s salary as of the prior July 1 provided
� that, if benefits are to be increased, ihe Insured is actively at work on such
. date, if not, then on his return to active work.
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. � ELIGIBILITY FOR It�SURANCE . '
. ;!�:�Any person ��ho is an employee on the effective date of this Policy shall be
� eligible for insurance on the effective date. Each nev� employee shall be
eligible for insurance on the date he has completed. the eli9ibility period '
shorm in the Schedule of Benefits. The eligibility period shall also apply •
to Qresent employees if so indicated in the Schedule of Benefits.
EFFECTIVE DATE OF THE INSURED'S IMSURANCE
. Each emplo.yee who is eliaible for insurance shall be insured if he submits
aaplication to the City of Redding on the aFplication forr.i provided,
pirovided that: ' .
1. Any employee who submits such aoolication before the date of be- •
comin� eli9ible cr within 31 days after such date shall be in- -
sured from the first day of the Policy month coincident viith or �
next following his date of eligibility, if he is actively at work
• on� such date, othennise fror� the date he returns to active work.
TERMINATION OF THE INSURED'S INSURANCE • � -
The Insured's insurance viill .terminate, without notice, on the earliest of ' . .,.
the following dates: -
1. The last day of the Polic.y month durina which he is retired, pen- •
sioned, leaves voluntarily, or is dismissed from the employment -
of the City of Redding, or otherwise ceases active arork for the
City. However, ir. the event of disability, temoorary layoff, or
approved leave of absence, payment of the required premium will
continue the insurance in force for a period automatically termi-
, nating on the earliest of the followinq dates: (a) in the event
. of disability, the end of the period of disabilit,y; (b) in. the �
event of tem�orary layoff or aparoved leave of absence, the end of •
3 months; or (c) the date the insurance terminates in accordance
, with 2, 3, 4, or 5 below, provic�ed that in no event shall the
� insurance be continued in force beyond the date the Insured is
. retired or pensioned by the City of Redding or enters the regular . .
�nploy of another emoloyer. •
2. The last da,y of the PolicY month during which his membership in
an eligible class terminates. .
3. The last day of the Poticy month durinq which he enters full-time
• military, naval , or air service. ' •
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� 4. The end �of the period for which the pr�nium for his insurance is
last paid.
5. The date this Policy terminates. � � � ' •
• REINSTATEMEyT . �
If the Insured's insurance terminates because oremium na.yments for him are
discontinued while he is disabled and such insurance would have remained �
in force if such premium payments had been made, his insurance will be re-
. instated without evidence of insurability after he returns to active work
for the City of Redding for at least two weeks. Such reinstated insurance �
shall commence from the first day of the Policy. month next following the
date of return:
Any other employee reinstating his insurance must meet the requirements
applicable to a new employee. . �
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CONTINUANCE OF iNSURANCE DURING LAQOR DISPUTE ' '
Notwithstanding anythin� to the contrary elsewhere in this Policy, if an
lnsured, because of a lahor dispute, ceases to ��ork for the City of' Reddi�g
� and the City of ReAding is contributing all or a portion of the n►'emium for
such Insured's insurance oursuant to the terms of a collective bargaining -
. agreement, the Insured may continue his insurance and that of his dependents , �
subject to the following terms and conditions: ;
l. The continuation of insurance for an Insured and his dependents
is contingent u�on (a) pa.yment by the Insured of a premium con- �
tribution monthly, to the union which represents the Insured, in
the amount and in the manner hereinafter orovided; .(b) the collection �
of such contributions by the union or unions from at least 75% of
the Insureds covered under this Policy !vho cease wor!c because of �
• the labor dispute; and (c) the payment of the premiums by the union i
or unions to the City of Redding. . �
2. If any premium due under this Policy is unnaid at the date of �
, cessation of work, no continuation of insurance shall be made here- � {
under unless such prenium is paid by the union or unions prior to
. the. date the next premium becomes due under this Policy. �
3. 7he amount of each Insured's monthly premium contribution on each
premium date while his insurance is being continued hereunder shall j
be the rate applicable to him in effect under this Policy. on the k�
date of cessation of r�ork. This rate may be increased by an amount
not exceeding 20% on the premium due date coinciding with or next • �
�, following the date of cessation of work. Such increase shall apply ,
during the time insurance is continued hereunder. Any other rights '
which the City of Redding has to adjust premiums in accordance with �
the other orovisions of this Policy shall not be limited or super- ;
seded by this provision. •
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4. The insurance continued in accordance with this special provision
shall terminate on the earliest of the following dates:
. a. The date of expiration of the period for which the last premium
' payment is made by the union or unions on account of. the Insured's
insurance.
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• b.. The nremium due date for wh"ich premium contributions are received
. fran less than 15N of the Insureds not working because of the ;
. labor dispute.
c. The premium due date coinciding with or next following the date
the individual be9ins full-time employment with another employer.
d. The prer�ium due date coinciding with or next following the ex- •
piration of a period of six months frrni the date the lnsured
' � � teased to work because of the labor dispute. •
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. +� CONTINUAP7CE OF:.It�1�URANCE DURING LADOR DISPUTE - �ontinued) , .
5. The continuation of insurance in accordance with this� special
� provisian shall not apply to any .benefits� `or loss of time which
may be provided by Lhis Policy. .
6. The City of Redding may require that the entity responsible for �
tollection of the premium contributions furnish adequate Dooks and •
records to enable it to properly pay claims. Any premiums
received by the City of Redding under these provisions for any
• period for which the City of Reddi,ng is not obligated to continue
insurance hereunder shall be returned to the entity responsible -
• for collection of.premium contributions. The City of Redding •
shall nave no responsibility to see that the money is .properly • ,
refunded to the individuals. �
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CONTINUANCE OF INSURANCE FOR RETIRED E�fPLOYEES
The following provisions shall supersede the. provision terminating an � . �
. Insured's insurance. upon his being retired or pensio�ed by the City of
Redding. �
' Eligibility �
My Insured who is retired under the Public Employees' Retirement program
shall be eligible for continuance of his insurance under this Policy.
Effective Date
� Each retired employee who is eligible for continuance of his insurance •
and for v+hom the required premium is paid sha11 be insured from the first �
day of the Policy month coincident with or next following the date of his
retirement..
Termination .
A retired employee's insurance will terminate without notice from the
City of Redding on the earliest of the following dates: �
� 1 . The end of the period for which the premium for his insurance �
is last paid, or � �
' 2. The date this , Policy terminates, . � . � `°
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, ..:.,�LERIC4L ERR�P,.. . '
The insurance of any individual shall not fail to become effective by �
failure, due to clerical error, to give proper_ notice of such individual 's
application for insurance, provided insurance would have become effective � °
, had proper notice and premium payments been made from the date such insurance .
would have become effective. A change in amount of insura�ce of any Insured
shall not fail to become effective as provided herein due to clerical error
in reporting the proper classification, provided the correct preinium is paid
for the time the insurance was in force.
INDIYIDUAC CERTIFICATES �
City of Redding will issue to the Insured an indiyidual certificate describing
' the Insured's coverage and to whom payable.
ELI6IBILITY OF THE INSURED WITH RESPECT TO HIS DEPENDENTS
M Insured shall be eligible for insurance with respect to each person who is �
• a dependent on the latest of: (1j the�Insured' s date of eligibility, (2) the
date of birth with respect to a newborn child, or (3} the first day of the
• . Policy month coincident with or next following the date any person other than
. , a newborn child becomes a dependent of the Insured. When husband and wife are
both included in any of the classes of persons eligible for insurance under
this Policy, their children shall be eligible as dependents of only one of them.
. ' EFFECTIVE DATE OF INSURANCE WITH RESPECT TO A DEPEt�DENT �.
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' M Insured shall be insured with respect to a,dependent on the applicable date
set forth below, provided the Insured is covered under this Policy o� such
date, the Insured applies for all eligibte dependents and the required premium
� is paid. .
, 1 . If contributions from the Insured are required to provide insurance
orr his dependents, the insurance for each dependent sha11 become
effective in accordance with the following provisions:
a. If the Insured submits written applicatian for a dependent not
later than 31 days after the eligibility date of the dependent,
• to the City of Redding on the application fo►m provided .by it,
� the insurance for such dependent shall become effective on the
• , date the dependent becomes eligible. However, if the application
is received more than 3 months after the �end of the 31 days,
evidence of insurability may be required.
b. If the Insured submits written application for a dependent later
than 31 days after the eligibility date of the dependent. the
insurance for such dependent shall become effective on the first
day of the Policy month coincident with or next following the date
of approval by the City of Redding of such application and evidence
of insurability as may De required by the City of Redding with
• respect to such eligible dependent.
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. ��EFFECTIYE DATE OF 'INSURANCE WITH RESPECT TO A DEPENDENT - (Continued) . ,
2. If contributions from the Insured are not required to provide �
insurance on his dependents , the insurance with respect to each '
dependent shall become effective on the date such dependent becomes
eligible.
