UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF MICHIGAN

SOUTHERN DIVISION

WILLARD L. SLOAN, EUGENE J.

WINNINGHAM, and JAMES L. KELLEY, 

on behalf of themselves and a similarly 

situated class, Case No. 09-cv-10918

Hon. Paul D. Borman

Plaintiffs, Magistrate Mona K. Majzoub

v. Class Action

BORGWARNER, INC., BORGWARNER 

FLEXIBLE BENEFITS PLANS and

BORGWARNER DIVERSIFIED 

TRANSMISSION PRODUCTS, INC.,

Defendants.

_____________________________________________________________________________/

EXHIBIT 30 

TO 

PLAINTIFFS’ MOTION 

FOR SUMMARY JUDGMENT

AS TO LIABILITY

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 1 of 55 Pg ID 5762
UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF INDIANA 

INDIANAPOLIS DNISION 

BORGW ARNER DNERSIFIED TRANSMISSION PRODUCTS, INC., 

v. 

UNITED AUTOMOBILE, AEROSPACE AND AGRICULTURAL IMPLEMENTS WORKERS 

OF AMERICA, LOCAL NO. 287, et 31. 

CIVIL ACTION NO. 1 :06CV0058 

UA W LOCAL 287'S APPENDIX IN SUPPORT OF ITS 

MOTION FOR SUMMARY JUDGMENT AND IN OPPOSITION TO 

BORGWARNERS' MOTION FOR SUMMARY JUDGMENT 

Hourly Retirees fusurance Booklet Draft 

dated March 24, 1987 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 2 of 55 Pg ID 5763
I 

Interoffice "'-'emo 

100 

-

W .. _ 

Drive 

Chlcag. 

IBiaDIs. 

601106 

Tot.phone 

3127829700 

BOrgW'amer 

Data March 24,' 1987 

r. 

Hourly Retirees Insurance Booklet Draft 

Bill Studlow 

Dick Nuerge 

Enclosed isa draft ,of the insurance booklet for your hourly retirees prior to October 1, 1986. 

Omitted from the draft are the Dental, Hearing and 

Substance Abuse plans. Included are Organ or Tissue 

Transplant, Mandatory Second Surgical Opinion and 

Medical Case Management benefits. If a benefit is 

included that should not be, please so indicate on the 

draft. 

If the retiree benefits detailed in this draft are the 

same as the benefits listed in the retiree section of 

the active employee booklet, you may want to forego 

this draft and order additional employee booklets for 

distribution to the pre-10/l/86 retirees. 

Dick, if you have any questions do not hesitate to 

contact me. 

BS:ds//4602G 

Enclosure 

cc: Marty Burghgraef 

DTP013873 

1 

'j 2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 3 of 55 Pg ID 5764
, , 

CONTENTS 

Plan of Insurance 

SECTION I - Life Insurance Benefits 

SECTION II - Basic Hospital and Medical Benefits: 

Hospital Confinement Benefits 

Surgical Benefits 

Mandatory Secona Surgical Opinion Technical Surgical Assistance 

In-Hospital Medical Expense Benefits 

Prolonged Attendance Benefits 

Examination of a Newborn 

Medical Emergency Benefit 

Diagnostic X-Ray and Laboratory Benefits 

Physiotherapy Benefits 

Radiation Therapy Benefits 

Convalescent & Long Term Illness Benefits 

Out-Patient Psychiatric Care Benefits 

Prescription Drug Benefits 

Chemotherapy Benefits 

Vision Care Benefits 

SECTION III - Major Medical Expense Benefits 

SECTION IV - Medical Case Management /:/'&'" "F-r s:'~""rI{lM/ v:.()'/!!~1Jlv ~R-c TlSSV6iRJJJJ.fPLR Pi (,y:::vc I 

SECTION jQC- Participating in the Plan 

SECTION ~- Termination of Insurance 

SECTION VIII,- Certificate 

Page 

2 

4 

6 

6 

8 

10 

10 

11 

12 

12 

13 

13 

14 

17 

18 

22 

24 

26 

30 

34 

36 

41 

43 

DTP0I3874. . 

" 

, 

, 

, 

, 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 4 of 55 Pg ID 5765
Dear Transmission Systems Retirees: 

The Basic Hospital and Medical Benefits listed on the Pl an of insurance page and explained in the pages that follow is designed" to provide protection from 

the financial burden a serious illness or accident often imposes and includes 

liberal life insurance coverage; , 

The full cost of all health insurance is paid by the Company along with 

certain Life Insurance coverages based on your date last worked and your years of service. " 

1 

RiChard A~ Ntienle 

Manager 

Insurance & Pensions Department 

" Transmission Systems 

DTP013875 -

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 5 of 55 Pg ID 5766
PlAN OF INSURANCE 

FOR VOU AHD YOUR DEPENDENTS 

BAStc HOSPITAL AffD MEDIcAL BENEFIts 

DallY 

Hospital Extra Surgical Life Benefit Hospital Expenses Insurance Up to Charges Up to 

* Usu.l and ** ** Customary Usual Usual 

Cost of and Cus- and CusSeml- t~mary tomarY 

Private 

Room 

* Employee, Retired on/after 3/1/74 

keep Full Life amount in effect the 

day prior to retirement until age 65, 

then Life reduces per schedule described 

on following page,. Employees retired 

on Total and Permanent Disability Pension 

also keep the Transition and Bridge benefit until age 65. 

X-Ray and Major All 

In-Hospital Laboratory Medical OutMedical Expenses Expense Patient 

Expense Up to Up to"" Surgery 

** ** $200,000 Paid at 

Usual Usual 100% 

and Cus- and Customary ~omary 

+ Basic Hospitalization and Medical benefits also include: - Prolonged Attendahce Benefits - Examination of a Newborn - Physiotherapy Ban.fits - Radiation Therapy Benefits - Eonvalescent and ,Long Term Illness 

Benefits - Out-Patient Psychiatric Care aenefits - Pr.escription Drug Benefits - COoemotheropy Benefits - Medical Emergency aenefits - Vision Care Benefits 

Employees Retired prior to 3/1/74 have 

retired Life benefits as described in 

booklets and Health Insurance Agreements applicable at the time of retirement. (Effe,ttve 4/1/81 these amounts 

are increased by $500.) - Mall Order Drug Plan - se. ynur Senefit 

Administrator for further information. ~-/Jdff!1Pl 

under age 65: your coml>illed 10 perce Medical) of Hlj>a#entl!;&j;iiiliie' • c~lle",j.~ ye.r will not exceed $300 per individual 

nor ~OO for all insured family members. When these limits are reached, plan payments for 

NoSPlrlJl.. ..... r..,..t! nt and Mi<lG&~"- expenses increase from 90 percent (Dr 80 percent under Major Medical) to 100 percent for the remainder of the calendar year. 

~xpen.es counted towards the stop-loss limits only include your 10 percent share (or 20 

percent under Major Medical) of covered items. 

SlOP tp~-; 

tW ';vXu~ 01\\ 

~ ~ ,"' rf

3

t"0;_ .. _ .._0 

2 

DTP0I387f; . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 6 of 55 Pg ID 5767
PLAN OF INSURANCE (Continued) 

Th ese items do not count' towards the stop-loss limits: 

. M.~OR Ht;.ore.hll . o the amount you pay for the M'I'seeHm!€11iJtI.S- deduct,ble. 

o the amount the plan reimburses for any covered expense, and 

o any expense not covered by the plan; 

If stop-loss expenses are incurred in December~ they are credited to your 

stop-loss limits in that year and in the following calendar year. 

Any Retired employee or dependent (other than a newborn child) who is 

confined in a hospi'tal on the date a new or increased benefit is to become 

effective will not become insured for that benefit until discharged from 

the hospital; 

F'or' "those 'retirees/survivors" wbo' "have "Medicare: Your combined 10 percent,-r,:-')JtlSf?'PJ 

copayment share (or 20 percent under Major Medi ca 1) of I'ft!3i~~It9*!leli5'eS--" 

iIlfId IfthlellalieilUs expenses incurred during a calendar year will not exceed 

$175 for any individual nor $350 for al1 insured family members. When 

these 1 imits are reached, pl an payments for {RpaU~nt llld IIi seeHallcoQs 

i/NCS1"ITIll-eXpem;es increase from 90 percent (or 80 percent under Major Medical) to 

100 percent for the remainder of the calendar year; 

Expenses counted towards the stop-loss limits only includ~ your 10 percent 

share (or 20 percent under. Major Medical) of covered items. 

""'Ti-lG:SE" mU"I$ Pe. war aOf)N1"" TawJ;)RDS 'TNIS.' Srap-I....oss UM rrs: 

o the amount you pay for the.t1~ s sell tlMIHIS deduct i b 1 e; . 1I\~1l: M«:DI<tJ:ll.. 

o the amount the plan reimburses for any covered expense, and 

a any expense not covered by the plan. 

If stop-loss expenses are incurred in December, they are credited to your 

stop-loss limits in that year and in the following calendar year. 

3 DTP013877- " 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 7 of 55 Pg ID 5768
SECTION I - LIFE INSURANCE 'BENEFITS 

A~ Normal Retirement Benefits 

If you retire under the Normal Retirement provisions of the Company Retirement Income Agreement on or after April 1, 1974, a portion of your Group Ufe Insurance will be: continue at no cost to you as outlined 

below; (Your Normal Retirement Date will be your 65th birthday or the 

first of the month following the month of attaining age 65.) , 

1: For employees retired on or after April 1; 1974 but prior to April 1. 

1980.* . 

(a) If you hare 20 years or more of Continu0uS Service., the amount 

continued is determined as follows: . 

-' , , .. , ' 'YMr' 'of' Retirement' . ~ .. ' ... 3rd Year . and 

" , , " ... "', .. , .. , --., .. -- "lst'YeaY',··, ,2tll!:Year"" . thereafter 

$4,800 $4.200 $3.600 

(b) If you have 10 through 19 years of Continuous Service; 

". -- .... -Vein" 'of' Retirement _ ... ' ... , 3rd Year 

and .. ' , . , , .. ' ......... , .... , .... 'lst'Year" '''2nd 'Year' .. "thereafter 

$3,600 $3,000 $2,400 

* Effective 4/1/81 the amounts shown in (a) and (b) above will be 

increased by $500: 

2. For Employees retired on or after April 1;.1980; 

(a) If you hare 20 years or more of Continuous Service, the amount 

continued is determined as follows: 

,', . , . , . 'Year' of Retirement 

1st Year 2nd Year 

$5,400 $4,800 

3rd Year 

and 

thereafter $4,200 

(b) If you have 10 through 19 years of Continuous Service, 

1st Year 

$4,200 

4 

Year of Retirement 

2nd Year 

$3,600 

3rd Year 

and 

thereafter 

$3,000 

DTP013878 ' 

\ 

I 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 8 of 55 Pg ID 5769
B~ Early Retirement Benefits 

If you retire early under the provision of the Retirement Income Agreement 

you may elect to continue your amount of insurance in effect on ·the day 

preceding your retirement date by completing an agreement to pay the 

required contribution for such amount of insurance. When you reach age 65 

or cease to make the required contribution. whichever is, earlier, your 

amount of insurance will be determined in accordance with the schedule 

outlined under A; above; 

By Special Agreement for those employees retired on or after March l~ 1974 

and effective July 1, 1974, employees who maintained tb.eir full 1 He 

insurance amount in force for the above prpviSion al)d .those retired on or 

after July 1. 1974 will have their life insurance amount in effect' 

immediately prior to retirement continued in that amount until age 65. At 

age 65 the . amount. reduces in the three steps outlined under Normal 

Retirement A. above. 

