Teamsters Western Region & Local 177 Health Care Plan - Continued Coverage While Disabled

IMPORTANT NOTICE

FOR HEALTH COVERAGE TO CONTINUE WHILE

DISABLED…

Please contact the Administrative Office at (855) 215-2039 or

see the reverse side of this document for important steps to follow when you are disabled.

Please note:

If you do not timely notify The Hartford (formerly Aetna) at (866) 825-0186 of

your leave of absence and file the appropriate documents, your health coverage

may be terminated and will not be reinstated until your leave of absence is

reported or your disability benefit is approved. You MUST call The Hartford

immediately at (866) 825-0186 to report your leave of absence. In addition, you

MUST report your actual return to work date to The Hartford ASAP by calling

(866) 825-0186.

You may also go to https://abilityadvantage.thehartford.com and use your UPS ID to register. From this

portal, you may manage your leave of absence; check status of your leave; and submit documents

electronically.

To continue health coverage while you are unable to work due to:

A) An on the job injury, your employer may contribute to the plan for up to 52 weeks of eligibility.

B) A non-work related illness or injury, your employer may contribute to the plan for the first 4

weeks of your disability. You MUST first contact The Hartford at 1-866-825-0186 to report your

leave of absence and you MUST also notify UPS HR (or your direct manager). UPS will then

determine if you are eligible for four weeks of contributions to the health plan while you are

disabled. You MUST also report your actual return to work date to The Hartford ASAP by calling

(866) 825-0186.

a. If eligible and approved for Short-Term Disability (STD) benefits, your health benefits will

be extended with a disability waiver for the duration of your approved disability up to a

maximum of 26 weeks.

i. If you work in NJ, NY, or HI, you will need to file your short-term disability claim

with The Hartford at https://abilityadvantage.thehartford.com or call 1-866-825-

0186 to reach a disability representative at The Hartford. Additionally, you may

submit documents via facsimile at 1-833-357-5153 or by email at

GBIinformationUpload@thehartford.com.

ii. For all other states, Disability Filing Procedures and Forms are available at

www.wr177healthcare.com or you may also contact the Fund Office at (855) 215-

2039.

iii. If you reside in CA, you should also file a claim with the State of CA. For CA

benefits, go to https://www.edd.ca.gov/Disability/DI_Claim_Process.htm.

b. If eligible (must be Full-time) and approved for Long Term Disability (LTD), your employer

may contribute to the health plan for up to 52 weeks of your LTD leave of absence. You

MUST contact The Hartford at 1-866-825-0186 with at least sixty (60) days’ notice to

initiate your LTD Benefits.

PLEASE NOTE: LTD benefits are not automatic and are not guaranteed simply because

you were approved for Short-Term Disability. If The Hartford denies your LTD claim, you

will be provided appeal rights and you should be prepared to elect (and pay for) COBRA

continuation coverage while your appeal is pending.

c. If your disability continues beyond 26 weeks and you are a Part-time employee, you will

be offered COBRA continuation coverage.

d. You may be eligible for a Family Medical Leave of Absence. If approved, your employer

may contribute to the health plan for up to 12 weeks of your approved FMLA leave.

e. You MUST report your actual return to work date to The Hartford ASAP by calling (866)

825-0186.

It is very important to contact the Administrative Office at (855) 215-2039 if your benefits were

terminated due to a disability and you need guidance on getting your benefits reinstated.

Administrator: Southwest Service Administrators, Inc.

P.O. Box 43110, Phoenix, AZ 85080-3110 ● Phone: 855-215-2039 ● Fax: 602-324-0555● www.wr177healthcare.com

The Fund complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age disability or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-215-2039 (TTY: 855-983-9889).

注意 ： 如果您使用繁體中文 ，您可以免費獲得語言援助服務。請致電 1-855-215-2039 (TTY: 855-983-9889)