3. If the premium for the Insured's coverage would not be increased
by the addition of a dependent, the insurance for such dependent
shall become effective on the date the dependent becomes eligible.
If a dependent, other than a newborn child, is confined in a hospital or
an institution that is a place for rest, a place for the aged, a place for . •
• drug addicts, a place for alcoholics, a convalescent .hospital , a nursirig �
home, or a similar institution on the date such dependent's insurance would
otherwise become effective, such dependent's insurance shall not become
effective until the day following the date such confinement ends. �•
TERMINATION OF IP�SURANCE WITH RESPECT TO A DEPENDENT �
The insurance of an Insured with respect to a dependent will terminate.
without notice from the City of Redding on the earliest of the following
dates:
1 . the date the Insured's insurance terminates; �-
2. the end of the period for which the premium is last paid on account
. of the Insured's dependent insurance; or
� 3, the last day of the Policy month during which the dependent ceases
. to be a dependent as defined herein.
INCONTESTABILITY
• This Policy shall be incontestable, except for nonpayment of premiums, after
' . it has been in force for 2 years from its date of issue. No statement made
� by any individual relating to the insurability of any Covered Person shall
' be used to deny a claim or in contesting the validity of the insurance with
. respect to which such statement was made after such insurance has been in
force prior to the contest for a period of 2 years during such Covered Person's
lifetime nor unless it is contained in a written application signed by him.
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UNIFORM PROVISIONS ' ' �
(Not applicable to any Life Insurance Benefits) , � •,
Notice of Claim. Written notice of claim must be given to fhe �ity of Red-
ding within 20 days after the accurrence or commencement of any loss covered
bythis Policy, or as saon thereafter as is reasonably possible.
Claim Forms. City of Redding, upon receipt of a written notice of claim, will
furnish to the claimant s�ch forms as are usually furnished by it for filing
proofs of loss. If such forms are not furnished within 15 days after the
giving of such notice, the claimant shall be deemed to have complied �rith
the requirements of this Policy as to proof of loss upon submitting, within
the time fixed in this Policy for filing proofs of loss, written proof
covering the occurrence, the character and the extent of the loss for which � �
claim is made.
Proofs of Loss. Written proof of loss must be furnished to the City of Redding,
in case of claim for loss for which this Policy provides any periodic payment
contingent upon continuing loss, v�ithin 90 days after the termination of the �
period for tahich City of Redding is 'tiable, and in case of claim for any other �
• loss, within 90 days after the date of such loss. Failure to furnish such
proof within the time required shall not invalidate nor reduce any claim if
it was not reasonably possible to give proof within such time, provided such
proof is furnished as soon as reasonably possible and in no event, except in
the absence of legal capacity of the Covered Person, later than 1 year from
the time proof is otherwise required. � .
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Time of Rayment of Claim. Indemnities payable under this Policy .for any
loss other than loss for which this Policy provides periodic payments will .
� be paid as they accrue immediately upon receipt of due written proof of such �
� . . loss. Subject to due written proof of'loss , all accrued indemnity for loss
for which this Policy provides periodic payment will be paid weekly and a�y
balance remaining unpaid upon the termination of the period or liability
Nill be paid imnediately upon .receipt of due written proof.
Payment of Claims. If any indemnity of this Policy for other than loss of
life shall be payable to the estate of the Insured, or to an Insured or �
beneficiary who is a minor or otherwise not competent to give a valid
release, City of Redding may pay such indemnity up to an amount not exceeding
E1 ,000.00 to any relative by blood or connection by marriage of the Insured
. or beneficiary who is deemed by the City of Redding to be equitably entitled
thereto. Any payment made by the City of Redding in good faith pursuant to
this provision shall fully discharge the City .of Redding to the extent of
Such payment. . .�
Subject to any written direction of the Insured in an applicatian or otherwise �
. all or a portion of any indemnities provided by this Policy on account of hos- .�
pital , nursing, medical or surgical service may, at City of Redding' s option,
and unless the Insured requcsts otlierwise in writin9 not later than the time
for filing proof of such loss, be paid directly to the hospital or individual
�endering such services, but it is not required that the service be rendered
by a particular hospital or individual . .
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. - , UNI 0 M PROVISIONS - (Continued) v . ,
Physical Examinatior :,:�:t�Autopsy. City of Redding at its own' expense shall
have thc right and opportunity to examine the person of any individual whose
in�ury or sickness is the basis of claim wlien and as often as it may reason-
ably require during the pendency of a claim hereunder and to �make an autopsy
in case of death, where it is not forbidden by law. . _.
Legal Action. No action at law or in equity shall be brought to recover on .
this Policy prior to the expiration of 60 days after written proof of loss
has been furnished in accordance with the requirements of this Policy. No
such action shall be brought after the expiration of 3 years after the time
written proof of loss is required to be furnished. ,
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MEDICAL EXPENSE QENEFITS - -
Hospital Benefit . _ '
If a Covered Person, while insured under this benefit and as a result of •
sickness or accidental bodily injury, (1 ) under9oes medically necessary ' :
surgery or emergency treatment in a hospital while not confined as a reg-
is'tered bed patient, or (2) is medically necessarily confined as a registered
bed patient in a hospital , the City of Redding will pay the charges incurred
' by the Insured, up to the maximums shown in the Schedule of Benefits, for:
a. Room and board, including intensive care unit confinement; •
b: Services of an anesthetist received in a hospital and other services
and supplies provided by the hospital •and administered while so �
� confined or treated (other than expenses for wom and board, nurses'
. fees, doctors' fees, personal items and items that do not have any
therapeutic value for the treatment of the sickness or injury being •
treated) ; and
c. Medically necessary professional ambulance service for the initial
transportation or subsequent transfer of the injured or sick CovPred �
Person to the nearest hospital providing services for the treatment
of the injury or sickness; such subsequent transfers are covered only .
. if inedically necessary services were not -available at the hospital
� from which the Covered Person was transferred: .
The maximums shown in the Schedule of Benefits will be automatically reinstated
(1 ) with respect to an employed Insured,. upon return to his regular and customary
empioyment on a full-time basis for a continuous period of 2 weeks, and (2) •
with respect to any other Covered Person, when periods of hospital. confinement
are separated by a period of 30 days or ri�ore.
. Continued Coverage While in a Convalescent Hospital . If a Covered Person, .
while insured u�der this benefit and as a result of sickness or accidental �
bodily injury, is confined in a convalescent hospital , the City of Redding
will pay the charges incurred by the Insured for services and supplies (other
. than doctor's fees, personal items and items that do not have any therapeutic �
� value for the treatment of the sickness or injury being treated) furnished the
Covered Person during such confinement up to the maximums shown in the Schedule
of Benefits, provided; .
a. Such confinement follows at least 5 consecutive days of hospital con- �
finement which was covered under the Hospital Benefit;
y
b. Such confinement be9ins within 7 days following termination of such
. hospital confinement; and
t. Such confinement is certified to be medically necessary for the con-
tinued treatment of the injury or� sickness by the doctor who certified
the hospital confinement.. , •�;
This covera9e is payable as part of the Hospital Denefit and the provisions of �
the Hospital Denefit relating to maximwns and reinstatement of benefits shall
also apply to this coveragc.
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� � ''�� • •, ' M DICAL EXPENSE BENEFITS � � �
� Surgical denefit � � _ �
If a Covered Person; while insured under this benefit and as a result of
sickness or accidental bodily injury, undergoes a medically necessary surgical
operation, the City of Redding will pay the charges incurred by the Insured
for such operation up to the maximums shown in the Schedule of Benefits.
If multiple procedures are performed through a single incision, payment ,
will be made for the procedure for which the larger benefit is payable.
If multiple procedures are performed in separate operative fields through
separate incisions during the same surgical occasion, 50% of the values of
the lesser procedures will be allowed in addition to the value of the mejor
• procedure, up to the maximum amount shown in the Schedule of Benefits.
When the services of 2 or more Principal Surgeons and/or 2 or more Assistant .
Surgeons are required in the management of a surgical procedure, the compensation
provision in the-Schedule of Operations will be applicable, but in no event
shall the aggregate payment exceed the amount shown in the Schedule of :
Benefits.
The maximum amount payable for all operations will be automatically reinstated,
. . (1 ) with respect to an employed Insured, upon return to his regular and
eustomary empioyment on a full-time basis for a continuous period of 2 weeks ;
and (2) with respect to any other Covered Person, when surgical operations
requiring hospital canfinement are separated by a period of 30 days or more.
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{
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� " � A1�DICAi.1•:�P1:NSC It1sNl:1'ITS • '
''' Schcdulc o[ Operations . •
To lind Ihe maxinnnn �mnunt p:iy:ible for thc c�pens�s o[ any operation sho�vn brlow, multiply ihe unit .