C~ DisabiTity Retirement Benefits Life 

If you become totally and permanently disabled and retire under the Total 

and Permanent Disability Retirement provisions of the Transmission Systems 

Retirement Income Pl an Agreement the full amount of Life InSUrance in 

effect on the date of such disability retirement will be continued until 

your Normal Retirement Date at which time Life Insurance will be reduced 

in accordance with the schedule outiined under A: above: 

D~ Limitations . 

Such Life Insurance will be continued only while the insured plan 

continues in effect and while the insurance plan remains unchanged in this 

respect •. 

An employee who qualifies under the provisions of this section and who 

retires under the Transmission Systems Retirement Income Plan Agreement 

shall be considered an employee for Group Life Insurance purpos~s; 

therefore, the Conversion Privilege shall not apply to those so retiring. 

Employees who terminate their employment with the Company and who are 

entitled to Vested Deferred Retirement Benefits are not eligible for 

continued Life Insurance Benefits. 

5 DTP013879 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 9 of 55 Pg ID 5770
SECTION II - BASIC HOSPITAL AND MEDICAL BENEFITS 

Hospital Confinement Benefits 

When benefits are payable 

Benefits are payable for confinement in a legally constituted hospital as a 

result of an accidental bodily injury or illness not connected with 

employment. Such confinement must be for at least the minimum period specified below and must be recommended by a legally qualified physician. 

Cause of Minimum Period Confinement· '" .. " ..... , ." 'of'l!onfinemerit ........ " .. " .... , " , .... , .. " , .. , ...... 

Surgery 

Sickness 

Injury 

None Required; 

None Required; if treated in hospital for any unforeseen acute sickness re,quiring treatment of 

an emergency nature~ otherwise a registered bed p~i~t. . 

None Required; if emergency care is rendered, 

otherwise a registered bed'patient. 

How much does phn pay? 

(a) You wi 11 be pai d 90% for the following subject to the Stop Loss 1 imits 

shown on page 2 in this booklet: 

1. The usual and customary cost of the Room and Board charge if 

confinement is in a ward or semi-private room (including nursery charges of an insured newborn child), or if a private room is used," 

the allowance will be equal to the hospital's average charge for a 

two-bed room. ' 

2. The usual and customary allowances for other hospital expenses which 

are recommended by a legally qualified physician. provided such 

expenses are incurred during a confinement period for which Room and 

Board benefits are payable. However. expenses for ambulance service 

will be payable on the basis of the following schedule: 

a. Within city limits - up to $50.00. 

b. Within 50 miles radius - up to $10Q.00. 

c. Over 50 mile radius - up to $150.00. 

Effective April 1, 1982 this ambulance benefit will include medically 

necessary ambulance services from one hospital to another hospital or 

to a CAT SCAN Facil ity if such hospital does not have CAT SCAN 

Facilities. ' 

6 DTPO l388'0 ' 

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" 

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2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 10 of 55 Pg ID 5771
l.~\ 

flow much does plan pay? (Continued) 

3: The actual charge if confinement is to a hospital intensive care, 

coronary care or isolation unit on a day for which the insured person 

would otherwise be entitled to benefits for hospital room and board. 

(This benefit will be paid in lieu of any room and board benefit for 

that day.) i ' U4t 

QiD ~ (b) 

r ~""p,,, 1 "t,,,,,,. "" " '''''''''Y ",., ~1t. oJ" 11 '''' ",, , ,,,",, ,," "-~, 'oor wing within the hospital which is distinguishable from the other hospital 

r'" ~ .\~~>I'faci1ities because it . 

P 

\.yr:~ (a) is operated solely for the purpose of providing room and board and 

''I, :,yJJ I professional care and treatment for critically ill patie.nt,s including J'Al- Gilbo D' constant observation and care by a Registered Nurse (R.N.) or other 

l~':6~ VI highly trained hospital personnel and 

,IIi (b) has speCial supplies and equipment necessary for such care and treatment r available ona standby basis for immediate use: 

The term shall not include any hospital facility maintained for the purposes 

or providing normal post-operative recovery or service: 

HOW long? 

The pl an will pay benefits for as long as 365 days for anyone period of 

confinement, except this maximum period will be reduced by one day for each 

two days of confinement in an extended care facility for the same condition. 

Successive periods of confinement to a hospital and/or an extended care 

facility due to the same or related cause will be considered as one period of 

confinement; 

Maternity benefits 

For purposes of determining the amounts of benefits payable, no distinction is 

made between confinement for maternity and confinement for other reason. 

Not covered by hospital benefits 

Surgical, medical or nursing fees; charges for the purchase of braces, 

appliances or ambulatory apparatus; charges for the rental of braces, 

appliances, or ambulatory apparatus during anyone period of hospital 

confinement which, when added to all previous charges for such rental during 

such period of hospital confinement, are in excess of the price normally 

charged by the hospital for the purchase of any such equipment; blood or blood 

derivatives; confinements and charges not recommended and approved by a 

legally qualified physician. 

7 DTP0138"8f 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 11 of 55 Pg ID 5772
i 

Surgical Benefits (You will be paid 90% for 1;he following.~ subject to the 

Stop loss limits shown on page 2 in this booklet.) 

When benefits are payable 

Benefits are payable for any surgical procedure performed by a legally 

qualified physician as a result of an accidental bodily injury. or illness not 

connected with employment. 

Hospital confinement is not necessary; 

How much? 

Payment will be made on a Usual and Customary basis; 

In determining what constitutes Usual and Customary, the Insurance Company 

will take into consideration: . 

1; The usual fee which the individual physician most frequently. charged to 

the majority of his patients for a similar procedure or service. 

2; The fees which fall within the customary range of fees charged in a 

locality by- most physici ans of similar training and experience for the 

performance of a similar procedure or service; . 

~; Unusual circumstances or medical complications requiring additional time, 

skill and experience in connection with the procedure or service. 

In the absence of' unusual circumstances or medical compl ications as referred 

to in "3" above, the usual .and customary fee will be deemed not to exceed the 

lesser of "1" and "2" above. 

i);.t~£"I. Mandatory Second Surgical Op1nicon 

tvfr This part of the plan will also pay for a mandatory second surgi£.al opinion 

\~ - I [1 under the following conditions: 

, . ty· If an elective, non-emergency surgical procedure is recommended, a second ;;f [fO 

~~. . (surgical opinion. on the need for that procedure must be obtained, before p,t,,jp' surgery, if that procedure is on the list that follows: 

~ff· An elective, non-emergency surgical procedure means a surgical procedure: 

(a) that can be done at the doctor's or patient's convenience; 

(b) for which a person has a choice of whether or not.to have it done. 

8 DTP013882 . 

I 2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 12 of 55 Pg ID 5773
Mandatory Second Surgical Opinion (Continued) 

List 'of Procedures 

1. Bunionectomy (removal of bunion) 2. Cataract removal and/or intraocular implant 3. Cholecystectomy (removal of gall bladder) 4~ Coronary bypass 5. Dilation and Curettage (0 & C) 

6. Hemorrhoidectomy (removal of hemorrhoids) 7. Herniorrhaphy (hernia repair) 8. Hysterectomy (removal of uterus) 9. Knee surgery (including excision of knee cartilage) 10; Laminectomy (removal of part of vertebrae) 

11; Ligation and stripping of varicose veins 12~ Mastectomy and other breast surgery 13~ Prostatectomy (removal of part or all of prostate gland) 14~ Submucous resection (repair of deviated septum) 15. Tonsillectomy and/or adenoidectomy 

The Second Surgical Opinion must be: 

( a) in writing; (b) by a board certified specialist in the specialty of the proposed ,procedure; who personally examines the patient and who is not associated 

with the first doctor who recommended surgery; , . (c) given after the first opinion by another doctor on the need for the same 

procedure. 

Covered Charges for a Mandatory Second Surgical Opinion include: 

(a) charges of the doctor who offers the second opinion; (b) charges for diagnostic x-ray and laboratory exams used by the doctor to 

form the opinion. 

Benefits for covered charges for a mandatory second surgical opinion will be 

paid in full. This amount will be paid for not more than two second opinions for the same procedure after the procedure was first recommended. Each 

opinion must be by a different doctor. 

This benefit is in place of all other benefits for the same charges which 

could be paid elsewhere under the plan. 

If you do not obtain a Mandatory Second Surgical Opinion as required, charges of the doctor who does the surgery wi 11 be 1 imited to 50% of the amount that 

would have been considered for payment if the opinion had been obtained. 

On request, Equitable will provide names of board certified specialists so 

that the patient will be able to comply with this Mandatory Second Surgical Opinion requirement •. (If specialists are unavailable in your area, you will 

be given names of other qualified doctors to satisfy this requirement.) 

9 DTP0I388J . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 13 of 55 Pg ID 5774
Mandatory Second Surgical Opinion (Continued) 

Many of the items 1 i sted above can be provi ded either whil e confined in a 

medical facility or on an out-patient basis; If you have a choice, you are 

encouraged to receive these services on an out.patient basis. In this way you 

help reduce the cost to the plan by eliminating unnecessary confinement and 

you become entitled to 100 percent reimbursement: 

Tecnnical surglc'al assistance 

In the event that necessary techpical surgical assistance is not available as 

a service provided by an intern, resident physician or house officer of the 

hospital in which an operation is performed, the surgeon or surgeons rendering. 

necessary surgical ass i stance to th.e surgeon performing the operation wi 11 be 

paid on a Usual and Customary basis. 

Generally; to be payable; the nature of the operation would be such that the 

skills of more than o"e "Surgeon" are needed to carry-out the surgery for this 

benefit to be payable. 

Corrective cosmetic procedures 

Benefits will be paid for cosmetic surgical procedures provided the surgery is 

for the correction of Ca) congenital anomalies while the individual is less 

than 12 years of age unless medical necessity for delaying the procedure is 

clearly established, or (b) conditions resulting from accidental injuries or 

traumatic scars. 

Obstetrical benefits 

Benefits for an obstetrical procedure will be paid on a Usual and Customary 

basis. Such benefits shall be inclusive of pre~ and post-natal care. 

Not covered for surgical benefits 

Surgical fees for dental work or treatment except for removal of unerupted 

teeth or for multiple extractions if a patient is confined to a legally 

constituted hospital with a concurrent hazardous medical condition. -. 

In~Hospital Medical Expense Benefits (You will be paid 90% for the following subject to the Stop loss limits shown on page 2 in this booklet.) 

Benefits for doctor1s visits 

Benefits are payable for the charges incurred as the result of a legally 

qualified physician's visit to you or your dependents during a period of 

hospital confinement as a registered bed patient because of accidental bodily 

injury or illness not connected with employment. 

How much? 

Payment will be made on a Usual and Customary basis. Usual and Customary is 

defined under Surgical Benefits. 

10 DTP013884 

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1 

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2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 14 of 55 Pg ID 5775
How much? (Continued) 

When surgery is performed; payment will be made for visits by a physician 

prior to surgery, regardless of whether the same physician performs the 

surgery. After the surgery is performed, payment will be made for visits by a 

physician, when such physician is not the one who performed the surgical procedure. 

Bedside consul tat'ion 

In addition to the above you will be paid, on a Usual and Customary basis, for 

bedside consultation during a period of hospital confinement when rendered by 

a physician. other than your attending physician but only when such 

consultation is required by the attending physician as necessary for diagnosis 

and treatment of an injury or illness not connected with emplpyment. 

