Exhibit 10(m)

 

Schedule of Benefits
Plan 843-003

 

Benefit Period

Calendar Year

 

 

Dependent Age

End of the calendar year of age 19, or to end of the calendar year in which the
child attains age 25 if allowed as a federal tax exemption.

 

 

Pre-Existing Condition

None

 

 

Deductible Per Year Per Individual

$30.00

 

 

Co-Insurance

None, except as specified

 

 

Out-of-Pocket Limit

 

 

 

Individual

$1,000.00

Family

$2,000.00

 

 

Outpatient Services Surgery 100% Coverage

 

Routine Office Visits

100% Coverage after Deductible

Diagnostic X-Ray & Lab

100% Coverage

Prenatal Care

100% Coverage after Deductible

Well Baby Care

100% Coverage after Deductible

Child Immunizations

100% Coverage

Pap Smears (Annually)

100% Coverage

Therapy, Physical Rehabilitation, Speech, etc.

100% Coverage After Deductible

Allergy Testing

100% Coverage

Allergy Serum & Injections

100% Coverage

Emergency Room/Facilities

90% Coverage after Deductible

Emergency Room/Physician

90% Coverage after Deductible

Ambulance Service

90% Coverage

Urgent Care

100% Coverage

 

 

Inpatient Services

 

Semi-Private Room & Board

100% Coverage

Hospital Services (operating room, x-rays, lab, drugs. supplies. etc.)

100% Coverage

Surgery-Physician Charge

100% Coverage

Physician Visits in Hospital

100% Coverage

Maternity Benefits

100% Coverage

 

 

Mental Health Care and Substance Abuse

 

Outpatient Services

80% Coverage after Deductible

Inpatient Services

80% Coverage after Deductible

 

 

Miscellaneous

 

Prescription

$5.00 Co-Pay with Prescription Card at Participating Pharmacies

Eye Examinations

Not Covered

Medical Equipment & Supplies

80% Coverage

Home Health Care Services

100% Coverage

Skilled Nursing Facility/Hospice Care

100% Coverage

 

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The Dayton Power and Light Company

Group Insurance Plan - Summary Plan Description

Plan #843-003

 

The Dayton Power and Light Company Group Insurance Plan is a comprehensive
indemnity medical plan maintained by The Dayton Power and Light Company, P. O.
Box 8825, Dayton, Ohio, 45401. The Company’s Employer Identification Number is
31-0258470. The plan’s number as filed with the United States Department of
Labor is 501.

 

Any service of legal process about this plan should be made to Human Resource
Administration, The Dayton Power and Light Company, 1065 Woodman Drive, Dayton,
Ohio, 45432.

 

ELIGIBILITY

 

Active employees and their dependents who have not otherwise been enrolled in an
insured plan offered during annual open enrollment.

 

Eligible dependents include:

 

•                  Your spouse.

•                  Your unmarried children under age 19.

•                  Your unmarried children under 25 years of age who are
principally dependent upon you for maintenance and support, are not regularly
employed on a full-time basis and are full-time students in a college or
university.

•                  A dependent child who is physically or mentally incapable of
self-support.

 

The term “children” includes your own child, stepchild, legally adopted child
and any child who is principally dependent upon you for maintenance and support
and living with you.

 

Dependents who are on active duty with the military are not covered.

 

PLAN BENEFITS

 

Plan 843-003 is a comprehensive medical plan that covers most medical expenses
at 100% after the plan deductible of $30 is met. The deductible is an individual
deductible that applies to each family member each calendar year. See the
Schedule of Benefits for specific coverage levels.

 

This plan allows members to go to any licensed medical provider. However, the
plan does require pre-approval for certain major procedures. Your medical
provider should submit a request for pre-authorization to assure that medical
expenses win be covered for major elective procedures.

 

Prescription Benefit

 

Your prescription benefit allows you to fill prescriptions at any participating
Paid Prescriptions pharmacies. Simply show your DP&L HealthCare card to a
participating pharmacy and it will be filled for a $5 co-pay. Generic drugs will
be provided when available.

 

The Paid Prescriptions pharmacy network includes most major pharmacies
throughout the United States. Locally, it includes locations such as Revco,
Kroger, Meijers and Cub Foods.

 

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Out-of-Pocket Maximum

 

Annual out-of-pocket costs for covered expenses are limited to $1,000 per person
and $2,000 per family.