Value scl opposilc tlic speci[ic operatiott by lhc Joll:�r L•ictor shu�vn under llie Sur6ic;d 13ciie[i� in the Schedule
of Bene[its.
� ' . ' Unit Value '
��e rollow•
Number D�cription Sur eon u .Days Anestlutist"
S1C[N . • .
0238 Gxcision ot pilonidal cyst or sinus . . . . . . . . . . . . . . . . . 30.0 60 3.O+T •
0101 Incision and drainage ot�I:in cyst . : :'. . . . . . . .'. . : . . . 2A 0 3.O+T .
0171 Biopsy or sl;in . . . .� . . . . . . : . . . . 3:0 15 3.O+T :
BRCAST •. • -.• • .• ' . , . .
, ,,;..: ....
0444 Gscision ot breast tumor, unilateral : . . . . . . . ... . . . . 15.0 30 3.O+T
0457 . Completc (simple) I�lastectomy ' � � . . . . . . . ;
. .. , , , , , , , . . 30.0 45 3.O+T
0470 Radical I1lasteclomy . . . . . . . . . . . . . . . . . . . . . . . . . 70.0 60 3.O+T �
"FRACTU1tGS � � '
0656 T'asal,uncomplicated,closed reduction . . . . . . . . . . . .. . . b.0 0 :
,._
0771 Pelvis, compound, open reduc6ion . . .. ... . . . . . . . . . . . . 75.0 120 3.O+T �.
0321 Radius and iJna simple, closed reduction . . . . . . . . . . . . . 25.0 120 3.O+T
0364 Femur,simple or compound,open reduction . . . . . . . : . . 80.0 180 S.O+T `
NOSE ' '
1928 Submucous resection . . . . . . . . . . . . . . . . . . . . . . . $0.0 90 3.O+T . �
HEART •
$340 Repair aortic �a,�•e,valr•otomy . . . �. . . . .. . . . . . . . . . . . 150.0 90 15.O+T .
2350 Repair myocardial aneurysm . . . . . . . . . . . . . . . . . . . . 200.0 90 15.O+T ,•.
2317 Ezcision intracardiac tumor : . . . . . . . . . . . . . . . . . . 200.0 90 15.O+T � �
TIIROAT • � • ' -
2992 Tonsillectomy with or tivithotd • ' '�
adenoidectomy -undcr age 18. . . . . . . . . . . . . . . . 15.0 . 30 3.O+T
?�i93 -age 1S and over . . � . . . . . . . . . . . 20.0 30 3.O+T
DIGGSTIV� -
8114 Total gastrectomy . . . . . '. . . . . . . . . . . . . . . . . . 100.0 90 6.O+T
. . . � ;.
811G Siibtolal or liemi-oastrnctomy, �rith vagotomy . . . . . . . .. . . 9D.0 60 G.O+T :
3261 Appenclectomy . . . . . . . . . . . . . . . .. . . . . . . . 40.0 45 4.O�T.
8504 Cholecystotomy . . . . . . . . . . . . . ;;50.0 95 5.O+T
3515 Cholecpstectomy . . . . . . . ,. : . . . �: ' �G0.0 45 5.0+1' _
3571 Exploralory laparotomy . . ,,90.0 45 4.O+T ..
I:BCfUA7 � - ,
33?'/ Ilemorrlioi�lectomy, c�icrnal, complete . . . . . . . . . . . . . 20.0 90 3.0+'1` �
5380 llentorrl;oideclomy, inlrrn:il and exterrr.d . . . . . . . . . . . . . 30.0 90 3.0+'1' :
8356 Fissurectumy aud hemorrl�oidectomy . . . . . . . . . . . . . . 30.0 . 90 3.O+T ":
�iritn�n � . , .
Sf31 Ilcrni:� =inrui�f:il, unilatcr:�l . . . . . . . . . . . . . . .'. . . . . . 35.0 95 3.0+'f �
3G4G I��::nc�r.J, unil:u.•r:�l . . . .. . . .. . . . . . . . . . . . . . . . . . . 35.0 45 3.OF'T
U1t1I�Alt1' Sl'S'Cli\1 '
3SOS Ncphmlumy �vilh dnina;;c;nephroclotny . . . . . .. . . : . . . 80.0 90 5.OF'I'
3911 Cystectnut�•, p:irti:�l . . . . . . . . . '. ... . . . . . . . . . . . . . 70.0 90 G.O�'1' .
I�tAi.ls Gli\I'I':11. 51'S1'1•:\t' � . .
Al2'l (:i�c�nncision, ucwb��rn . . . . . . . . . . . . . . . . 3.0 15 '
4111 �Prostatcrlum�•, p•.riu�:J,.u6lolal� . . . . .�. .. . . . . . . . . . . 84.0 �)O G.O�T .
431J 1'ru�l:drelumy, perine:J, raJir.�l� . . . . . . . . . . . . . . . . . . ]OO.0 f!0 G.O�'1' ,
. .
� . , Sr.l��t(le o[ Operations• (Conlinucd) ,. `J. . . ^ . ' . '
. Unit Valui�
Code [�allow:-. . .
!�innhr.r _ IJrscripliun Sur�;con �ip Uays AncsUiclist'G
I�I:MAf.I•: GLf�'l'1'AL SYS'Cl�.p•1 . ,
4G14 '1'ot;il hystcrcctotny (corpus and cervix) �vill� ur �vilhout tubes,
and/ur o�:�rics, o:u or bulh . . . . . . . . . . . . . . . G0.0 45 4.O kT .
RGiS SII�)i:iCC[VIC:II �suLtntal I��•stc«•ctomy) . . . . . . . . . . . . . . 55A � .45 4.0f4' �.
4G12 llil.dion and eurcllape o[ ulerus . . . . . . . . . . . . . 15.0 15 3.0+'f �•
4G83 Utcrine suspcnsion . . . . . . . . . . . . . . . . . . . . . . . 90.0 45 . 4.O+T .
'i'f•1YR01D
4911 , Local excisiou of small c��st ot lliyroid . . . . . . . . . . . . . . 40.0 45 5.0+1'
4914 Thyroideclorny, total or complete . . . . . . . . . . . . . . . . 70.0 45. 5.O+T
I3YC . � • ., '•
5501 Sclerectomy for glaucoma,ivitli sc'�ssors, puncli or trephination 60.0 45 6.O+T
EAR �
6961 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . 8.0 0 3.O+�T _
G971 . h4astoideclomy,simple . . . . . . . . . . . . . . . . . . . . . . . 50.0 180 4.O+T
'�'I'otal anesLhesia value equcds tlie calue lisled for the �rocedure (the ��alue of all
anesthetic serdces except �dministering time, or wiusuai detention with ':.�
patient), pliis 1'ime Units (1 unit each 15 minutes startinp �vith.lhe br�innin� �
, of administration of ane;thetic agents and ending �vh�n•no longer in personal ; .
atlendamce). \o fee �vill be allo�sed local intiltration or digit..l b!ocl: anesthesia �
administered by the operatin;;suraeon. IC lhe anesthetic is administcred by the .
' . attending surgeon, tlie value sl�atl be fifty per cent (50'b) of the calculated �
• value. . _
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SURGICAC ASSISTANTS
6993 Assist at surgery, 20% of Unit Value(s) of surgical
procedure(s) ..
6994 . Minimum alloi•rance . . . . . . . . . . . . . . . . 7.0 •
If the operation performed .is not listed in this schedule and is not excluded from �'
toverage under tfiis Policy, tfie City of Redding will determine the unit value for such
operation based on a listed operation of relative severity using the Surgery section �
of the Relative Value Studies adopted by the California Nedical Association on
August 8, 1964.
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MEDICAL EXPENSE BEP�EFITS ' '
' Medical Care Benefit '
If a Lovered Person, o+hile insured under this benefit and as a result of
sickness or accidental bodily injury, is medically necessarily treated by
a doctor, the City of Redding will pay the charges incurred by the Insured
for each call for such treatment up to the maximums shown in the Schedule of
Benefits. •
No more than one call on any one calendar day will be covered under this �
benefit with respect to any one Covered Person. Payment will. not be made under
this benefit for a call made by. or to a doctor at the time of a surgical
�•operation, or for postoperative calls, if payment is made for the operation
under .the Surgical Benefit, nor will payment be made for medical services
which are covered under the Hospital Benefit. ,
A call at a hospital will be considered a hospital call - only if the Covered
Person receiving treatment is necessarily confined as registered bed patient .
in the hospital at the time of the call ; otherwise, such call will be con-
sidered an office call .
. Matecnity Benefit . �
� . • If a Covered Person, while insured under this benefit; incurs charges in
tonnection with pregnancy, whether for childbirth, miscarriage or medically -
necessary abortion, and complTcations thereof, the City of Redding will pay
Such charges on the same basis as charges incurred for any illness. Hoo�ever;.
pregnancy a�hich commenced before the effective. date of the Covered Person's .