Consultations rendered by hospital staff members or required by hospital rules 

and regulations are not covered: 

Not covered 

Physicians' charges for visits following a surgical operation unless the 

physician is not the one who performed or assis.ted in the performance of the 

operation; for expenses incurred for eye or hearing examinations, treatment of 

the teeth or periodontium lmless th,e visits are made for treatment of an 

injury; drugs, dressings or medicines. 

No payment will be made for In-Hospital Medical Care of a newborn child unless 

the charges are incurred for treatment, other than routine pediatric care, 

made necessary because of (a) premature birth, (b) abnormal congenital 

condition, or (c) a diagnosed sickness or injury. (A newborn child wi 11 be 

considered to have been born prematurely if the weight of such child at birth 

is less than 5 1/2 pounds) •. 

Prolonged Attendance Benefits (VOLI will be paid 90% for, the following~ 

subject to the Stop Loss limits shown on page 2 in this booklet.) 

How much 

If an injury or illness is such that life is in danger and special medical 

skills and supervision are required which cannot be rendered by personnel 

employed by the hospital, but only by your attending physician, you will be 

paid for the fees charged for the prolonged attendance of your attending 

physician up to a maximum of $16.00 for each hour following the first full 

hour of continuous attendance during one period of hospital confinement. Pro 

rata adjustments will be made for periods of attendance of less than a full 

hour. 

Such benefits are in lieu of Benefits for Doctor's Visits described above. 

11 DTP013885 ' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 15 of 55 Pg ID 5776
Not covered 

No payment will be made for attendance that is not required by the patient IS 

critical state or following a surgical operation unless the physician· i~ not 

the one who performed or assisted in he performance of the operation. In 

addition no payment will be made for eye or hearing examinations, treatment of 

the te~th or .periodontium unless att!lndance is required for treatment of an 

injury, drugs, dressings or medicines. 

Examination of a NewbGfn (You will be paid 90% for the follewing; subject to 

the Stop Loss limits shown on page 2 in this booklet~) 

How milch 

Benefits will be paid up to $15.;00 for the routine examination of a newborn 

child. wh.ile hospital confined, by a physician other than the delivering 

physician. 

Limitation 

Payment will be limited to the initial examination only. No payment will be 

made for charges for which benefits are payable elsewhere under the plan. 

Medical Emergem:y Benefit (Ybu will be paid 90% for. the following; subject 

to the Stop Los~ ·limits shown on page·2 in this ·booklet.) 

How much 

In the event of a medical emergency requlrlng care by a legally qualified 

physician whose services are not otherwise covered by the Plan, the Employee 

will be covered for the physician IS charges up to a maximum of $30 for each 

emergency which shall include all complications arising from the same 

condition or incident. A "medical emergency" is defined as the sudden and 

unexpected onset of a condition requiring medical (not surgical) care which 

the Employee· or Dependent obtains immedfately after the onset or -as soon as 

possible after the onset. Medical emergencies are limited to heart attacks, 

cardiovascular aCCidents, pOisoning, convulsions, diabetic reactions, severe 

allergic reactions resulting in acute respiratory distress, loss of 

consciousness and such other acute conditions as may be determined by the 

Equitable to be medical emergencies. 

Not.covered 

Charges for dental work or treatment. 

12 DTP013886 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 16 of 55 Pg ID 5777
Diagnostfc. X-Ray and Laboratory Benefits (You will be paid 100% for the 

following. ) 

Covered expenses 

Benefits are payable for charges for Diagnostic X-ray and Laboratory 

examinations made or recommended by a legally qualified physjcian, provided 

such examinations did not result from causes connected with employment. This benefi~ will include charges for CAT SCAN procedures (head or other bodily areas) •. 

How much? 

Payment will be made on a Usual and Customary basis; Usual and Customary is 

defined in General Provisions; 

Not covered 

Charges incurred while confined to a hospital; 

examination, or exami nat i on of the teeth. or 

examination is made for diagnosis of an injury. 

charges for eye or ear 

periodontium unless the 

Physiotherapy Benefits (You. will be paid 100% for the fo116wing~) 

When benefits are payable 

Benefits are payable for physiotherapy services when such services are 

performed in the out-patient de~artment of a legally constituted .hospital by a 

qualified physiotherapist, provided that a legally qualified physician has 

certified that such phYSiotherapy is. necessary for treatment of an illness or 

injury not connected with employment. 

How much? 

You will be paid up to $20.00 per treatment subject to a maximum limit of 15 

treatments for any illness or any and all injuries sustained in one-accident. 

Not covered 

Charges for treatment in connection with a chronic condition; charges for 

rental or purchase of braces, prosthetic appliances or other durable 

equipment; charges payable elsewhere under your Group Insurance Program; the 

fees of a physiCian therapist or for any other professional fees; charges for 

more than one treatment per day. 

13 DTP01388-7 -

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I 

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2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 17 of 55 Pg ID 5778
Radiation Therapy Benefits (You will be paid 100% for the following:) 

When benefits are payable 

Benefits are payable for X~Ray. radium or external radiation therapy treatment 

performed by a legally qualified physician or radiologist for any condition 

set forth in the Radi ation Therapy Schedule as set forth on the following 

pages; , 

Hl'iw much? 

You will be reimbursed in accordance with the following Schedule. If more 

than one treatment. is received on any one day~ payment will be limited to the 

treatment which qualifies for the highest maximum amount as determined by the 

Schedule. 

14 DTP01388t . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 18 of 55 Pg ID 5779
" 

RADIATION THERAPY SCHEDULE 

(No payment will be made for conditions not listed) 

Condition Treated by roentgen 

ray, betatron or external 

application of radium 

Mal<imum Payment Per Day of Treatment 

Proven Malignancy 

l~ HEAD AND NECK 

Brain and pituitary;:;;;;;;~;;;;; 

Oral and nasal cavity •••••••••••• Pharynx~ ~ ~ ~ ~ ~ ~~ ~ ... ~ ~ ~ .~~ ~." ~~ ~ ~ ~ ~ ~ 

Larynx ~ -~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Thyroid .....•.•.•...•....•••.•.•• 

2~ CHEST 

Primary .brol!c~o-:PlllmC1n"rY .1l)'!-1ig-:. 

nancy •••••••••••••••••••••••••• 

3; ABDOMEN 

Gastro-intestional tract Esopha9us~~~;~~~~~~~~~~~.;~~~~~ 

Stomach-~ ; ... ~ • ; ~ :. ~ ~ ; ; ~ ~ ~ ~ ~ ; ~ ~ ~ ; 

Colon~; ••••••••••.••••••••••••• ~ 

Genito-urin'!-rY.~r'!-~~., .. , ... , .... Ureters •••• ~ ••••••••••••••••••• Bladder.~.~~~~.~;~; •.• ;~;;~~~~; 

'Testicle' and r~gi~I!"1.I!~d~s~~., 

Kidneys •.•••••••• -........... , .•••.•• 

Prostrate and regional nodes ••• 

Penis and regional nodes:.;;; •• 

Gynecological tract 

Uterus and adnexa •••••.•..•••.• 

4. BREAST 

Unilateral ••••••••••••••••••••••• 

Bilateral .......................... . 

5. MISCELLANEOUS 

Bone ......... .-.......... ".~ •••••• , ... . Leukemia ........................... ~ 

Myeloma ....................... " ............ . Spinal cord ..................... ~ •• 

Polycythemia vera •••••••••••••••• 

Lymphomas (malignant or benign) •• 

6. SUPERFICIAL (skin and lips) Malignant lesions without 

metastasis ....................... . 

15 

16:8B 

22:50 

22:50 

16;88 

16;88 

16.88 

22.50 

16.88 

22:50 

16.88 

11.25 

16:88 

16.88 

11.25 

16.88 

7.50 

Maximum Payment Per Condition 

$450:00 

337.50 

337:50 

337:50 

337;50 

337:50 

337:50 

337.50 

337:50 

450.00 

450:00 

337:50 

337:50 

337.50 

337:50 

450.00 

337:50 

225:00 

337:50 

337:50 

225.00 

337.50 

DTP0138S'9 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 19 of 55 Pg ID 5780
RADIATION THERAPY SCHEDULE (Continued) 

Condition Treated by roentgen 

ray, betatron or external 

application of radium 

Maximum Payment Per Day of Treatment 

Proven Malignancy (Continued) 

6~ SUPERFICIAL (skin and lips) (Continued) Malignant lesions with metastas1s;~~~~~~~;~~~~;~;~~;~~ $ 22~50 

Non~Malignant Conditions 

l~ TUMORS 

Brain and pituitary;;;;;;;;;;;;;; 

Bone ~ ~ ~ ~ •••• ~ ~ ~ ; ~ ; ~ ~ ~ .~ ~ ;. ~ ~ ~ ~ ~ ; ~ ~ ~ 

Sp~nal cord .. •. ~ ~ •.. ~ •••• ~ ~ ~~~. ~ ~ ~ 

2~ AEMANGIOMA ANOVASCUlAR NEV!;;;;; 

3' ~ BURSITIS~ ; ~ ~ ; ; ~ ; ; ; ~ ~ ; ; ; ~ ~ ; ~ ~ ; ~ ; ; ~ 

Treatment of Proven.Malignancy by oral administration, parenteral or 

intracavitary i~jection of radio-

$ 22;50 

16.88 

16;88 

7 ;50 

7;50 

active isotopes. Initial treatment;;;;;;;;;;;;;; 75;00 

Each additional treatment;;;;;: 37;50 

Maximum Payment Per Condition 

$112.50 

$450;00 

337.50 

337.50 

75~00 

75;00 

Maximum for all such treatments of 

anyone mal ignancy 225:00 

Treatment of Proven Malignancy by implantation of radium or radon 

seeds by endoscopy (excluding cost 

of radioactive material). 

Up to 3 seeds •••••••••••••••••• 

4 to 8 seeds.~ ••••••••••••••••• 

9 to 13 seeds ••••••••••••••••• ~ 

14 to 18 seeds ••••••••••••••••• 

18 and over ••••••.••.•••••••••• 

$ 37;50 

75:00 

112:50 

150.00 

225;00 

Not c-overed Charges which result from di agnosti c procedUres and those for conditions not listed in the 

schedule; charges for the purchase. rental or 

cost of radium or other radioactive materials; 

for' the use of roentgen rays or the rays of other 

radioactive material for diagnostiC purposes or 

charges which are covered under any other portion of the Transmission Systems Group Insurance Plan. 

16 DTP013890 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 20 of 55 Pg ID 5781
ConvalescE!nt & Long-Term Illness Benefits (You will be paid at 90% for. the 

following; subject to the Stop Loss limits shown on page 2 'In this booklet.) 

When benefits are payable 

Benefits are payable for confinement as a registered bed patient in an 

E)(tended Care Facility (as defin.ed below) due to injury or long-term illness, 

provided such confinement occurs within 14 days of a confinement which has 

la$ted a minimum of 3 days in a legally constituted hospital and that such 

E)(tended Care confinement was for the same or related cause as the previous 

hospital confinement; In the case of confinement for mental illness; transfer 

from the legally constituted hospital must be immediate; 

(EXTENDED CARE FACILITY; The .term e)(tenqed care facility means a convalescent 

chronic disease facil ity or nursing home, whether operated independently or as 

part of a general hospital, which is accredited by the Joint Commission on 

Accreditation of Hospitals or is recognized as an E)(tended Care Facil ity by 

the Secretary of Health, Education and Welfare of the United States pursuant 

to Title XVIII of the Social Security Act of 1965, as amended, provid~d that 

such facility is approved by Equitable at the time confinement commences.) 

How much does plan pay? 