 

Plan Maximum

 

You and each of your covered dependents are eligible for up to $1,000,000
lifetime coverage.

 

PAYMENT OF MEDICAL CLAIMS

 

In order for your medical expenses (excluding prescriptions) to be paid, you and
your medical provider must complete a claim form and submit it Klais & Company,
Inc. at the address listed on the form. Claim forms are available through Human
Resource Administration.

 

Most medical providers will accept a claim form for your medical benefits
instead of requiring cash payment and submit the form on your behalf for payment
directly from Klais & Company, Inc. If you have to pay for the claim yourself,
submit the claim form along with copies of your paid receipt for reimbursement

 

When the claim has been processed, you wilt be notified of the benefits paid. If
any benefits have been denied, you will receive a written explanation.

 

PLAN ADMINISTRATOR

 

The Dayton Power and Light Company Group Insurance Plan is administered by Klais
& Company, Inc. Their address and telephone number are:

Klais & Company, Inc.

1867 West Market Street

Akron, OH 44313-6977

(800) 331-1096

 

COVERED EXPENSES

 

Most medical expenses are covered including hospital, surgical, and doctor’s
charges; testing; treatment; and supplies.

 

The plan covers the following charges as specified by the plan Schedule Of
Benefits for medically necessary services and supplies ordered by your doctor:

 

•                  Hospital room and board at the semi-private rate.

•                  Intensive care and cardiac care unit charges.

•                  Hospital services and supplies while confined in the hospital
(Only medically necessary services and supplies are covered Items such as
television, telephones and newspapers are not covered.)

•                  Hospital outpatient treatment, services and supplies for
illness, injury or outpatient surgery. (Certain surgical procedures are
performed on an outpatient basis.)

•                  Hospital outpatient pre-admission tests performed prior to
inpatient admission.

•                  Medical treatment by a physician for an illness, diagnosis of
an illness or accident.

•                  Surgery by a physician, including elective sterilization and
abortion. (Certain surgical procedures require a second opinion.)

•                  Charges for pregnancy are covered the same as any other
medical expense for you or your spouse.

•                  Active services of an assisting surgeon.

•                  Anesthetics and their administration by a physician or
professional anesthetist.

•                  Services and supplies provided by an approved ambulatory
surgical center.

•                  Doctor’s examination and reporting charges for second
surgical opinions by a board-certified specialist are fully paid.

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•                  Local professional ground ambulance service when emergency
transportation is required. (Non-emergency transportation by taxicab, limousine,
railroad, air ambulance or other non-emergency vehicle is not covered.)

•                  Drugs and medicine prescribed by a physician and dispensed by
a pharmacist. Only drugs and medications that require a prescription are
covered.

•                  Home health care services benefit is limited to 8 hours per
24-hour period.

•                  Skilled nursing facility/hospice care services benefit is
limited to 180 days per calendar year.

•                  Insulin, hypodermic syringes and needles and other associated
medically necessary supplies.

•                  Diagnostic x-rays and laboratory services; blood, blood
plasma and its administration; oxygen and its administration; radium,
radioactive isotopes and x-ray therapy.

•                  Surgical dressings, casts, splints, trusses, braces,
orthopedic shoes attached to braces, crutches, support-type surgical stockings
or sleeves, and colostomy supplies.

•                  Prosthetic devices to replace lost physical parts or organs,
including artificial limbs, hands and eyes.

•                  Initial cost and fitting of external breast prosthesis after
mastectomy.

•                  Rental of necessary durable medical equipment including (but
not limited to) a wheelchair, hospital bed, glucose monitor, apnea monitor, iron
lung or other equipment for administration of oxygen, and supplies necessary in
use of durable medical equipment. Medical equipment is covered if medically
necessary and cost effective. (The cost purchasing this equipment and the
replacement and repair of equipment may be covered. Before purchasing equipment
you must receive written pre-authorization for the purchase from the Plan
administrator.)

•                  Initial cost of contact lens and its replacement when
required after cataract surgery.

•                  Services of a registered physical therapist or occupational
therapist who is not a close relative and does not live in your home.

•                  Speech therapy by a licensed speech therapist under the
supervision of a physician for a condition resulting from injury, sickness, or
congenital disorder (such as cleft lip or palate). Benefits are not paid for a
speech condition resulting from developmental or learning disabilities or
personality disorder.