. insurance under. this benefit shall be subject to the "Pre-existing Conditions"
� provisions of this Group Policy, if any. No charges incurred after the date
the Covered Person' s insurance terminates shall be covered under this benefit,
even though the pregnancy existed on the date of such termination, unless
� the "Extended Insurance" provisions of this Policy apply.
Diagnostic X-ray and Laboratory Examination Benefits ' ,
. If a Covered Person, sahile insured under this benefit and as a result of
sickness or accidental bodily injury, requires medically necessary X-ray
or laboratory examinations for diagnostic purposes, the City of Redding
erill pay the charges incurred by the Insured for such examinations up to the
maximum shown in the Schedule of Qenefits; provided such examination was
authorized by the attending doctor.
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��� �V 1 • ,- '
MEDICAL [XPENSE BENEFITS ' � �
� Accident Expense Benefit .
If a Covered Person, vihile insured under this benefit, suffers accidental
bodily injury which requires any of the services and supplies listed
below, the City of Redding will pay the charges incurred by the Insured �
for such services if such services are medically necessary and are received
by the Covered Person within 90 days after the date of such injury, whether .
or not the Covered Person is still insured under this benefit.
1 . Services of a doctor. � �
2. Hospital confinement.
3. Services of a nurse.
4. X-ray and laboratory examinations made for diagnostic purposes.
5. Drugs and medicines. •
. . 6. Any of the following items which are necessary for the repair or
alleviation of bodily damage; crutches, eye examinations, glasses,
, hearing aids, artificial limbs, artificial eyes, and fitting there-
of. and cosmetic surgery.
7.. Dental treatment such •as replacement of natural teeth, construction
of bridges, treatment of dama9ed roots, or other detailed dental
' procedures which may be necessary.
Payment made under this benefit with respect to a Covered Person for any one
• accident shall not exceed the maximum shown in the Schedule of Benefits. • �
. Payment shall apply only to the extent of expenses incurred in excess of
, the amounts payable under all other Medical Expense Benefits (other than any
Ma�or Expense Benefit) after taking into account any amounts excluded there-
under.
� � Mafor Expense Benefit :
If a Covered Person, while insured under this •benefit and as a result of
. sickness or accidental bodily injury, incurs expenses for any items shown
under Covered Charges in excess of any other Medical Expense Benefits
provided in this Policy and the Cash Deductible, the� City of Redding will
pay the percentage shown in the Schedule of Benefits of such excess Covered
Charges incurred in any calendar. year.
Cash Deductible. The Cash Deductible is the amount of Covered Charges which
a Covered Person must pay himself before benefits are payable under this
benefit. The Cash Deductible applies with respect to each calendar year,
and separately with respect to each Covered Person regardless of the number
of disabilities. �
• '`> ' ' M DICAL EXPENSE BENEFITS � � .
Major Expense Benefit - (Continued)
. The Cash Deductible is shown in the Schedule of Benefits. If all or any �
part of a Covered Person's Cash Deductible for a calendar year is applied
against Covered Charges incurred with respect to the Covered Person during
the last 3 months of that calendar year, the Covered Person's Cash Deductible
for the next calendar year witl be reduced by tfie amount so applied.
Common Accident Provision. .Only one Cash Deductible will be applicable
each calendar year with respect to all Covered Charges incurred during .
such calendar year for all injuries sustained by 2 or more Covered Persons .
. in the same family in a common accident. •
� If all or any part of the Cash Deductible with respect to a common acciAent
� is incurred during the last 3 months of a calendar year, the Cash .Deductible
with respect to the common accident for the next calendar year will be reduced
by the amount so applied. .
�The annual Cash Deductible for the common accident will be divided among the �
Covered Persons involved in the accident to the extent necessary to satisfy
the Cash Deductible for. each person in the following order: the Insured,
the Insured' s spouse, and the Insured' s children in the order of their ages,
commencing with the o1dest. � .
� Maximum Amount. The maximum amount payable by the City of Redding under this -_
benefit with respect to a Covered Person during such Covered Person's life-
ttme, whether or not there has been any interruption in the continuity of -.
his insurance, shall not exceed. the maximum amount shown in the Schedule
of Benefits. � � .
. Extended Insurance. If a Covered Person is totally disabled on the date his �
� insurance terminates , this benefit shall continue to be payable with respect � .
. to Covered Charges incurred solely as a result of the injury or sickness '
causing such disability, subject to the following conditions: �
a. Benefits with respect to such Covered Charges must have been payable
� had such insurance remained in force.
b. Such benefits sha11 not be payahle for Covered Charges incurred more �
than 12 months after the date insurance terminates. �
c. The Covered Person' s total disability due to the cause of the disability
• which existed on the date insurance terminated has not ended before
Lhe date the Covered Charges are incurred. '
Covered Charges. Tiie term "Covered Charges" �vherever used in this Major
Expense Eienefit applies only to charges incurred as a result of the following
when medically necessary for the treatment of sickness or accidental bodily
injury, subject to the "Exclusions and Limitations" section. .
l . Medical or surgical services of a doctor; '
2. Services of a nurse, if ordered by a doctor;
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'• ��- �ti1 �� ' I'IEDICAL EXPENSE DENEFITS u .� ' .
Major Expense Benefit - (Continued) � '
The Cash Deductible is shown in the Schedule of Benefits. If all or any
part of a Covered Person's Cash Deductible for a calendar year is applied
against Covered Charges incurred with respect to the Covered Person during
the last 3 months of that calendar year, the Covered Person's Cash Deductible
for the next catendar year will be reduced by the amount so applied.
Common Accident Provision. Only one Cash Deductible will be applicable
each calendar year with respect to all Covered Charges incurred during _
such calendar year for all injuries sustained .by 2 or more CovAred Persons .
' 1n the same family in a common accident. �
� If all or any part of the Cash Deductible with respect to a common accident
is incurred during the last 3 months of a calendar year, the Cash Deductible
with respect to the common accident for the next calendar year will be reduced
by the amount so applied. �
The annual Cash Deductible for the common accident will be divided among the
� Covered Persons involved in the accident to the extent necessary to satisfy
the Cash Deductible for each person in the following order: the Insured,
. . Lhe Insured' s spouse, and the Insured's children in the order of their ages,
commencing with the oldest.
Maximum Amount, The maximum amount payable by the City of Redding under this �
benefit with� respect to a Covered Person during such Covered Person's life-
time, whether.or not there has been any interruption in the continuity of
his insurance, shall not exceed the maximum amount shown in the Schedule
of Benefits. � � �
Extended Insurance. If a Covered Person is totally disabled on the date his
insurance terminates, this benefit shall continue to be payable with respect
to Covered Charges incurred solely as a result of the injury or sickness
eausing such disability, subject to the foltowing conditions : •
a. Benefits with respect to such Covered Charges must have been payable �
� had such insurance remained in force. ` ;
• � b. Such benefits shall not be payable for Covered Charges incurred more
than 12 months after the date insurance terminates. •
� t. The Covered Person's total disability c+ue to the cause of the disability
• which existed on the date insurance terminated has not ended before .
the date the Covered Charges are incurred. •
• . Covered Charges. The term "Covered Charges" wherever used in this Major '
Expense Benefit applies only to charges incurred as a result of the following
when medically necessary for the treatment of sickness or accidental bodily
in3ury, subject to the "Exclusions and Limitations" section. �
� 1 . Medical or surgical services. of, a doctor; ' ��
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• 2. Services of a nurse, if ordered by a doctor; ��
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` ;, ,� , ' • . `7'iEDICAL EXPENSE I3ENEFITS � ' •
Ma,jc^.,Exper..se>9a�Pfit - (Continued) �
3. Physical therapy services rendered pursuant to a method of
treatment .prescribed by a doctor of inedicine; .
4. Services and supplies (other than personal items and items that do .
' � not have any therapeutic value for the treatment of the sickness
or injury being treated) furnished to a, Covered Person by a hos- ,
pital -
a. rnom and board, up to the maximum shown in the Schedule of
Benefits;
' b. � intensive care unit, up to the maximum shown 1n the Schedule
� of Benefits; • .
c. other hospital charges for services such as fees for operating
room, X-rays and laboratory examinations; .
d. other hospital charges for supplies such as drugs and medicines,
, anesthetics, whole blood and blood plasma (unless the Covered
. Person is entitled, from any source, to its replacement) , bui
. � excluding supplies that do not have any therapeutic value for
. the treatment of the sickness or accidental bodily .injury being
• treated. •
5. The following services and supplies when not included in items 1 •
through 4 above: . '
� a. drugs and medicines;
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b. diagnostic X-ray and laboratory examinations; f
c. anesthetics and oxygen and their administration;
d. X-ray, radium and radioactive isotope therapy;
� e. whole blood and blood plasma (unless the Covered Person is
� entitled, from any source, to its replacement) and services
necessary for the administration thereof;
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f. rental or initial purchase (but not repair, replacement or
restoration) , whichever is more appropriate, of wheel chair.