You will be paid: 

I ~ The full cost of Bed and Board charged by the Facil ity for a ward or a 

semi-private room. If a private room is used the allowance will be equal 

to the average charge made by the Facil ity for a two-bed room; However, 

the daily benefit payment should not e)(ceed the most common charge for a 

two-bed room of the legally constituted hospital to which the patient was 

confined immediately prior to his confinement in the Extended Care 

Facility. 

2. The charge made for necessary services and supplies by 

Facility (other than nurses' fees or physicians' 

recommendation of a legally qualified physician. 

How long? 

the E)(tended Care 

fees) upon the 

The ma)(imum number of days for which you may receive payment is based on a two 

year period (730 days). For primary mental illness the maKimum period is 90 

days. 

To determine the actual number of days for which you are eligible under this 

benefit, the 730 or 90 day figure must be reduced by 2 days for each day of 

confinement in the legally constituted hospital for the same condition. 

For retired employees age 65 and over the two-day reduction clause does not 

apply for the first 100 days of confinement in the Facility. 

DTPOU891 

17 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 21 of 55 Pg ID 5782
Not covered 

No benefit will be paid for: 

Confinement in an institution. used principally as a rest facility or facility 

for the aged, drug addicts. or alcoholics or primarily for custodial or 

dom! cil i ary purposes; confinement for tuberculosis, menta,lretardation, 

senility or similar conditions not subject to favorable modification by 

medical treatment; charges for unnecessary care or treatment; 

Successive periOds of confinement in an extended care facility resulting from 

the same injury or same or related sickness will be considered one period of 

continuous confinement unless they are separate~ by 6 months, or in, the case 

of an active employee. by his/her return to work.; 

Doctor's vi'slts during cOrifinements in an Extended Care Facilfty (Vou will 

be paid at 90% for til!! following,; subject to the Stnp loss limits shown on 

page 2 in thi's bookleD •. ) 

Benefits are payable for charges by a legally qualified physician for 

treatment received. Payment wi.l1 be made for only one visit per day and 

limited to two visits per week. Benefits for visits are payable up to the 

following amounts: 

1st Visit 

2nd Visit 

3rd Visit through the 10th Visit 

11th Visit and thereafter 

Not covered 

$15;00 

10;00 

4:00 per' visit 

3.00 per visit 

No pa~:nt will be made for the physician who is responsible for the 

supervlslon of the Facility, unless he is in charge of the patient's case. 

Payment wi 11 not be made for charges for treatment in connectiun with the 

teeth or periodontium. eye or ear examinations, nursing services, drugs. dressings, or medicines, or for fees charged for treatment received after an 

operation is performed. 

Out-Patient Psychiatric Care Benefits 

When benefits are payable 

Benefits are payable for Psychiatric Services for treatment of mental illness 

or functional nervous disorders, when such services are' performed at: (a) an 

Out-Patient Psychiatric Facility,' upon recommendation of a qualified 

phYSician, and (b) for charges for such services billed by a physician (or in 

the case of psychological testing, by a Psychologist). 

DTP0138~2' 

18 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 22 of 55 Pg ID 5783
How much? 

You will be paid a percent of Actual Charges Considered a Covered Expense under the following Schedule of Out-Patient Psychiatric Care Benefits subject 

to a maximum limit of $1,000 per patient per calendar year; 

OUT-PATIENT PSYCHIATRIC CARE SCHEDULE 

% of Actual 

Charge 

Psychiatric Service 

A-l Out-Patient Psychiatric Facil ity 

A-2 Electro-shock Therapy and 

Anesthesia for Electroshock Therapy ,Initial 

Subsequent 

A-3 Prescription Drugs and 

Medication dispensed by Out-Patient Psychiatric Facility (as of January l~ 

1970 this will not apply to 

individuals insured for 

Prescription Drug Benefits) 

*A-4 Psychological Testing 

A-5 Visits by Members of 

Patient's immediate Family for counseling by other 

than Qualified Physician 

B-1 Full Psychotherapeutic Session (50 minutes) 

1st through 5th SeSSions 

6th through 10th Sessions 

11th through 15th Sessions 

16th and subsequent Sessions 

Considered a Maximum Payment Covered Expens'e Not to Exceed 

19 

100% $30;00 for each day on 

which a visit is made 

or overnight confinement occurs; 

100% ' 

100% 

100% 

100% 

100% 

100% 

85% 

70% 

55% 

$50;00 per treatment 

$40.00 per treatment 

$ 5.00 per prescription 

$76;50 per 12 consecutive months 

$10.00 

$50;00 per session 

$42.50 per session 

$35.00 per session 

$27.50 per session 

DTP013893 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 23 of 55 Pg ID 5784
OUT-PATIENT PSYCHIATRIC CARE SCH·EDULE (Continued) 

% of Actual 

Psychiatric Service 

B-1 Full Psychotherapeutic Session (50 minutes) (Continued) 

Half Psychotherapeutic Session 

(20 minutes to 50 minutes) 

1st through 5th Sessions. 

6th through 10th Sessions 

11th through 15th Sessions 

16th and subsequent Sessions 

B-2 Group Psycho1therapeutic Sessions 

B-3 Visits by Members of Patient's 

Immediate Family 

Patient 19 years of age or more 

Charge Considered a 

Covered Expense 

100% 

85% 

70% 

55% 

85% 

85% 

Patient less than 19 years of age 

lst·through 5th visit 100% 

6th through 10th visit 85% 

11th through 15th visit 

16th through 20th visit 

*8-4 Psychological Testing 

B-5 Limited Treatment in OutPatient Psychiatric Facility 

70% 

55% 

85% 

100% 

Maximum Payment Not to Exceed 

$30;00 per session 

$25; 50 per ses.s i on 

$21.00 per session 

$16:50 per session 

$.8:60 per session 

$42:50 per full session 

$25.50 per half session 

Maximum of 5 visits 

per patient 

Same as B-1 depending 

on whether full or 

half session 

Maximum of 20 visits 

per patient-· 

$76.50 per 12 consecutive months 

$10.00 per day on 

which visit is made 

* Combined benefits under A-4 and B-4 not to exceed $76.50 in any 12 

consecutive months. 

20 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 24 of 55 Pg ID 5785
OUT-PATIENT PSYCHIATRIC CARE SCHEDULE (Continued) 

LIMITATIONS: No payment will be made for expenses incurred for 

(1) psychiatric services rendered in connection with emotional and 

personality disorders and illness not classified ,a!? "., such in the 

International Classification of Dis~ases of the, U.S. Department of 

Health, Education and Welfare (V. Psychoneurotic and, Personality 

Disorders No; 300-329; as amended); 

(2) psychiatric services extending beyond that period of time reasonably 

necessary, according to generally accepted professional standards, to 

evaluate the patient's disorders and illness and determine whether the 

same is amenable to favorable modification by accepted psychiatric 

treatment: 

For the purpose of determining the appropriate percentage of the actual charge which is considered a covered expense, a resumption of, psychiatriC sessions 

within a period of twenty-four months shall be ,considered to' be a continuation 

of the qriginal series of treatment se~sions. Each session, regardless of 

duration, shall be counted as one session. 

Covered Expenses 

Not covered 

Subject to certain provisions and qualifications, the following are considered as covered charges: 

1 ~ Professional Staff and ancillary services of 

Out-Patient Psychiatric Care Facility 

2. Drugs dispensed by Out-Patient Facility 

3. Services of other qualified physicians 

4. Electro-shock and anesthesia therefor 

5. Psychological 

psychologist testing by qualified 

6. Counseling visits of patient's family. 

Psychiatric Services for untreatable mental 

deficiencies or retardation; services which 

cannot, according to ,'generally accepted professional standards, reasonably be expected to 

achieve a favorable modification of the emotional 

or personality disorder or illness of the 

patient. Psychiatric services provided without 

cost to the employee or dependent under any health care program supported in whole or in part by Funds of the Federal Government or any state 

or pol itical subdivision thereof or which would 

be so provided if no insurance coverage existed; 

services provided elsewhere under the Group plan. 

21 DTP013895 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 25 of 55 Pg ID 5786
Prescription Drug Benefits 

Definitions 

Prescription L.egend Drug means any medicinal substances, the label of which 

under the Federal Food, Drug and Cosmetic Act is required to bear the legend, "CAUTION: federal, L.aw Prohibits Dispensing Without A Prescription, II and 

injectible insulin. 

Physician shall mean a doctor of medicine~ a doctor of osteopathy or a 

podiatrist, a doctor of dental surgery or a doctor of dental medi,cine, legally licensed to prescribe medications within the scope of his license. 

Provider means any pharmacy~ physician, dentist, Qr any other person or 

organization legally licensed to dispense Legend Drugs. 

Prescription order shall mean the request for each separate drug or medication 

by a Physician or Dentist and each authorized refill of such order. 

What is covered? 

Covered Drug Charges are those incurred while insured and on account of 

accidental bodily injury or sickness not connected with employment. These 

charges shall only include the usual and customary charges which are in excess 

of the deductfble amount. 

What are covered drug cha~ges? 

Covered Drug Charges consist of charges for Legend Drugs and injectible insulin when dispensed by a physician or a licensed pharmacist upon written 

prescription order, and needles and syringes for the, injection of insulin in a 

quantity relative to the amount of insulin dispensed. 

How 'much? 

Covered Drug Charges in excess of $4.00 per NON-GENERIC prescription will be 

reimbursed. The GENERIC'deductible is $2.00 per prescription or ref}ll. 

Maximum quantities 

Benefits will not be paid for drugs dispensed in quantities greater than a 

34-day supply with the exception of Maintenance legend Drugs which may be 

dispensed in accordance with the following table: 

22 DTPO 1:f8c:j6 

", 

, 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 26 of 55 Pg ID 5787
Maximum quantities (Continued) 

Maintenance Legend Drugs to be Dispensed in 

Maximum Quantiti,es of 34-Day Supply or lOO':'Unit .. , P, ...... , _ .. , .. , q p q 'Doses; -Whichever,is,Sreater" ...... q _ ...... , .... - q, ...... , 

Acetazolamide Metolazone 

Acetohexamide Nitroglycerin Allopurinol Pentaerythritol Tetranitrate 

Bendrofl umethi azide Phenylbutazone Senzthiazid.e Poly thiazide 

Chlorothiazide Potassium Chloride Liquid Chloropropamide Primidone 

Colchicine and Probenecid 

Colchicine-Probeneciq _ _ Propranolol Hydrochloride Conjugated Estrogens U.S.P. Quinidine Sulfate 

Digitalis Leaf Reserpine Digitoxin Spironolactone Furosemide Tolazamide 

Sitalin Tolbutamide 

Hydrochlorothiazide Triamterene 

Methychlothiazide Trichlormethazide 

Isoniazid Para-Aminosalicylic Acid 

Natural Thyroid Phenytoin (Diphenylhydantoin) Levothyroxine Thyroglobulin L iothyronine Propylthiouracil 

Not covered 

Covered Drug Charges shall not include expenses incurred: 

1. for drugs during a period of hospital confinement; 

2. for drugs or medicines lawfully obtainable without the Prescription Order 

of a Physician or Dentist; 

3. for that portion of the charge which is in eXcess of the usual and 

customary charges for the drug or medicine dispensed; 

4. for contraceptiVe medication, even if such medication is a Prescription Legend Drug, and any charge for therapeutic devices or appl iances (e.g., hypodermic needles and syringes. except as provided for the injection of 

insulin, support garments, and other non-medical substances) regardless of 

their intended use; 

5. for the administration of Prescription Legend Drugs or Injectib1e Insulin; 

6. for any prescription refill in excess of the number specified by the 

Prescription Order, or any refill dispensed after one year from such order; 

7. for which the employee or dependent is entitled to receive reimbursement 

under Worker's Compensation Laws oris entitled to without charge under 

any local, state or federal government programs; 

23 DTP0138'3-7 ' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 27 of 55 Pg ID 5788
Not covered (Continued) 

8; for drugs for which a benefit is payable under another part of these Basic 

Hospital and Medical Benefits; 

How do you file a claim? 