•                  Non-surgical procedures of the spine including, but not
limited to subluxations, manipulations, traction and adjustments are covered.
Such charges must be performed by a licensed provider and be considered
medically necessary in terms of generally accepted medical standards. Covered is
limited to 20 visits in a calendar year unless the chiropractor can provide
acceptable proof of the need for continued treatment.

•                  Certain procedures involving oral surgery are covered.
Cutting procedures necessary for the care of teeth and gums and for repair of
extractions will be covered, if the cause is accidental.

•                  Certain other cutting procedures such as the removal of bone
impacted teeth, surgery of the bone structure (osseous), bone cavities
(alveolectomy), roots (apicoetomy) and gum structure (gingivectomy) will be
covered.

 

CHARGES THAT ARE NOT COVERED

 

Although the plan covers most medical expenses, some charges are not eligible.
The Plan does not cover the following expenses:

 

•                  Any service or supplies that are not prescribed by a
physician, that are not medically necessary, that do not meet generally accepted
professional standards, or that are experimental or controversial in nature.

•                  Services or supplies that are for personal comfort or of a
luxury nature (such as television, telephone, beauty or barber services,
newspapers, guest cots, or guest meals).

•                  Dental work or oral appliances including but not limited to
services, supplies, or appliances provided in connection with treatment to
alter, correct, fix, improve, remove, replace, reposition, restore, or treat:

•                  the jaw, any jaw implant, or the joint of the jaw (the
temporomandibular joint);

•                  teeth;

•                  the parts of the upper or lower jaw which contain the teeth
(the alveolar process and ridges);

•                  the meeting of upper and lower teeth; or

•                  the chewing muscles.

 

[These services, supplies or appliances are not covered even if they are:

 

(1) needed because of symptoms, sicknesses or injuries which affect some other
part or parts of the body; or

 

(2) provided in connection with any examination or treatment of the teeth, gums,
jaw or chewing muscles because of pain, injury, decay, malformation, disease or
infection.]

 

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•                  Any charges not reported to the insurance company within one
year after which the charge was incurred. (A claim should be submitted within 90
days or as soon as reasonably possible.)

•                  Drugs, medicines or other pharmaceuticals that can lawfully
be obtained without a prescription (such as patent medicines, dietary
supplements or vitamins and sickroom supplies).

•                  Treatment of any injury or sickness that is covered by
Workers’ Compensation or occupational disease law. Expenses incurred by a donor
or potential donor of an organ or tissue for use in a transplant operation -
whether you are the donor or recipient.

•                  Custodial care/rest cure.

•                  Expenses for weight control or treatment of obesity not
caused by an organic condition.

•                  Travel or transportation expenses except as specifically
explained in an earlier section.

•                  Radial keratotomy.

•                  Expenses for sex transformation, treatment of sexual
dysfunction, reversal of sterilization, or direct attempts to cause pregnancy
such as hormone therapy, artificial insemination and in vitro fertilization.
(Treatment to determine the cause of infertility - such as examinations,
diagnostic testing and surgery - is covered in the same way as any other
illness. If a medical condition is established, treatment of the condition is
also covered. But treatment to cause pregnancy when no medical condition is
established, or to reverse sterilization, is not covered.)

•                  Treatment of eye refractions, eye exercises or vision
training, or the fitting or cost of eyeglasses or contact lenses. (Contact
lenses are covered only when required as a result of cataract surgery.)

•                  Foot orthotics, orthopedic shoes, cervical collars (except as
specifically provided), athletic equipment, or protective wear.                .

•                  Services provided or paid by the U.S. Government or any of
its agencies.

•                  Nonmedical equipment used in the home, such as sun or heat
lamps, heating pads, whirlpool baths, exercise devices, ramps, handrails, air
conditioners, purifiers or humidifiers.

•                  Cosmetic or reconstructive surgery except for repair of
congenital birth defects in a newborn infant, repair of injuries received while
covered by the plan, or repair of defects which result from surgery for which
plan benefits were paid,

•                  Custodial care.

•                  Injury or sickness resulting from war or armed aggression, or
incurred during active duty or training in the armed forces, National Guard, or
Reserves of any state or country.

•                  Expenses that would be payable in the absence of this
coverage under the extension of benefits provision of a prior group health plan.

 

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