' hospital bed, iron lung, and other •durable medical or surgical
equipment which has a solely therapeutic value for the treat-
ment of the sickness or accidental bodily injury being treated
and no other use whatsoever, if prescribed by a doctor, and, if
required as a result of and immediately following surgery,
. purchase of artificial limbs and eyes , contact lenses or glasses,
and brea>t prothesis; � .
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�•' . '`` - •' ' MEDICAL EJ(PENSE 6ENEFITS v �
Ma,�or Expertse Denefit - (Continued}
g. any of the following items which are medically necessary for
- the repair or alleviatioh of bodily damage caused solely by
� . accidental bodily injury sustained while the Covered Person
is covered under this benefit: vaccinations, inoculations and
p�eventive shots, dental wnrk or treatment, eye examinations,
glasses, hearing aids, artificial limbs, artificial eyes, and
� fitting thereof, and cosmetic surgery; . •
h. medically necessary professional ambulance service for the '
. initial transportation or subsequent transfer of the injured
or sick Covered Person to the nearest hospital providing .
services for the treatment of the injury or sickness; such .
subsequent transfers are covered only if inedically necessary •
services were not available at the hospital from which the
` Covered Person was transferred; and.
i. dental services required for the excision of impacted unerupted
teeth.
• 6. Home Health Care Services furnished by a Home Health Care Agency � .
• to a Covered Person following at least 3 days of confinement in a •
hospital or convalescent hospital shall• be covered up to a maximum
of 100 visits (one visit per day) during any calendar year, prov�ded
(1 ) home health care commences within 14 days after release from
, a covered confinement, and (2) .the Covered Person' s doctor certifies
such services are medically necessary for the continued treatment
of the injury or sickness a.nd not for custodial care. • '
;
• Mental or Nervous Conditions Covered Charges. Covered Charges incurred for
the treatment of a�y mental or psychoneurotic disorder (but not for character,
Dehavior or intelligence disorders) are covered as follows : •
a. When confined in a hospital as a registered bed patient -
• payable on the same basss as any other disability but subject
to the maximum as shown under a. in the Schedule of Benefits.
. b. When not cbnfined in a hospital as a registered bed patient -.
• � covered only if indicated under b, in the Schedule of Benefits
and then to the extent shown under b. in the Schedule of
' Benefits. � .
C. Payment is limited to the amount shown under c. in the Schedule
of Benefits for all such treatment with respect to a CovPre�l.
- Person during such Covered Person's lifetime.
;• ,4 , • = l�iE.DICAL EXPENSE BENEFITS v� ' •
Major Expense Benefit - (Continued) �
Automatic Restoration of Maximum Amount. If, at the begi'nning of any calendar
year, the amount payable with respect to any Covered •Person is less than. the
a�ximum amount shown in the Schedule of Benefits, the City o,f Redding will
automatically restore the anount shown in the Schedule of Benefits or the
differenre between the amount payable and the maximum amount, whichever is
less. This provision shall not apply while the Covered Person is covered
under "Extended Insurance" noc shall it apply to any amount paid for the
treatment of any mental or psychoneurotic disorders. ' , .
Pre-existing Conditions. Charges incurred due to any disease which became
manifest or injury which was sustained before the effective date of the Covered
Person' s insurance under this benefit shall be covered only up to the maximum
shown in the "Schedule of Benefits." However, this limitation shall not apply
to any charges incurred after the earlier of: .
1 , any 90-day period that ends on or after the effective date of the � .
Covered Person' s insurance under this benefit if such Covered
Person during such period does not receive in connection with
' such disease or injury (a) any medical , surgical , hospital , or
nursing treatment or services of any kind, or (b) any drugs or
medicines lawfully obtainable only upon the prescription of a -
doctor; or •
2. the date the Covered Person has been insured under this Policy for ".
6 consecutive rtronths. ' •
. Extended Insurance , . .
If e Covered Person is totally disabled on the date his insurance terminates,
the Medical Expense Benefits , other than Accident Expense, and t4ajor Expense
Benefits, shall continue to be payable, with respect to charges incurred
solely as a result of the injury or sickness causing such disability, subject
• , to the following:
a. Such benefits must have been payabte had such insurance remained
in force.
b. Such benefits shall not be payable for services �more than 90 �
days after the date insurance terminates, except that hospital
Charges othenaise covered under the Hospital Denefit will be
payable with respect to a confinement which commences within
the 90-day period.
c. The Covered Person's total disability due to the cause of :
_ . disability �ahich existed on the date insurance terminated has
not ended before the'date tlie service is received.
Any Accident Expense .and Major Expense 6enefits are payable as provided in
the benefit. .
.': t•'. ' � � �t4EUICAL EXPENSE DENEFITS v '� • •
� Exclusions and Limitations � �
The �4edi�al Experse Benefits do not cover any expe�se of a Covered Person
that results from: .
1 .. a condition for which the Covered Person is� not under the care of �
e doctor; '
2. accidental bodily injury arising out of or in the course of employ-
- ment for compensation or profit;
3. sickness for �•+hich the Covered Person is entitled to, or does in fact
receive, any indemnity, benefits or compensation under any workmen' s
• � compensation law or act;
4. hospital confinement, medical or surgical services or other treat- �
ment furnished or paid for by or on behalf of the United States, or �
any State, Province or other political subdivision unless there is
an unconditional requirement to pay such charges whether or not
' there is insurance; _ . �
� 5. treatment on or to the teeth; treatment of gums (other than for tumors) ;
extractions of teeth (other than excision of impacted unerupted teeth) ;
treatment of dental abscess or granuloma; except for hospital expenses
and doctor's charges as specifically provided; '
6. eye refractions or other examinations for eyeglasses or contact � � -
lenses, or eyeglass or contact lens prescriptions, except as '.
specifically provided; .
7. callus or corn paring or excision; toenail trimming; non-surgical
treatment of chronic foot conditions such as weak or fallen arches ,
flat or pronated foot, metatarsalgia, hallux valgus, or foot strain;
. or any manipulative procedure on the foot;
. 8, routine physical examinations and related X-ray and laboratory tests ;
9, vaccinations, inoculations and preventive shots , except as required . �
as a result of accidental bodily injury;
10. lntentionally self-inflicted injury, while sane or insane;
11 . a state of war or any act of war, declared or undeclared; '
12: the treatment of narcotism or addition to other habit-forming drugs ;
13, custodial care;
. 14. pregnancy, resulting childbirth, miscarriage, abortion, or any com- �
plications of pregnancy, except as specifically provided; or
15. _pregnancy, except as specifically provided under "Maternity Uenefits" . '
: �;;� ,� . , U C� . . � - .
, RESOLUTION NO. •
A RESOLUTION OF Tf1E CITY COUNCII� OF THE CITY OF REDDING '
APPROVING ADMZNISTRATIVE SERVICES AGREEMENT WITH CALIFORNIA '
� WESTERN STATES LIFE INSURANCE COt�1PANY. � '.
• WHEREAS, the City of Redding has adopted its own medical �
and dental insurance plan, and
WHEREAS, the City of Redding has requested Cal-West to �
fnrnish administrative assistance under the plan, and to act as .
claims administrator under the plan, .and in such capacity to pro- "
cess pay claims and disburse claims payment thereunder, •
• NOSJ, THEREFORE, BE IT RESOLVED that the City Council of • �•
' ;
the City of Redding hereby approves the Administrative Services
Agreement, 'dated January 1, 1982, bet�oeen the City of Redding and
the California western States Ltfe Insurance Company. -
. I HEREBY CERTIFY that the foregoing Resolution was in- �i
troduced and read at a regular meeting of the City Council of the .
City of Redding on the day ,of ' , 1982, and was duly '
adopted at said meeting by the following vote: �.>
.
AYES: COUNCILMEN: .;
,.
NOES : COUNCILMEN: . . :�
ABSENT: COUAlCILMEN: ,;
�
ATTEST:
ARCHER F. PUGH
Mayor of the City of Redding .
ETHEL A. RICHTER, City Clerk
FOI2M �APPROVED: ``
� . :.?
RANDALL A. FIAYS, City Attorney
;
' . �
�� � ,� � � � �. . .
V
RESOLUTION NO. .
A RESOLUTION OF THE CITY COUNCII; OF THE CITY OF REDDING
APPROVING ADMINISTRATIVE SERVICES AGREEMENT WITH CALIFORNIA �
WESTERN STATES LIFE INSURANCE COI9PANY. . i
WHEREAS, the City of Redding has adopted its own medical ,
and dental insurance plan, and
wHEREAS, the City of Redding has requested Cal-West to � •
furnish administrative assistance under ttie plan; and to act as ,
claims administrator under the plan, .and in such capacity to pro- .
cess pay claims and disburse claims payment thereunder, �
. . .,
NOj4, THEREFORE, BE IT RESOLVED that the City Council of
the City of Redding hereby approves the Administrative Services �
,.