If you take your prescription to a provider which has agreed 'to participate 

through Pharmaceutical Card System; Inc; (PCS) in the prescription drug plan of Borg-Warner Corporation: 

1. Be prepared to pay up to $4:00 for NON-GENERIC or $2:00 for GENERIC,' and 

2. if the cost of a prescription exceeds the stated deductible present your PCS plastic identification card to the provider and complete and sign the 

upper right-hand section of the provider's claim voucher. 

If you take your prescription to a provider which is not a participating PCS 

Member: . 

1: obtain a prescription drug direct reimbursement claim form from your Insurance Office, take it to the provider; 

2: if the cost of the prescription exceeds the stated deductible fill-out the 

employee portion, have.the provider complete the pharmacy portion; 

3. pay the provider for the full cost of the prescription; 

4. mail the completed form to PCS for processing: 

Chemotherapy Benefits 

Hospital Charges (In-Patient or Out-Patient) For Chemotherapy 

Chemotherapy benefits are provided on both a hospital in-patient and 

out-patient basis to cover malignancies~ provided that such cond'itions are 

treated according to the rules and regulations of the hospital. The therapy includes use of any equipment, supplias and facilities required for proper administration of the chemotherapeutic agent, provided that such medication 

has been accepted for. inclusion in the U.S. Pharmocopeia, National Formulary, 

or has been accepted by the Federal Drug Administration and/or has received 

official approval by the American Medical Association Council on Drugs. 

The application of experimental or research chemotherapeutic drugs and/or the 

use of any equipment associated with chemotherapy rendered in the home are not 

covered benefits. 

Intra-arterial infusion chemotherapy 

a. lntra-arteri al infus ion chemotherapy is the use in cancer therapy of a 

mechanical pump to infuse various medicaments at 'a controlled rate through 

a catheter placed surgically in an artery of an arm or a leg. 

24 DTPOl3'B98 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 28 of 55 Pg ID 5789
Intra-arterial infusion chemotherapy (Continued) 

b~ Benefits will be allowed when provided at the hospital and treatment 1s 

not on an investigative Qr research basis; Usage .of equipment in the home 

is not a covered benefit. 

Medical 'care for chemotherapy 

Chemotherapy is the treatment of malignant disease.s by chemical antineoplastic 

agents. Therapy involves administering the agents at a controlled rate 

through a catheter placed surgically in an artery. ' 

When benefUsare payable 

Benefits are payable for separate administration of in-patient'Chemotherapy in 

1 leu of an in-patient medical day benefit, when rendered by a physician. Benefits ar~ also payable for hospital out-patient and physician's office 

Chemotherapy. Coverage is for the following categories of therapy: 

a. Parenteral (excluding subcutaneous or intramuscular); 

b; Infusion (continuous or intermittent); 

c. Perfusion; and 

d. Intracavitary; 

Benefits are also provided for up to three follow-up visits following each 

treatment (limited to one such visit per week). A follow-up visit is defined 

as a scheduled visit which would have resulted 'in the administration of a 

chemotherapy treatment except for medical complications which caused a 

postponement in the administration of the treatment. 

Covered chemotherapy drugs 

Covered Chemotherapy drugs (antineoplastic agents) are those whlcQ.have been 

accepted for inclusion in the U.S. Pharmacopeia, National Formulary, .or has 

been accepted by the Federal Drug Administration and/or has received official 

approval by the American Medical Association Council on drugs. 

Not covered 

Benefits are not provided for oral Chemotherapy, SUbcutaneous or intramuscular 

injections of drugs, experimental or research Chemotherapy drugs (antineoplastic agents), or administration in the home. 

DTP01389~ . 

25 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 29 of 55 Pg ID 5790
Vision Care Benefits 

Definitions 

"Opthalmologist" means any licen:!ied doctor of medicine or osteopathy legally 

qualified to practice medicine, including the di~gnosis, treatment, and 

prescribing of lenses related to conditions of the eye. 

"Optometrist" means any person legally licensed to practice optometry as 

defined by the la~s of the state in which the service is rendered. 

"Optician" means one who makes or sells eyeg1asses prescribed by an 

ophthalmologist or optometrist to cure or correct defects in the eyes, and 

grinds the lenses or has them ground according. to prescription, fits them. into 

a frame, and adjusts the frame to fit the face. 

"Participating Provider" means an opthalmologist; optometrist; or optician who 

has signed an agreement I:/ith the Equitable to provide frames to individuals 

insured for this coverage. 

"Nonparticipating Provider" means an oplithalmologist; optometrist, or optician 

who has not signed an agreement wi.th the Equitable to provide frames to 

individuals insured for this coverage. . 

"Contact Lenses" means opth.almic corrective lenses; as prescribed by an 

opthalmologist or optometrist, to be fitted directly to the patient's eyes. 

"Lenses" means ophthalmic corrective lenses; as prescribed by an 

opthalmologist or optometrist, to be fitted into a frame. 

"Frame" means a standard eyeglass frame into wldch two lenses are fitted. 

"Covered Vision Expense" means the Usual and Customary Charge for vision care 

services and materials, as described below when provided by ophthalmologist, optometrist, or opticians. . 

Covered vision expenses 

A. Vision Examinations: 

1. Refraction, including case history, coordinating measurements, and 

tests; 

2. The prescription of glasses where indicated; and 

3. Examination by an ophthalmologist, upon referral by an optometrist, 

within sixty days of a vision examination by the optometrist. 

26 DTP013900 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 30 of 55 Pg ID 5791
Covered vision expenses (Continued) 

B. Lenses and Frames: 

When lenses are prescribed by an ophthalmologist or optometrist, the 

necessary materials and professional services connected with the ordering. 

preparation. fitting; and adjusting of: 

1; Lenses (single vision; bifocals; trifocals; lenticular); If the 

individual selects lenses, the size of which results in an additional 

charge. only the Reasonable and Customary Charge for normal size 

lenses of the same material and prescription will be considered a 

Covered Vision Expense; If the individual selects photochromic lenses 

or lenses "with a tint other than Number 1 or Number 2, only the Usual 

and Customary Charge for clear glass lens~s of the same prescription 

will be considered a Covered Vision Expense. 

2; Contact lenses following cataract surgery; or when visual acuity 

cannot be corrected to 20/70 in the better eye except by their use, or 

when medically necessary du!! to keratoconus. irregul ar astigmatism or 

irregular cor~eal curvature. If contact lenses are prescribed for any 

other reason, $35 is the maximum amount that will be considered a 

Covered Vision Expense; 

3; Frames~ If frames are obtained from a Participating" Provider, the 

individual may make a selection from the display shown by the 

Partici pating Provider and there wi 11 be no out-of-pocket expense to 

the individual other th an as descri bed under "Co-Payments. II However, 

if the selection at the Participating Provider is not from the display 

shown. or if the individual obtains frames from a Nonparticipating 

Provider, $15 is the maximum amount that will be considered a Covered 

Vision Expense. 

Co-payment 

For each person, there is a $5.00 co-payment applicable to the Cov_ered Vision 

Expense for each vision examination and a $7.50 co-payment for the combined 

Covered Vision Expenses for lenses, contaCt lenses, and frames. The total 

copayment for each person, during any period of 12 consecutive months, will 

not exceed $12.50. 

How much 

Benefits will be paid up to the usual and customary charge for Covered Vision 

Care Expenses, less the applicable Co-Payment amount. 

DTP01390r . 

27 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 31 of 55 Pg ID 5792
How much (Continued) 

Benefit amounts will change as of the-dates shown below: 

Type·of-Expense 

Complete exam 

Lenses: 

Single Vision 

Bifocal 

Trifocal 

Contact Lens 

Pl an pays actual 

charge up to a .. -maximum ·of --: 

1/1/87 = $30;00 

1/1/88 = $30,00 

1/1/89 = $30.00 

1/1/87 = $35;00 per pair 1/1/88 = $40,00 per pair 1/1/89 =$45.00 per pair 

1/1/87 = $45:00 per pair 1/1/88 = $50;00 per pair 1/1/89 = $55.00 per pair 

1/1/87 = $55;00 per pair 1/1/88 = $60,00 per pair 1/1/89 = $65.00 per pair 

1/1/87 =$35;00 per pair 1/1/88 = $40:00 per pair 1/1/89 = $45;00 per pair 

Medically Prescribed Contact Lens 1/1/87 = $65;00 per pair 1/1/88 = $70~00 per pair 1/1/89 = $75.00 per pair 

Frames 

Frequency limitations 

For each person. there are the following limitations on the frequency with 

which charges for certain services and materials will be considered Covered 

Vision Expenses: 

Vision Examination 

Lenses and Contact Lenses 

Frames 

- Once during any period of 12 

consecutive months. except as provided in Section A.3. 

- One pair during any period of 12 

consecutive months. 

- Once during any period of 24 

consecutive months. 

DTP013902· 

28 

_I 

I 

I 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 32 of 55 Pg ID 5793
Frequency limitations (Continued) 

Effective January 1; 1987; for each person there are the following limitations 

on the frequency with which charges for certain services and materials will be 

considered Covered Vision Expenses: 

Vision Examination 

Lenses ·and Contact Lenses 

Frames 

Once per ca 1 endar year. except as 

provided in Section A.3. 

- One pair per calendar year; 

- Once during any two consecutive 

calendar years, unless there is· 

medical documentation submitted to 

reflect that the frames were needed 

because the prescription required a 

different change ,that required new 

frames and lenses. However, no more 

than one new frame will be allowed per calendar year. 

The limitations on lenses. contact lenses; and frames apply whether or not 

they are a replacement of lost, stolen, or broken lenses, contact lenses. or 

frames. 

Not covered 

No benefits will be paid for expenses incurred for: 

A. Any lenses which do not require prescription; 

B. Medical or surgical treatment of the eye; 

C. Drugs or any other medication; 

D. Procedures determined by the carrier to be special or unusuaf; such as, 

but not limited to, orthoptics, vision training, subnormal vision aids. 

aniseikonic lenses, and tonography; 

E. . Vision examinations or materials furnished for any condition, disease, 

ailment. or injury arising out of or in the course of employment; 

F. Vision examinations performed and lenses and frames ordered: 

1. Before the covered individual became insured for this coverage; 

2. After the termination of the covered individual's coverage; 

3. To the extent that they are obtained without cost. 

29 DTPO 13903- ' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 33 of 55 Pg ID 5794
SECTION II~ - MAJOR MEDICAL EXPENSE BENEFITS 

Purpose of these benefits 

Major Medical coverage is designed to pay a substantial portion of the 

excessive expenses which may result fr.oma serious accidental bodily injury or 

illness not connected with employment. Hospital Confinement is not necessary 

to be eligible for benefits; 

Amount of benefits 

Payment will be made for 80% of all Covered Charges incurred during a Benefit 

Periad in excess of the deductible amount, except as explained .. under the 

paragraph entitled "Psychiatric Treatment." Such Covered. Charges shall 

include only the u~ual and customary charges for the service, supplies and 

treatment furnished. Benefits will be paid under this plan up to a maximum of ~200.000 with respect to anyone individual in his lifetime; 

If an individual has less than $200;000 of benefits remaining on any January 

1. then an automatic reinstatement of benefits is made in an amount equal to 

the 1 esser of 

1; $1 ,000, and 

2. the amount necessary to increase benefits to $200,000. 

