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David Geffen School of Medicine at UCLA Graduate Medical Education
 
General Provisions

WHAT IS THE CERTIFICATE OF COVERAGE?

This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you:
  • the coverage for which you may be entitled;
  • to whom Unum will make a payment; and
  • the limitations, exclusions and requirements that apply within a plan.

    WHEN ARE YOU ELIGIBLE FOR COVERAGE?

    If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of:
  • the plan effective date; or
  • the day after you complete your waiting period.

    WHEN DOES YOUR COVERAGE BEGIN?

    When your Employer pays 100% of the cost of your coverage under a plan, you will be covered at 12:01 a.m. on the later of:
  • the date you are eligible for coverage; or
  • the date Unum approves your evidence of insurability form, if evidence of insurability is required. When you and your Employer share the cost of your coverage under a plan or when you pay 100% of the cost yourself, you will be covered at 12:01 a.m. on the latest of:
  • the date you are eligible for coverage, if you apply for insurance on or before that date;
  • the date you apply for insurance, if you apply within 31 days after your eligibility date; or
  • the date Unum approves your evidence of insurability form, if evidence of insurability is required. Evidence of insurability is required if you:
  • are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or
  • voluntarily cancelled your coverage and are reapplying. An evidence of insurability form can be obtained from your Employer.

    WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN?

    If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will begin on the date you return to active employment.

    ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING DUE TO INJURY OR SICKNESS?

    If you are not working due to injury or sickness, and if premium is paid, you may continue to be covered up to your retirement date.

    ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING?

    If you are on a temporary layoff, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your temporary layoff begins.

    If you are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins.

    ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE NOT WORKING DUE TO A LABOR DISPUTE INVOLVING YOUR EMPLOYER?

    If you are not working due to a labor dispute involving your Employer, and if premium is paid, coverage will be continued until:
  • the expiration of 6 months from the date you ceased active employment;
  • the date you accept active employment with another Employer; or
  • the date less than seventy-five percent (75%) of the employees affected by the labor dispute are continuing insurance; whichever occurs first.

    To keep your insurance in force, you must pay, on time, to your Employer or Union, an amount equal to 120% of the required premium during the continuation. Your Employer or Union will forward your premium to us.

    WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT?

    Once your coverage begins, any increased or additional coverage due to a change in your annual earnings or due to a plan change requested by your Employer will take effect immediately or on the date Unum approves your evidence of insurability form, if evidence of insurability is required. You must be in active employment or on a covered layoff or leave of absence.

    If you are not in active employment due to injury or sickness, any increased or additional coverage due to a change in your annual earnings or due to a plan change will begin on the date you return to active employment.

    Any decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior to the decrease.

    WHEN DOES YOUR COVERAGE END?

    Your coverage under the Summary of Benefits or a plan ends on the earliest of:
  • the date the Summary of Benefits or a plan is cancelled;
  • the date you no longer are in an eligible group;
  • the date your eligible group is no longer covered;
  • the last day of the period for which you made any required contributions; or
  • the last day you are in active employment unless continued due to a labor dispute or due to a covered layoff or leave of absence or due to an injury or sickness, as described in this certificate of coverage. Unum will provide coverage for a payable claim which occurs while you are covered under the Summary of Benefits or plan.

    WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS?

    You or your authorized representative can start legal action regarding a claim 60 days after proof of claim has been given and up to 3 years from the time proof of claim is required, unless otherwise provided under federal law.

    HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED?

    Unum considers any statements you or your Employer make in a signed application for coverage or an evidence of insurability form a representation and not a warranty. If any of the statements you or your Employer make are not complete and/or not true at the time they are made, we can:
  • reduce or deny any claim; or
  • cancel your coverage from the original effective date. We will use only statements made in a signed application or an evidence of insurability form as a basis for doing this. Except in the case of fraud, Unum can take action only in the first 2 years coverage is in force. If the Employer gives us information about you that is incorrect, we will:
  • use the facts to decide whether you have coverage under the plan and in what amounts; and
  • make a fair adjustment of the premium.

    HOW WILL UNUM HANDLE INSURANCE FRAUD?

    Unum wants to ensure you and your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution.

    It is a crime if you knowingly, and with intent to injure, defraud or deceive Unum, or provide any information, including filing a claim, that contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. Unum will pursue all appropriate legal remedies in the event of insurance fraud.

    DOES THE SUMMARY OF BENEFITS REPLACE OR AFFECT ANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE?

    The Summary of Benefits does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance.

    DOES YOUR EMPLOYER ACT AS YOUR AGENT OR UNUM'S AGENT?

    For the purposes of the Summary of Benefits, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deemed the agent of Unum.

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