Agreement, dated January l, 1982, between the City of Redding. and
the California Western States Life Insurance Company. � :
�,
I HEREBY CERTIFY that the foregoing Resolution was in- �
'i
troduced and read at a regular meeting of the City Council of the � '
City of Redding on the . day of . , 1982, and was duly �`
adopted at said meeting by �the following vote: . f
. � ;
AYES: COUNCILMEN: '
.•�
NOES: COUNCILMEN: �+
. `;
ABSENT: COUNCILMEN: .;
.t
ATTEST: • .i
ARCHER F. PUGH •1
Mayor of the City of Redding '�
ETHEL A. RICHTER, City Clerk �
FORM APPROVED:
RANDALL A. fSAYS, City Attorney
x
' ,
• �
�' � � �� � • - -
, _� , . , .
DENTAL EXPENSE QENEFIT • • -
If a Covered Person, ti•rhile insured under this benefit and as .a result of '
disease or accidental injury, incurs expenses for any items shown under
Dental Charges in excess of the Cash Deductible, the City of Redding will
pay the percentage shown in the Schedule of Benefits of such Dental Charges.
Benefit Waiting Period
The Insured must be covered under this benefif for any waiting period shown
in the Schedule of Benefits before benefits will be paid for Dental Charges
of a Covered Person.
� Cash Deductible . •
The Cash Deductible, if any, is the amount of out-of-pocket Dental Charges
which a Covered Person incurs before benefits are payable. Any Cash Deductible
and the frequency of its application is shown in the Schedule of Benefits.
If all or any part of. a Covered Person's Cash Deductible for a calendar
� year is applied against Dental Charges incurred with respect to the Covered
Person during the last 3 months of that calendar year, the Covered Person's
Cash Deductible for the next calendar year wilt be reduced by such amount.
• - Dental Charges r
The term "Qental Charges" wherever used in this Dental Expense Benefit applies
only to the dental procedures listed in this benefit. With respect to a
particuler procedure, the Dental Charge is the dentist's usual , customary
and reasonable fee for such procedure. '•
� °Usual" fees are those fees ordinarily charged by an individual dentist for
• a given service to ali his private patients. • -
� The fee is "customary" when it is within the range of usual fees charged
by dentists of similar training and experience for the same service within
. the community. .
The fee is "reasonable" when it meets the "usual" and "customary" criteria �
and, in the opinion of the City of Redding or the responsible dental society' s
review committee, is justifiable considering the special circumstances of
the particular case . in question. ;:
� ' Plan of Treatment '
The Covered Person shall request his dentist, prior to rendering a service,
to submit to the City of Reddinq a plan with X-rays showing the Covered
� Person's dental needs and the treatment necessary in the professional judgment
of the dentist. This is not required in emer9encies and for brief routine
procedures in which the total fee does not exceed 535.00. In the event of
optional procedures involving different fees , the smaller fee will be decmed
by the City of Redding to be the Denfal •Charge.
( ) �
..� -? , ' , - DEN1Ti E%PENSE BENEFIT - (Continued� � � •
� Plan of. Treatment - (Continued) . - . � ,
� The City of Reddii�.j i����y requi� a as part of the proof of loss a •complete
dental chart showing any extractions, fillings or other work performed
prior to the daCe of the loss for which claim is being made; itemized bills
. of the dentist or other sources of services, supplies and treatment; and
laboratory or hospitel reports, or casts, molds or study models, or other
, similar. evidence of the condition or treatment of the teeth or mouth. •
Extended Insurance
If a Covered Person's insurance terminates, City of Redding ��ill pay
for Dental Charges incurred through the calendar month following the
month in which the termination occurs, subject to the maximums shoo-m in the • �
Schedule of Benefits , provided this Policy is in effect on the date the
service is performed a�d the Plan of Treatment vlas received by the City "
of Redding while the Covered Person was insu*ed.
Limitations . ;
This benefit does not cover any expense of a Covered Person that results � �
from: . .
. 1 . accidental bodily in�ury arising out of or in the course of any .`
employment for campensation or profit;
2. disease for which the Covered Person is entitled to, or does in ��
fact receive, any indemnity, benefits or compensation under any .
Workmen's Compensation law�or act; ' . '.
3, congenital malformations or cosmetic surgery or dentistry for
wholly or partially cosmetic reasons ; �
4, any dental procedure which started prior to the date such pro- '
cedure would be covered under this benefit; or
. 5. replacement of lost or stolen appliances: .
_ `>
� � �i.
� . � . .. � . ,r
' :r
�:�. -N: , � . . - � � . - , .
� DLNTAL �YP1:N5[: T31;NI:�IT— (ContinucJ)
PP.'LZ'ENT(VE � :.,;•'STOfL1TlVli PItCC[DURC•S .
Ptoa Aoa . • .
No. � Rocedures �o. � � Procedurcf .
VISITS ANU li:(A�fIN,\110�5 . . . . `—Cysb nnd Nropbsm�(f.onl.)
D20 Ofli[c rifil for tnatment and obarv5tinn o�injurieS 271 Rcuc�iun af mah�a��nt tu:nor � � , .
to tceN and yupponinr �Wcnua oUi.t than for )75 7'�anmUnv�ion ui Wnth or tooth bud � � ,
. �ou�nc opcntive pru::Ju�:s liteyvLv oifiee . 276 Removal o( lo�ei¢n body (rom bone IinCepcndent � .
' houn) � � ' procedurcl
D70 Pfo(es�iun�f visits a(ht ho�rs (ncnust may eket � 277 Radicil n:r:ction of Aone for tumor with bone;•saft . '
paymrnt on bau o( s:rviai andercd or visiU, 278 Staxillory suiurutomy for remo�•al uf aoth Uognent
whiehever is r.r,•atrr) or forci;;�body � ' �
D40 Special conw:Eation Cce (by .spcculist far eax ' 279 Closvee of oral fistuV of maiilluy sinus . � .
yrtscnulion when Cu^.noaic �IJCCdOiGS have �60 Gxcision of cyst,small .
' bten'pedonneJ by,r,enrral JtnG�t) 781 Exeirion of tyst.�vge('S em or IaFed �• �
D69 Pro,hylaxis-c:�JCrcn to xar I:(onre�n:r 6 mon�hs) ' ' 282 SeGucuroetony for osteamye5tis or barr. �bsees�,
DSO Piophy6xis-U.��m.nt (to ia:luuc scling and � � superfici:il ,
poGfhine)(once per 6 months) ' � � 285 Condyleetomy of tcmporommdibuler joint
96l Topical appticanon oC sodium Iluor,de (one 289 l�feniscettumy of tempo�omandibuLvjoint � � ",
lrealment i^duJinr prophylasis under oge 4) � Mixeilancoue ' . ' '
J62 Topica� appGco�ion of siannous tluoriCe (one ' � 290 Incisiun and remov�l o(forei3n 6ody from soft . �
�re�tmrnl inctuding prophylazis - paymenl tiuue ' ' . .
limited to oncc e�ch yeat to age 19I. �91 Freneetomy . ' .
980 Eme�cnry uracmcnt-palhativ�.per vivt � Tg2 SuNtc of soft tissue wounJ or injury � . �
K-RAY 4 PAT710LOGY ' .. 293 Crown exposure for ortAoJonUa .
.Film (eei incluCe crun and diagno:it (other than I94 Injecuun o!sclerosing�ge�t into temporomandibular
Injuries): ' joint .
(10 Singlefilm . . .- . . . • 295 Trcatmrnt of tnc�ninal neuralaa Dy in;retion into. .
Il k Addiconai,up w !2 fJms � ' � ' . - ' xcond and ihud divisiona ' • � �
I12 :k;ntue dann�re scr.es consistin^of at tcast 14 films � - 296 Peripharal nerve biock,branchei of Sth eranial �
117 Inua•ural, occlusal vie�v, ma.r'Juy or mandibulu, . . ANESTHESIA • •
eaoh • 400 .Ger_ral,mlated to surgcal procedures only � � ' '
I14� Superior or in@rior muHluy,cxvao�al, 1 film . .
I15 Superior or i.�ferior ma�illaty,estrioral, ?G�ms PEWODQVTICS . � �
116 Ditewing fdms,u�cluding eaamin:�ion .. 45! Eme oency trea�ment (periodonul �bs:ess, aeute
2Nms . . � .. - periodonritis.etc.) ' . � . .
4 fJms � � � � 452 Sub�inpval cure�t�ae,roo:p�ninc(noe prophylasis) '
� Addition:J films .. � ' � . 453 .Correction of ocdusion, ml�ted to pcnodontul � � -
ISO Biopsy oCor�llissuc' . � ' problems - . .