For an individual who has received benefits of $1 ;000 or more, the full 

maximum of $200,000 may be reinstated at the time the Insurance Company 

receives satisfactory evidence of insurability; 

What are covered expenses? 

1. Charges for services by a legally constituted and operated hospi!~l. 

2. Charges made by a physician legally licensed to practice medicine and 

surgery for diagnosis, treatment and surgery. 

3. Private duty nursing service charges of a Registered Nurse. 

4. Charges for local ambulance service, eqUipment, medication, appliances. 

X-Ray services, laboratory tests, the use of radium· and radioactive 

isotopes, oxygen, iron lung, physiotherapy and similar services, supplies 

and treatment. 

5. Oral Surgery charges by a Doctor of Dental Surgery for cutting procedures 

for the treatment of diseases or injuries of the jaw or the extraction of 

impacted teeth if performed while the insured person is confined in a 

hospital for at least 18 hours. 

30 DTP0139(T4 . 

I 

I 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 34 of 55 Pg ID 5795
Charges not covered 

1. Charges fQr services; supplies and treatment unless ,prescribed by a 

physician legally licensed to practice medicine al1d surgery, or, if Oral 

Surgery is performed, by a Doctor of Dental Surgery. 

2~ Charges in connection with dental work or treatment; tooth extractions, or 

dental x"rays, unless such charges are (a) hospital charges incurred whi le 

confined, (b) for oral surgery as provided above, or (c) incurred as a 

result of accidental injury to sound natural teeth occurring while insured. 

3; Charges incurred in a Federal Hospital or because of war; 

4. Charges for eye refractions; the fitting or cost of eyeglasses and hearing 

aids, transportation (except 10calambillB.nce service), h,eal th examinations 

(except in connection with accidental injury or illness). ' 

5" Maternity charges of a dependent child except complications in connection 

with pregnancy, resulting childbirth, mi~carriage or abortion. In 

determining the amount of benefits payable, charges due solely to the 

com. plicatic:ms wi 11 be considered. I 1-- 11/;11 #AhMO I " e~~.vt;; vJi:li ("{'.;i P .... /O~ 1r4JV ) ~ kf,.~J'rn ti,"H-'V.6; ';"'I'-;:'!::Pflt.x·')(.'l- ,.,- . Ded~~tibr: a~;;;Ih~ ~ ~ 0'1""" fA 11-Y,lAM ~1'~ ~. . 

The deductible amount for each individual during any period of six consecutive 

months of a calendar year will be the sum of: 

) [ , . 

) Xl..') 1. a cash deductible of $125, effective October 1, .. 1986'. If prior to ~ '~~ October 1, 1986, you met the,previous deductible of $100, you do not have f.p.'~ to meet the $125 deductible. If prior to October 1, 1986, you did not 

ip II' J.; ~ meet the previous deductible of $100, then the $125 deductible must be ~1)J.,t met, and . . 

2. the amount paid under the Basic Hospital and Medical Benefits. 

The cash deductible applies only once in any calendar year even though you may 

have several different accidents or illnesses; however, the expenses used to 

satisfy such deductible must be incurred within six consecutive months of a 

calendar year, subject to the liberalization described in the following ~' paragraph. . ~ ~ , 

J~< ') {so that your Major Medical cl aim wi 11 not be subject to a deductible 1 ate in ~.N one calendar year and again on January 1 of the following year, any portion of \~ \\ the de. ductible satisfied from October 1 through December 31 will be used to 

'01',) reduce the deductible applicable to the first six months of the following 

'::\ \ \> 'I ca 1 endar year. 

, J', ' 

0"' '( , 

31 DTP01390S. . 

1 

.; 

, 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 35 of 55 Pg ID 5796
Maximum family deductible (Effective January 1; 1987; this benefit will no 

longer app1y~) 

If three members of a family each satisfy their cash deductible during a 

calendar year, then any remaining portion of the cash deductible for the 

calendar year will be waived for all other members of the same family with 

respect to expenses incurred after such family deductible has been satisfied. 

What 1's a beneflt perfod? 

A Benefit Period is the period of time during which an insured person may 

receive benefits with respect to such injury or illness; 

It begins with respect ~o 'an individual when; during a period of six 

consecutive months or less, he accumulates Covered Charges in excess of the 

Deductible Amount; 

It ends on the earliest of 

l~ the December 31 of the calendar year in which it begins; or 

2. the date insurance terminates; 

J

' \. \Jvw\ Common accident 

i Lfi,jd , ~1' If two or more persons insured as members of a family incur Covered Charges ,as eM /, a result of the same accident, only one combined cash deductible of $125, w111 

. ,"l'" be aRplied to the calendar year in which the accident occurs for all such "f ~ members of the family. 

However, such cash deductible 

months of the calendar year. 

following calendar year. 

must be established within six consecutive 

It will be re-applied beginning with the 

Once the $125 combined deductible is satisfied, benefits for each person ~lill 

be determined separately. 

If a family member involved in a common accident should incur Covered Charges 

not related to said accident, he will be required to satisfy the applicable 

deductible amount less his portion of the common accident cash deductible. 

However, in order for this to apply, this' combination deductible (common 

accident and the portion not related to the common accident) must be satisfied 

within the ~ame consecutive six month period of a calendar year. 

Any portion of any cash deductible satisfied from October 1 to December 31 

will be used to reduce the cash deductible to the first six months of the 

following calendar year. 

DTP0139B6· 

32 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 36 of 55 Pg ID 5797
Psychiatric treatment 

Covered Charges incurred in connection with professional fees for psychiatric 

treatment while not confined to a hospital shall not include fees in excess of 

$20 per visit with payment limited to 50% of such Cov,ered Charges, subject to 

a maximum payment of $10 per visit and a maximum ,total payment of $500 during 

anyone period of 12 consecutive months. However, such fees of, a practitioner 

other than a physician legally licensed to practice medicine and surgery shall 

not be covered. 

DTP013907-

33 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 37 of 55 Pg ID 5798
SECTION IV - MEDICAL CASE MANAGEMENT 

What is Medical Case Management 

Medical Case Management is a program to control, high health care costs 

connected with a severe personal injury or sickness. "Severe p.,ersonal injury 

or sickness" means any of the following, which result in the p'erson becoming totally disabled: major head trauma, spinal cord injury, amputations, multiple fractures, severe burns~ neonatal high risk infants, severe stroke. 

multiple sclerosis, amyotrophic lateral sclerosis, end stage cancer, acquired immune deficiency syndrome. 

The objectives of this program; ,once tl:le acute stage of an illness of injury is past and the patient has. stabilized, are ~o find and cover care effective 

and cost effective medical alternatives. Medical alternatives means 

rehabilitation serVices and supplies which: 

o may not be covered under ,other parts of the'plan; 

o can be used in place of other services and supplies that are covered 

elsewhere; and 

o are mor!! appropriate and less costly in the long term care of the 

patient. 

The flexibility of this program allows ali options of care to be explored and 

considered for coverage based on each specific case~ 

When the program begins 

The program will begin when an insured person suffers a severe personal injury 

or sickness and your employer and the Equitable agree, based on an objective review of: 

0 the person's medical status; 

0 the current treatment plan; 

0 the projected treatment plan; 

0 the long term cost implications; and 

0 the effectiveness of care, 

that benefits under this program should be paid because the objectives of the 

program will be met. 

34 DTP0139fJ8' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 38 of 55 Pg ID 5799
How benefits under the program will be paid 

Benefits under this program will be paid in accord with the following provisions: 

o Benefits will be paid for usual and customary charges .for the 

rehabilitation services and supplies furnished to the p~tient. 

o Benefits will be paid to the extent that they are in excess of the 

total benefits payable for such charges under all other parts of the 

plan. , 

o The injury. or sickness must happens and all charges must be incurred 

while the patien.t .is cov~red .under the plan; 

o The amount· of the benef)t payment for these charges will be 

determined by the Equitable. 

o The maximum benefit is subject to the overall lUst. maximum under 

the Gaml" mloenS'i'o'e Health Insurance Plan~ 

35 DTP013909' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 39 of 55 Pg ID 5800
"".-:'!7 SECTION v:k PARTICIPATING IN THE PLAN 

Who is eligible 

You are eligible to participate in this plan if you: 

f) 11- "r;?.JJWSM {'5$(Qe! S'YS~j ___ ? 0 are a retired employee of Borg-Warner('l!1tJ!iP"1/Vc; wt.~ 

o are covered. or eligible to be covered, by the group medical plan at 

J:jl.tJl~}~~~~;)C'§.;}}~re yell bad !~Ql:'k€ftl; and 

o on 'or before Your retirement date, had elected to continue your 

health benefits under the retirement plan at the time of retirement. 

Your eligible dependents are also eligible to participate in this plan; 

,;:: Eligible dependents are your spouse and dependent ci\ildren who are eligible 

O. '..r/fo."f for coverage under your ~ group medical plan. 'f. ,1#£11', "T1't)"",J8I"1tS,;;1 ",,,, S'/ sTt:f"It: ' 

1){? t.. Deferred~vested employees,;' employees who were not insured for health benefits . prior to retirement, . or employees whose coverage terminated ~ before ... , ... ',' ' .... , ... are not el igible to participate. 

Eligible dependents include: 

1ZS.-niU:.D 

A. the lawful wife or husband of the employee; 

"- and 

• ~IRl!.:P . B. any unmarried Chl1d of theAemp10yee who 1S 

--'J3l> 

'?? 

:::» C. 

(1) less than nineteen years of age; or who is nineteen years of age and 

less than twenty-five years of age and enrolled as a full-time 

student. 

(2) not employed on a regular full-time basis, 

~"'TlRe:D (3) legally residing in the household of the employee, I\.. 

R«n1<\W (4) dependent upon' the"employee for more than one-half his support as 

defined by the Internal Revenue Code and either qualifies thereunder 

for dependency tax status in the current year or has qualified as a 

dependent on theVemployee's most recent Income Tax Return, and . F.~7'IRkO . . 

any unmarried child of t~employee who has reached the limiting age (19 

or 25 if a full-time student) while insured and who is 

(1) permanently and totally disabled so as to be prevented from 

performing the duties of any occupation for wage or profit, and 

36 DTP013~l0 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 40 of 55 Pg ID 5801
Who is eligible (Continued) 

--:?' (2) legally residing in the __ thE},. employ~e for. more 

R!;'Y;flW ~agraph B. above. 

C2h11Q€:!) 

hGusehold Of the~emploYee and dependent upon 

than one-half hls support as outlined in 

excluding any dependent child with respect ,to wham a retired 'employee was 

not t"nsured on the day preceding retirement~ . 

In the event that 1t1~Ii851oye'e's marri'age is dissolved by court decree and 

the 'court decrees that the employee retain firianc'lal responsibiHty for 

medical 'care ,fGr iIpy~hi1drenof tlllla~l)Iarr'iage~ s\lth children wj11 be 

con"Sider'ed as dependents 'of t~ef?t_oyee proillded tlui!y '.meet ' the 

requirements set forth in, sub-secti"olll>(1} ~!ld (2) of sectt'onB .. above br 

tinder sub-settlon (1) of s'ection C. abGVEhand leSallyres'lde il1 the 

household of one of. th~ natural pareilt~ o,rare, enr~lledas full-time 

students in 'a scll(Jol., college or univer'~'ityandare dependent 'upon 'one 'of 

the natural 'parents for rnlllre than 'ol1e~ha1f Of their support as indiCated 

in sub-secthjn (4) of section /3.: above~ 

, /2k..I(UD., The term chilli. 'waH incl'ude a (;hild bll, ,rn of tile" employee. a ~hil legally ---- adopttldby th"i!'~~iiIfl1 oyee or a chi W. \'Ii t~ respect to Whlltg., .!/ul ,oyee has 

--;> initia~E1d~le.gal,adoptiOl'l proceedings, ant!! a stepchild, of '\!Ifi!A~' ployee Hving _~;:o>~ with tn~i!lIifil0yee ina normal parent-child relationship. 

rt 1s provided that nll orre may be a dependent who is eHgibl'e for the lnsura:~ce as an employee and 110 one may be a dependent Of more than one I?tnfUD 

emp 1 llyee. l' 

-'.iii>' YOU SHOULD NOTIFr YOliJD~~ EACH TIME iHE NOMBER Of YOUR ELIGIBLE 

DEPENDENTS CHANGES. .\.....~:::-~~ ~ .. 

v-' 

:\Jv~ J!',', Note 

l._if;W Mentally retarded llr physically handicapped dependent children will 'be covered 

I/JJ)~ e~ardless of age. . .. 

l

fJ ,}tf' 

! II ' " II ~.(J 15ponsored dependents 

'Jl' An insured employee may also insure eligible sponsored dependents by the 

employee paying the full 'cost of the coverage. and making appl ication for 

"Sponsored Dependent" coverage. 

A sponsored dependent is: 

);)!t) fi· A per SOil who is related to the employee by b}ood or marriage; or 

~fl!b2. If not related tQ the employee. resides with the employee as a 

)' .', ' his/her household; and , ,f>. ? 11~ ,1/ 

;}j'P'A IlltD . 

{vthV 37 

I" 

member of 

DTP0139U ' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 41 of 55 Pg ID 5802
Sponsored dependents (Continued) 

3; Dependent upon the employee for over half of his support and waS reported 

as a dependent on the employee's most recent Federal Income Tax return. or 

qualifies, in the current year for such dependency tax status (proof 

Q~I required). 

J'k '~ ~ponsored Dependents coverages exclude Major Medical and Vision' and the use of , I' ,:the plastic PCS drug card for prescriptions (the card is not usable for 

f) ~ '71

; epend~nts over 25 except employees spouse) but pre.scription can be covered by 

"(1'1 \.the "Dlrect Reimbursement" feature of the Prescriptlon Drug Pl an. 

)JilJi' , , , ' 

Be'coming eligible for dependents insurance 

Each employee will be eligible for Dependents Insurance on the later of: 

,; the date the employee becomes insured; and 

2; the date the employee acquires his first eligible dependent or sponsored dependent. 

When coverage begins 

1\4E' t;:Ff~Li}W D(JT(; ()F tel/d. !2-e-rJ(tt;{'icM Coverages under this plan will begin on ...... , .. , ...... , ...• 

Payment of claims 

All claims must be reported promptly. Your employer has the forms required. 

Occupational accidents and diseases 

,Benefits are not payable under the Basic Hospital and Medical, Mqjor Medical 

or Vision coverages for occupational injuries or disease which are covered 

under any Workmen's Compensation or Occupational Disease Laws. 

Coordination of benefits 

If an individual covered under the Group Health Insurance Policy (hereinafter 

referred to as "this plan"), is also covered under one or more other Group Plans providing Hospital, Medical, Major Medical or Vision benefits or 

services, then the benefits payable with respect to him under this plan may be 

reduced by the benefits payable under all other plans so that the sum of the 

benefits will not exceed the total Allowable Expenses. Benefits payable under 

another plan include benefits which would have been payable had claim been 

duly made therefor. 

38 

DTPOI3-91-2 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 42 of 55 Pg ID 5803
Coordination of benefits (Continued) 

"Allowable Expense " means any necessary; reasonable and customary item of 

expense at least a portion of which is covered under this plan. 

A "Group Pl an" is any employer group insurance coverage or other. arrangement 

of coverage for individuals in a group which provides hospital, or medical 

benefits or services on an insured or an uninsured basis (other than Franchise 

insurance or no-fault motor vehicle coverage): 

If; in coordinating the benefits of this plan with those of another plan, (a) 

the rules set forth in the following paragraph would require this plan to 

determine its benefits before the other plan and (b) the other plan which 

contains a provision non-duplication (or coordinating) its benefits with those 

of this plan would, according to its rules; determine its benefits after the 

benefits of that other plan will be ignored for the purposes of determining 

the benefits of this plan: 

The rules establishing the order of benefit determination are: 

(a) The benefits of a plan which covers the individual for whom claim is made 

other than as a dependent will be determined before the benefits of a 

plan which covers that individual as a dependent: 

(b) The benefits of a plan which covers the individual for whom claim is made 

as a dependent of a male will be determined before the benefits of a plan which covers that individual as a dependent of a female. However, if the 

claim is made for a child of divorced or legally separated parents, the 

benefits of the plan which covers the parent who in the current year 

claims such child as a dependent for Internal Revenue Code purposes will 

be determined before the benefits of another plan. if any. 

(c) When rules (a) and (b) do not establish an order of benefit 

determination, the benefits of a plan which has covered the individual 

for whom claim is made for the longer period of time will be determined 

before the benefits of a plan which has covered the individual for the 

shorter period of time. - .. 

For the purposes of Coordination of Benefits, the Insurance Company 

(a) may release to or obtain from any other organizations or individual$ any 

claim information, and any individual claiming benefits under this plan 

shall furnish the Insurance Company with any information which the 

Insurance Company may require; 

(b) has the right, if an overpayment is made under this plan because of 

failure to report other coverage or other reason, to recover such 

overpayment from any individual or individuals to whom it was made; 

39 

DTP0139!.3 _ 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 43 of 55 Pg ID 5804
"",.vI " 

Coordination of benefits (Continued) 

(c) has the right to pay tq any other organizations an amount it shall 

determine to be warranted, if payments which should have been made under 

this plan have been made by such organizations under other plans. 

In order to obtain all benefits available; a claim should be fiJed under each 

plan. 

\ IT Non~Dwp1fcation; Federal Medical 'or National Health 

.l(lJJ' \' 1. v .) To the extent that coverage under this plan may be dupl icated by coverage 

;'~Juvailable under any Federal Medicare Program or plan of National Health ,}~. In~urance now or later adopted,· such duplicate coverage will be deleted from 

II ,~~\ t~ls plan. \ nt~ tjJ~~ , , 

f:f~P } Usua 1 and customary 

In determining what constitutes usual and customary the insurance company will 

take into consideration: 

o the fees which fall within the customary range of fees charged in a 

local ity ,by most providers of medical service of similar training and 

experience for the performance of a similar procedure or service, and 

o unusual circumstances or medical complications requirin,g additional 

time, skill and experience in connection with the procedure or 

service. 

Charges/fees/expenses 

The term "charges", "fees", or "expenses", will not include the following items as determined by the Equitable: . -. 

(a) the amount, if any, in excess of what is reasonable and customary or the 

locality in which incurred. or 

(b) any amount for a service, supply or treatment not recognized as generally 

accepted in medical practice a's necessary for the diagnosis or treatment 

of the condition of the patient. In determining such amount, the 

Equitable may consider the certjfication of an appropriate professional 

review 'organization or peer review committee regarding the extent to 

which the services, supplies, procedures and tests are necessary for the 

diagnosis and treatment of a patient's condition. 

40 DTP013~14 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 44 of 55 Pg ID 5805
SECTION V~ TERMINATION OF INSURANCE 

Your health insurance 1's continued until your death - unless you request , termination of insurance; 

The spouse of a deceased retired 'employee who was retir'ed lInder the Retirement 

Income Program will have the BaSic Hosplt'aland Medieal Coverages~ alid Major 

Medical benefits including coverage forellgible dependent chHdren continued 

at no 'Cost provided the spouse does not 'remarry 'and is receiving benefits 

under the Retirement Incollle Program prov'fded thespottse 'and chlldren were 

insured on the date of the ,.employee"s death~ However; when stich spotise 

becomes eligible for Medicare* claims wi'11be calculated on the basis that 

such spouse has both Part A alid Part B coverage~ regardless ofhis/her actual 

status with Medlcare~ , ' 

The spouse of a deceaSed 'retired employee who is not receivtng benefits 'Ilnder 

the ReUrement Income Program may alSo eontinue the libove coverages including 

coverage for el·' • 'Hdren by payi'ng the full cost of such 

~ 

?coverages and remiliWing unrilarrie , provid~d the spouse aRd children were 

insured on the a 0 e rop ayee 1; death~ , 

To the extent that premiulII payments are required il'l the preceding paragraphs;, 

such payments must b"e mlide in advance of the fifth day of the month for which 

',crerage is being provided~ , " 

, termin te as indicated ab"ove or when you cease to be elfgible, 

on termi en sa· or when the group policy terminates" 

whichever is earHer~ 

vJ \U- c.{jlJTftJ~ V-- 1.-1" J~ _--::i'7" Your dependents' insurance...,;- whne you llre living - unti'l the date they no /;Jf!!¥! , longer qualify as your eligible dependent~ or until you request termination of ~ 

dependent 'coverage~ ~~ 

,,~;~ ',. I 

.,t/I.Jt:!. , 

.prJif. Privilege on termination of insurance 

Upon termination of your Group Hospital, Surgical and Medica-l Expense 

Insurance and that of your dependents the 'option o~ changing this insurance to 

an individUal policy of insurance may be exercised. Such individual policy is 

obtainable, without furnishing evidence of insurability; 

(a) by you. UpOD termination of your employment; 

(b) by the surviving spouse, if you should die, provided the family is' 

insured at your death; 

(c) by a child, upon attaining the limiting age or upon marriage, while 

covered under the group plan; 

41 DTP0139-15 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 45 of 55 Pg ID 5806
, 

PriVllege on terminat'on of insurance (Conttnued) 

provided written application and the first premium ,payment is made to the 

Society within 31, days after termination of insurance. The form of individual 

insurance policy, the coverage thereunder, and all other terms and conditions 

thereof shall be as provided by th,e rules of the Society for such individual 

policy at the time of application. The individual policy, if issued, shall 

become effective upon :the day following the date of termination of insurance 

under the Group policy. 

42 DTP0139L6 . 

, 

, 

! 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 46 of 55 Pg ID 5807
THE EQUITABLE LIFE ASSURANCE SOCIETY 

OF THE UNITED STATES 

hereby certifies that; employees of 

TRANSMISSION SYSTEMS 

HORG-WARNER CORPORATION 

(Herein called the Employer) 

who are insured under Group PolicyCies) No; 15973L;H are, subject to the terms 

and conditions of $aid policy{ies). insured for the benefits described ,in the 

Benefits provision. 

BENEFITS 

The Equitabl~ benefits for which you are insured are set forth in the pages of 

this booklet. Consult these p~ges for a further description of the terms and 

conditions of these coverages. If there is any coverage for which you are 

eligible which does not become effective unless you make the required election 

and contributory therefor; such coverage ~ill not become effective unless you 

so elect and are making such contributions. 

No assignment by you of any ins~rance under any coverage, except that covering medical expenses shall be valid. 