160 \iicro�copic e�aminoeion 4�2 Ginyvectomy per quadnr.t (includin; �posbsurgieil
� Note: Compktc inouth X•nys a:loweS onee a year visitsl ' •
� • unless sperial nccd is sSonn. Supplemretvy . . 47) . Cinpveetomy, osxous or muco�eins;ival su;gery,per �
Ditewing \-rays al�ou�ed upon request,but not ' quadcant(includes postauteical visits)
mom lhan oncc in coch 6 mo.ths. � 474 Gingivenomy, tteatment per tooth (Cc•.ver than 6 .
• _ , . � Icelhl � .
)RALSURCERY . � ' FJ�lpOpONTiCS . . ' . , •�
� E�tr�e6ons � . � . ' S00 Rdp capping � .
t00 Uncompiic�led (<inek) (ke� indudes rourine . 301 Ther�pcutic pulpowmy. (in �dJition to rcetor�tion) .
postopc:stive visitsj per trcad�ent
tOl L'ach aJdiGanal. tooth. (fee ineluCes rou4ne, 102 Vitalpulpoamy . � •
' postopenehr viaiis) . ' • S0� Reminenlization (CaOH, tempocary teitor�tion) per
!Ol s�����i«�,��,i oi«��c„a«�c:� . �oo�n�s�:��u�����o�:e���oniY ,
!20 Postopentire.�isil(cumn�and compGca�iona� Rool Canals
Impae�eJTeYtl�(rnclaV: f•Im) . � SIO Culluringeanal � �
UO Rcm�rvat oC Woth tsnft ha+ual � � , Sl l $in,r,k fookd unal Ihtnpy
!71 I:cmoral uf�oo�h Iparc�allY hony) 312 Ili�roolcJ �ooth eanal titerapy . .
t)2 Remoc:J of�eoth(complctcly Iwny. . � 513 Tri-�oacJ iooth canal Uicrany
. .ANeoUror Cincival'Rccunsuuc6nn � ' � .370 ApiucclnmY findndint:fillii;:of root conal) . -.
!SO AWco!;:tarny l�d.nmi�.u�)pr�qui.:ont 33! Apioreromy(srpantr yroceSur.) '
!S2 Ah•.olrcwmY t�n �.I.litiou to icmoral of tctt:U pet Fees Jo not inrlude �in.il rc��uraoi��n: nrc.seary '
yu�J�an� ' XKoys .onJ culmrcs uc in:luJ.A ii �buve
!S6 AheopL;p� wi���i�l�vc cs�cnsion,p:�urh� . atluwmttc.
'S7 Rcmw�.N oi p.d�ui wms . RIiSTOliA71�'F. UIiNI'ISTIIY (O�Ler Nan ini.iy�, trowns ,
!S8 I:rmuv.J of ma:W�I�uLu tuu p.r qwd�anl . �nJ L�iJ:��l
!39 I:srision of Irypc�{.I�suc Ifsmc{:cr a�.h . . Amalyam Rrr.�niium-Prim�ry 7ccih
C)•slsanJ\e.•plovns 60J CariU.tmvolvinelluulh .u�l.�ce . .
'60 Intu�or.�l in:i�ion��nd Jnin���e nf ab�:etif . � G01 Griiies involnn�: ? �aulh eurixn � .
'61 . G�n�.nal in:ivun au�l J�nue.te ul alncess 602 Cavilief mrulrmg ,l or mut. I���qh �utl�te� � .
'6: I:�cia.�n oi prricurnn�l�m;:iv� Am.�l.�in Itr.�ouliuna-Prrmanenl l'eeU� �
'GI Sialolil9u��nnY: �cnwr.d o( s�livuy e�lvlui. � 611 Cu�ihninv.dvm,^, li,�oth.uu:�.e . �
brt�a�ucdly 612 ('.�viU.�invalriug ! I�n��ti w�l.i:c+
tii Si�lulil:�,n.nny: rcmovat of �aliv�ry cal:utui. ' . Gl7 ('a�•itirt u�vni.im: J or mu�c I��uih tuiGces .
C�Inor�11Y . ' Sili:alr.l'I.��tic Itntut�liuns � .
AS Clown nl nd��ory ONuL� 640 Sih:�tt�'rmcnl IJhn ;
dR Pil�b.mbf vLr.uy ducl 645 1'I:npc Ii16nK ' � . '
7U New•rtom ul h.m��n luawt uf wfl litoue (2S tm ot •
la�Cc�) ' . '
_ . • . , . � . , . ._ ' , . . .. .. . .�...� .
' • • : . � DIsNT�C\i'L•:NSr I3f;NCl�IT— �co�������<<i� �
.�, � t ,
n�. �
• � • . . •
No. Auedurc� ' '' ,
Restonlire Ikntin�ry undrt Genetal Annthc;r . ' ' .
� (Covv�eJ only whu��cyui��d dae to mcnul dinbility . . .: . . �
of px�icnt) ' � , �
649 Long �ctia operative ca:cs perforr��ad und:c General • .
Ancs�hcsia on homly Ca>it: • '
—1 hour duntiun fr•>�n bremning to rnd • . .
� —2d�2 houts.marimum . . .
«).1/2 houts,mi�imum ' .. ' �
—�or mom houn ' . . � �
� 7he abovt includcf 'all operative pioceduref, � � � .
�xu,o�:o��. r����ow��«. �«�:s.v� a��cm:,c. . .
� � ftannous (luoride and onl prophyl�xis. Fecs fut � . .
' �neslhesiolo�;tsuee�c;uded. � . . , . . ,
' Crowm � - ' , ' •
670 Stainlcu Sted fvrimary) , ' . . ' . .
671 StainlcssSte:Ilpccmanrn0 . � ' . • ' . • .
6fitte0aneous . . ' .
790 Repain.dennires,acryLe � � � , ' ,' �
' Rrokcn dentun.�.paicin;(no tceUi involved) . � • . .
� Rcplxing nusing or. b.oken teeih, euh . ' .
additional � ' ' � '
SP�CE \IA!\T\IYE^S —�te includce al! adjusttnenb � . . • . . .
w•ithin 6 monNs(ollow�in;ins�lLition. � � . . • . .
. 800 Fired spse mainnincr(Sand type) . •� . ' � ' '
Remonhle acryGc space maC�evnet , ' . , � ,
BOl With s;�inicss stecl round�vire mt only � � � ' , ; �
'802 Stainless s:eel clasns and/or xtivaiu�g wite�. in . ' ' . . .
tddition per wire or cLup � . ' . . .
603 Study modcb � • ' � '
SIO Remov�ble -inhiSiting app6antt .m eortect . . � � . ' , ,
lhumbwckin� ' . ' • � �
" 871 O(fice visit �or obscnation.• adjustment �nd � . . � . . . -
. ' aetivationpervisit ' . . . � . , . ' .
832 1'ixed ur cemented inhibicLi; appliana to eorteet . . . � , . .
thumbsucking . � . ' . . •
FRACTURESANDDIS60CATf0YS- . � � . � . ;
Trcatment of fraca�rcs and dislocations of maxilla and mu�dible is� . ' � � . . ' • ' .
pryaDk 6y Aledital Erpenx Hencfiu. � ' � ' , ' � • ' _ ' . •
. ' . . � � . . . � . ��Y
. `
t
. ,� , � .
:, .�, � ,. _ . 0 U . , . .
' � nr.r�'f11I� i�.\F'ENSI: 13i:NCrIT •(Cuntinucd)
� RGPLdCL•�fENT PI20CL•DUR[S
Rac. Prot R«eduna
no. Poadurts . N�• .
lNL1YS � Rep�i�s,uownsandbridgn • -
61S 1 tooth suiface � � � 690 Rcp�'as —fce b�xd on tiir.c and I�bontory ehugef
636 �looth wd�cct � '. � penNrcsanJ I'arcials • . '
637 7 0� mo:= �oo�h wdaces . ' ' � pentu�es, pa�ti�l Jcnn�res anJ reline fecs inc�udc
638 OnlaYs pc�1oo�h,cxtra . � , �djustments for 6 montl� period following
Crownf ' . instyl�tion. '
6S0 Auy!ic � . . . . � �00 Complcte ma�cillarY dcnrt�m . �
651 AeryGc wi�h menl ' . ' ' 700 Compkte mandibulu dcnture .
652 Portcl�in ' - I�OTL•': 1'ces for sprciaGzed teehniques involving
657 Porcc!ainwithmelal . ' �� '. � .' preeision dentu[es, persuqalizinG or
660 Go1S Uull) ' � . ,. ehuaeterizatiun ace exduJed. FuLL i.e for ehe �
663 3/3 Co1J • � . � rnUre pioccJurc must be Gsted in thc Plan oi
672 C.oIA Jn�••el oin ' Treatment.
GI-ltiest.rn Li:e does not p�Y f��[acings on aowro, ��Z p���� �erylic uppo� or lower with gold or el�come ,
p�slerior �o ?nd 6icuspids (ii placeJ, e�7enx must eobalt alloy cl�sps—b�x(te
De bome hy.p+tienU. Gold nowm and eestor�tions ' � Teelh anddasps cnua per unit � ' �
are<o•+ered only whcn tec�h eannot be resto�ed with 703 p���� �pwer or epper w'ilh ch�ame eobalt atloy . .
a filliny matarinL � � � lingual or p�lat�l bat md acryGc saddles—bau fce .. � .