This certificate, which is furnished in accordance with. and subject to. the 

terms of the Group pol icy(ies). replaces any other certificate previously issued to you,covering the insurance described h~rein. It is not the contract 

of insurance. Each policy and the application of the Employer for it 

constitute the entire contract. This certificate is merely evidence of 

insurance provided under the po1icy(ies). The insurance is effective only after the person concerned is el igible for insurance and becomes and remains 

insured in accordance with the terms, provis'ions and conditions of each such 

policy. '2 ~_ ' 

j2~"t"·j2t~C~ LIFE INSURANCE -, 

Upon receipt of due proof~r death, the amount of Lite insurance for 

which you are insured under the Group policy shall be payable to the 

beneficiary designated by you, as entered on the insurance records maintained 

in connection with the insurance under the policy. Any part of such insurance 

for no beneficiary is designated or surviving at your death will be payable in 

accordance with the terms of the policy. 

PF 26003(la)(2) Amended by PF 18505 

43 

THE EQUITABLE LIFE ASSURANCE 

SOCIETY OF THE UNITED STATES 

DTP0139.17 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 47 of 55 Pg ID 5808
Protection after Termination 

A. If your Group Life insurance terminates because you terminate employment in the class or classes of employees insured under the Group pol icy, you 

may. within thirty-one days after such termination of insurance, make 

application for any type of Individual Life' insurance policy then 

customarily issued by the Equitaole (except a policy of term insurance or 

a policy providing benefits in the event of total and permanent disability 

or additional benefits for accidental death). No medical "examination is 

required and the policy will become effective thirty-one days after your 

Group Life insurance terminates, provided the premium is paid to the 

Equitab 1 e not 1 ater than such date. The amount you may convert may, at 

your option" be equal to or less than the amount terminated under the 

Group policy. ' 

If you die within thirty-one days following termin'ation of insurance as 

described in A. above. the Equitable will pay to y()ur beneficiary the 

amount of Group life Insurance you could have converted. 

B. If your Group Life jnsurance terminates because the. Group policy is 

terminated or amended, and you have ~een continuously insured under the 

Group policy for at least five years, you may also make application to 

convert your Group life insurance to an Individual life insurance policy 

upen the same conditions described in A~ above: However; the maximum 

amount you may convert shall be the amount terminated under the Group 

policy less any amount for which you may become eligible under any other 

Group policy within thirty-one days after this Group Life insurance 

terminates, but in no event shall the amount you may convert be more than 

$2,000. 

If you die during the thirty-one day period following the termination of 

your insurance as described in B; above and you have been continuously 

insured under the Group policy for at least five years, the Equitable will 

pay to your beneficiary the amount of insurance for which you were last 

insured under the Group policy less the amount for which you became 

insured under any other pol icy within thirty-one days after the date of 

such termination, but in no event shall such amount so payable be more 

than $2,000. 

PF 26003 (2) 

44 DTP013918 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 48 of 55 Pg ID 5809
Accldentand Health InSurance 

Upon receipt of due proof of claim; Accident and Health benefits are payable 

to you. 

Notice of Claim 

Written notice of the event upon which claim may be based must be given to the 

Equitable at its Home Office in the City Qf New York within 20 days after the 

date of the loss for which claim is made. Failure to give notice within the 

time required by the policy shall not invalidate or reduce any claim if it 

shall be shown not to have been reasonably possible to give such notice within. 

the required time and that notice was given as soon as was ~easonably possible. 

Upon receipt of such notice; you will be furnished forms for filing proof of 

claim. If such forms are not furnished within fifteen days after the receipt of notice the claimant shall be deemed to have complied with the requirements 

of the pOlicy as to proof of claim upon submitting within ninety days after 

the date" Qf the loss for which claim is made, written proof coyering the 

occ·urrence. character and extent of the loss for which claim is made. 

PrOof of Claim 

Written proof of cl aim must be furnished to the Equitable at its Home Office 

in the City of New York on the Equi~ableJs forms within 90 days after the date 

of the loss for which claim is made. Failure to furnish written proof of loss 

within the time required by the policy shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible to furnish 

such proof within the required time and that proof was furnished as soon as 

was reasonably possible. 

Exaininiit;ons 

The Equitable shall have the right and opportunity through its medical 

representative to examine any person when and so often as it may reasonably 

require during the pendency of claim under the policy and also the right and 

opportunity to make an autopsy in case of death where it 1.s not forbidden by 

law. 

45 DTP013'919 . 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 49 of 55 Pg ID 5810
Legal Proceedings 

No action at law or in equity shall be brought to recover under the policy 

prior to the expiration of 60 days after proof of claim has been furnished in 

accordance with the requirements of the policy, nor shall any such action be 

brought at all unless commenced within 2 years from the expiration of the time 

within which proof of claim is required by the provisions thereof. 

Payment of Benefits 

Payment of the benefits described in ,this plan will be made on the basis of 

your submission of proof that a charge, fee or expense'has been incurred. 

PF 26003(3) 'Amended by PF 18600 

46 

QQ 

MW-BC- (8702) 

Printed tn U.S.A. 

DTP0139~O' 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 50 of 55 Pg ID 5811
V SECTION~~ll - ORGAN OR TISSUE TRANSPLANT BENEFIT PLAN 

About tlie plan 

This benefit has been specifically designed to pay for charges for certain 

human to human organ and tissue tranSpl ants. It covers these charges when . they are incurred while you or a dependent, as the recipient of the organ or 

tissue transplant, are insured by the pla~. 

The organ and tissue transplants covered by this plan are: 

0 bone marrow; 

·0 heart; 

0 heartllung; 

0 liver; 

0 1 ung; 

0 pancreas. 

Benefits are payable if the recipient receives two opinions on the need for 

transplant surgery. The opinions must be given: 

o by a board certified specialist in the involved field of surgery; 

o in writing. The specialist must certify that alternative procedures, 

services or courses of treatment would not be effective in the 

treatment of the patient's condition. 

What the plan covers 

The plan covers charges for the following services in connection with a 

covered human to human organ or tissue transplant procedure: 

o organ and tissue procurement. This consists of removing, preserving 

and transporting the donated part. 

o transportation Of the recipient and a companion to and from the site 

of the transplant. If the recipient is a minor, transportation of 

two persons who travel with the minor is included. Reasonable ·and 

necessary lodging and meal costs incurred in the interim by such 

companions are ·included. Itemized receipts for all these charges are 

required. 

o hospital room and board and medical supplies. 

DTPO 13'921 

43 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 51 of 55 Pg ID 5812
What the plan covers (Continued) 

o diagnosis, treatment and surgery by a doctor. 

o private nursing care by: a Registered Nurse (R.N.)3 a Licensed 

Practical Nurse (L.P.N.). 

o the rental of, wheel chairs, hospital-type beds and mechanical 

equipment required to treat respiratory impairment. 

o local ambulance service; medication; x-ray services and other 

diagnostic services; laboratory tests; oxygen. 

o rehabilitative therapy !;onsisting of: 

training or a lisp): audio therapy; therapy; and physiotherapy. 

o surgical dreSSings and supplies. 

When benefits are payable 

speech therapy' (not for voice 

visual therapy; occupational 

Benefits will be paie! for covered transplant servic'es when they are received 

by you or your dependent during what is called a transplant benefit period. 

A transplant benefit period begins five days before the date of the organ or 

tissue transplant. It ends eighteen months after the organ or tissue 

transplant is done. But. if a covered transplant procedure is not done as 

scheduled due to the intended recipient's medical condition or death, benefits 

will still be paid for organ and tissue procurement, and for covered 

transportation, lodging and meal charges. 

The plan ,pays for covered transplant services on a usual and customary basis. 

This means the plan will pay the full amount of the bill for covered 

transplant services (up to the plan maximums) -- as long as you have_.not been 

charged more than the prevailing fee for the services received. 

If you are charged more than the, usual and customary allowance for a covered 

transplant service, you are responsible for paying the entire part of the 

charge over the allowance" 

Maximum plan payments 

There is a $1,000,000 1 imit on how much the plan will pay for all covered 

transplant services for each covered person during his or her lifetime. 

But, there are other maximums that apply to certain covered transplant services received during each transpl ant benefit period. These maximums are: 

o $10,000 for charges for organ and tissue procurement. 

DTP013932· 

44 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 52 of 55 Pg ID 5813
Maximum plan payments ,(Continued) 

o $10,000 for charges for private nursing care. 

o $10,000 for transportation, lodging and meals. There is also a daily 

limit on charges for lodging and meals of $200 per day. ' 

Two or more transplant benefit periods 

These are treated as follows: 

o if they are due to unrelated causes, they are treated as separate 

periods. 

o if they are due to related causes, they are treated as separate 

periods if: 

in your case, they are separated by your return to active work; 

or 

in the case of your dependent, they are separated by at least 

three months in a row. 

o if they are due to related causes, they are treated as one period 

when not separated as shown above. 

Not covered 

No benefits will be payable for services: 

o not ordered by a doctor. 

o for which an insured person would not legally have to pay if there 

were no insurance. 

o for an injury or sickness due to employment with any employer or self 

employment. 

o for custodial care. This term'means: 

room and board and other institutional or nursing services which 

are' provided for a person due to his or her age or mental or 

physical condition mainly to aid the person in daily living; or 

medical services which are given merely as care to maintain the 

person's present state of health and which cannot be expected to 

improve a medical condition to a great extent. 

DTPOB923' , 

45 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 53 of 55 Pg ID 5814
Not covered (Continued) 

o for an injury or sickness or for a related condition that existed 

within three months prior to the date the recipient becomes insured 

for the Organ or Tissue Transplant Benefit. This 1 imit wi 11 not 

apply to expenses for that injury, sickness or related condition that 

were incurred after the first of these dates to occur: 

the date after the person becomes insured for the Organ or 

Tissue Transplant Benefit' when no charges were incurred, for said 

injury or sickness for three months in a row; 

in your,case,at the end' of six months in a row in which you 

were continuously insured for the Organ or Tissue Transplant 

Benefit and actively at work; or 

the end of twelve months in a row in which .the' person was 

continuously insured for the Organ or Tissue Transplant Benefit. 

DTP013924' 

46 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 54 of 55 Pg ID 5815
- -

PARTICIPATING -IN THE PLAN 

Who is eligible 

You are eligible to participate in this plan if you: 

o are an act i ve or ret ired emp 1 oyee gf'".~' ,',. I Ie:'; and 

o are covered, or eligible to be covered, by the group medical plan ~ 

tbe BQt1Q,,'4ilJ:Dt?ILl~tj}~W'WAe:-e -you -w<»>*--(-w:;:;Whell? YGll-lIad- "'G'I'ltedo-::i:n;. 

tb"R;-Ue Q,.t;.- e rel<fr.elj-'emp.e-). 

Your eligible dependents are also eligible to participate in this plan. -

Eligible dep,endents are your spouse and dependent children who are eligible 

---?'- for coverage under your BCi 9 ilal lier group medical plan. 

When coverage begins 

Your coverage begins on the later of 

,\' I 'Jlfir! . 0 

,d·Jd /': 

September 1, 1985; and 

A/ -!- _ the date your coverage under the By, 9 Uaillier group medical plan 

begins. /:.. Je,·t H·'" . (' j;l , ~j . If you are not actively at work (or are confined in a hospital or other P institution, in the case of a retired employee) on the day coverage would 

otherwise begin, your coverage will not begin until you return to active work 

(or, in the case of a retired empl'oyee, are discharged). 

Coverage for your eligible dependents will begin on the later of: 

o the day your coverage begins; and 

o the day the dependent I s coverage under your B y J,fwAer group medical 

plan begins. 

If a dependent is confined in a hospital or other institution on the day 

coverage would otherwise begin, coverage for that depend~nt wi 11 not begin 

until discharged. (This does not apply to a newborn child confined from 

birth.) 

DTP013925 

47 

1 

2:09-cv-10918-PDB-MKM Doc # 104-15 Filed 05/14/12 Pg 55 of 55 Pg ID 5816