PROSTI�ETiCS • � - TeelhandeUipsese:aperunit . .
Bridge AbuimcnU(Sce Iniays&Crowns) • . Simple aUess brcalcn—cx�a , . �
Pon�ies � . ' . � 706 StrypUtc —b�sc fte . .
680' C:st;olJ(uni�arY) . . . . • TcethandcUsp —o�caperunit . . .
681 Stcele's facing ' � . . 707 Immediate spGnt dent�rc
682 TrU-Pontic type � � . , 72l Otfice rcGne—eold cuee—acryRe. . , .
6$I• POfCCI]C1 b]�(Cd t0 gJIE _ � • , Y2I DenWre teGne.
682 � Mu�ic procesed to 5old ' . 723 . Special tissue�eondilioning,�pet denturt;in,aAdition
Remov�ble(Uniloter�{ 6ridges) � � � to rcline � . � ,
o!d or chrome tobalt illoy tlosp � 71� DenNce dupGca�ion(jmnp casa)per denturc
'683 One piece castine, g pdding teeth to putial dcnturo to rep�ce e�tncted
rinehmrnt(ill �ypet)pcc unit—including ponties ��N��teeth: • �
RecemcnuGon � • . �93 First tooth , _ � , •
68S Inlay . . . . . . 794 Fint tooth with casp � .
6S6 Crown . " 795 Eath additioeal tooth and tlasp . .
687 Bridge ' � _ ' ' 196 PuNal dentuce ttp�irs—baxd on lime dnd labor�tory ..
. . eAarges . .
Exclusions � � �
l. Replacement of dentures .less than 5 years after a preceding placement,
except a replacement made necessary by the initial placement of an
opposing full denture which necessitates the replacement of an existing
. denture.
• 2. Replacement of a removable partial by a fixed bridge for .a period of .
5 years after the initial placement of the partial .
3. Any cro�•rn replacement made less than 7 years after preceding placement •,
unless replacement is for purpose of extending a fixed bridge. ",
� 4. Replac�ment of a fixed bridgc by a removablc partial for a period of
7 years after the i�iitial placement of tlie bridge, unless it is recessary
to extend thc bridgc. •
. 5. Appliances or restorations necessary to increase vertical dimension
• . or restore thr. occlusion. No�y�ever, the City of Redding a�ill allow
tl�e cost of procedur�s necessary to eliminate oral disease and for
restorations required to i•eplacc missing tceth. .
; . `/ ) C �
'`� r�; � � � V . \/. . �j�
- MEDICAL EXPENSE BEP�EFITS •�'
. Coordination of Denefits
Benefits Subject to Coordination of Benefits. All Medical and Dental
Expense Benefits provided under this Policy are subject to this provision.
Definitions. ' � �
1 . "Plan" means any plan providing benefits or services for or by. reason
of inedical or dental care or treatment, which benefits or'�ervices are .
provided by (a) group, blanket or franchise insurance coverage, .(bl � �
service plan contracts, group practice, individual practice, and other
prepayment coverage, (c) any coverage under labor-management trusteed �
plans, union welfare plans, employer. organization plans,. or employee ;
benefit organization plans, and (d) any coverage under governmental .
programs, and any coverage required or provided by any statute.
;�
The term "Plan" shall be construed separately �•�ith respect to each �
policy contract or other arrangement for benefits or services and �
separately with respect to that portion of any such policy, contract,
or other arrangement ti•�hich reserves the right to take the benefits or
services of other Plans into consideration in determining its benefits
and that portion which does not. . .
. 2. "This Plan" means that portion of this Policy which provides Medical '
and Dental Expense Benefits. �
3. "Allowable Expense" means any necessary, reasonable, and customary `'
item of expense at least a portion of which is covered under at least
• one of- the Plans covering the person for vihom claim is made.
When a Plan provides benefits in the form'of services rather than cash �
payments, the reasonable cash value of each service rendered shall be •
deemed to be both an Allowable Expense and a benefit paid. �
4. "Claim Determination Period" means a period cormnencing with any January 1
� . and ending at 12 o'clock midnight on the next succeeding December 31st .
or that portion of such period during which the person on whose expenses .
claim is based has been covered under this Plan. .
Effect on Benefits. , . .
1 . This provision shall apply in determinin9 the benefits as to a person �
covered under tliis Plan for any Claim Determination Period if, for the ' .
Allo�aable Expenses incurred as to such person during such period, the
sum of (a) the benefits that would be payable under. this Plan in the
. . absence of this provision, and (b) the benefits that would be payable
under all other Plans in the absence therein of provisions of similar '
purpose to this provision would exceed such Allowable Expenses. �
Y� �,F:� • .< _-ME4'ICkC EXPENSE BENEFITS - (Continuec� • -> r .
Coordir.a.*_�.�� ..of RPnefits - (Continued) � �
2. As to any Claim Determination Period with respect to v+hich this provision
is applicable, tlie benefits that would be payable under this Plan in the
absence of this provision for the Alloa�able Expenses incurred as to such
, person during such Claim Determination Period shall be reduced to the
. extent necessary so �hat the sum of such reduced benefits and all the
benefits payable for such.Allo�iable Expenses under all other Plans, ex-
cept as provided in item 3 belor+, shall not exceed the total of such ` � '
� . Alloviable [xpenses. Benefits payable under another Plan include the
benefits that would have been payable had claim been duly made therefor.
3. If (a) another Plan which is involved in item 2 above and which contains
a provision coordinating its benefits with those of this Plan would,
according to its rules, determine its benefits after the benefits of this
Plan have been determined, and (b) the rules set forth in item 4 belotia
would require this Plan to determine its benefits before such other Plan,
then the benefits of such other Plan will be ignored for the purposes of
determining the benefits under this Plan. _
. • 4. For the purposes. of item 3 above, the rules establishing the order of ,
benefit determination are:
. (a) The benefits of a Plan which covers the person on whose expenses
• claim is based other than as a dependent shall be determined before
the benefits of a Plan which covers such person as a dependent.
(b) The benefits of a Plan H�hich covers the person on whose expense �
' . claim is based as a dependent of a male person shall be determined
� before the benefits of a Plan which covers such person as a de-
� • � pendent of a female person. •
• (c� When rules (a) and (b) do not establish an order of benefit deter-
mination, the benefits of a Plan which has covered the person on
whose expenses claim is based for the longer period of time shall
be determined before the benefits of a Plan which has covered such
person the shorter .period of time.
5. When this provision operates to reduce the total amount of benefits
otherwise payable as to a person covered under this Plan during any Claim
Determination Period, each benefit that vrould be payable in the absence
of this provision shall be reduced proportionately, and such reduced
amount shall be charged against any applicable benefit limit of this Plan.
� Right to Receive and Release Necessary Information.
For the purpose of detern»ning the applicability of and implementing the terms
of this provision of this Plan or any provision of similar purpose of any other
Plan, the City of Redding may, with the consent of the Covered Person, release
to. or obtain from, any otlier insurance company, organization, or person any
information, �aith respect to any person, which the City of Redding deems to
be necessary for such purposes. Any person claiming benefits under this Plan
shall furnisli to the City of Redding such information as may be necessary to
implement this provision.
_ �� , � � �
"� � _ • MEf�1CAL EXPEIaSE DENEFITS - (Continued)�"' ��
Coordination of Benefits - {Continued) . �
Facility of Payment. , �
_ Whenever payments �•rhich should have been made under this Plan in accordance
with this provision have bzen made under any other Plans, the City of Redding
. shall have the right, exercisable alone and in its sole discretion, to pay
over to any organizations making such other payments any amounts it shall
determine to be wa�•ranted in order to satisfy the intent of this provision,
and amounts so paiG shall be deemed to be benefits paid under this Plan and,
to the extent of sucli payments, the City of Redding shall be fully discharged
from liability under this Flan. �
Right of Recovery. _ � �
Whenever payments have been made by the City of Redding with respect to '
Allowable Expenses in a total amount which is, at any time, in excess of the
maximum amcunt of payment necessary at that time to satisfy the intent of �
this provision, the City of Redding shall have the ri9ht to recover such
payments, to the extent of such excess, from among one or more of the.
following as the City of Redding shall determine: any persons to or for or •
• with respect to whom such payments were made, any other insurance companies,
' service plans, or any other organizations. �
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