Definition of Terms
"Actively at Work" or "Active Work" means that you are performing all of the material duties of your job with the Policyholder where these duties are normally carried out. If you were Actively at Work on your last scheduled working day, you will be deemed Actively at Work:
1. on a scheduled non-working day;
2. provided you are not disabled.
"Covered Person" means a Member or a Dependent on whose account benefits are in effect under This Plan.
"Dependent" means your spouse, your unmarried child, or their unmarried children except for:
1. a person who is in the military or like forces of any country or of any subdivision of a country;
2. a person who is eligible under This Plan as a Member;
3. a person who lives outside the United States or Canada;
4. a child who:
a. is 19 years of age or older and who is employed on a full-time basis; or
b. is 19 years of age or older and who is not a full-time student at an approved school, as determined by the Policyholder; or
c. is 23 years of age or older.
If a Dependent child is a Covered Person on the day before that child has reached the applicable age limit, that child will continue to be a Dependent after the age limit as long as:
a. that child is and remains unable to work in self-sustaining employment because of:
i. physical handicap; or
ii. mental retardation; and
b. that child is and remains chiefly dependent upon you for support; and
c. that child is and remains a Dependent, as defined, except for the age limit; and
d. you give us proof, when we ask for it, that the child is and remains so unable to work and dependent upon you since the age limit. We will not ask for proof more than once a year.
The proof must be satisfactory to us. Child includes:
a. a child who is supported solely by you and permanently living in the home of which you are the head, as well as their unmarried children under age 19; and
b. a child who is legally adopted; and
c. a stepchild who lives in your home; and
d. a child for whom benefits must be provided by court order, that we have been notified of (as set forth in a divorce decree).
No person may be covered as a Dependent of more than one Member. In the event of the entry of a judgement absolute of divorce dissolving your marriage, your former Dependent spouse will, unless the judgment provides otherwise, for the purpose of Dental Expense Benefits under This Plan be deemed to be your Dependent until the earliest of:
a. the date you remarry; or
b. the date your former Dependent spouse remarries; or
c. the date that the Dental Expense Benefits on account of your former Dependent spouse would otherwise have ended; or
d. if a payment is required by the Policyholder for the cost of the Dental Expense Benefits on account of your former Dependent spouse, the last day of the period for which a required payment was made; or
e. the date your former Dependent spouse is eligible for similar types of benefits under any other group plan or program; or
f. the date This Plan is changed to end the Dental Expense Benefits for your class; or
g. the expiration of the period of time specified in the divorce judgement during which you are required to provide dental care coverage for your former Dependent spouse.
"Dependent Benefits" mean the benefits which are provided on account of a Dependent under This Plan.
"Doctor" means a person who is legally licensed to practice medicine. A licensed practitioner will be considered a Doctor if:
1. there is a law which applies to This Plan and that law requires that any service performed by such a practitioner must be considered for benefits on the same basis as if the service were performed by a Doctor; and
2. the service performed by the practitioner is within the scope of his or her license.
"Family" means you and your Dependents.
"Member" means all full-time employees who are Members of a collective bargaining unit that has entered into one of the following collective bargaining agreements between the Board of Higher Education (“BHE”) and the Association of Professional Administrators, the Massachusetts Community College Council, the Massachusetts Society of Professors at the University of Massachusetts at Lowell, the Massachusetts Society of Professors/Faculty Staff Union at the University of Massachusetts, Amherst and Boston, the Massachusetts State College Association and the University Staff Association at the University of Massachusetts, Amherst (all Members of the bargaining unit are refered to as “Unit Members”. All part-time Unit Members working half-time or greater who meet the eligibilty requirements for the group insurance offered by the GIC of the Commonwealth of Massachusetts. Grandfathered Unit Members are all part-time Unit Members working less than half-time who began less than half-time employment prior to October 1, 1989. Unit Members who are working less than half-time and hired after that date are not eligible for benefits except if employed by the Massachusetts College of Art. Unit Members participating in the Fund’s dental benefits program will be referred to as Member throughout this Booklet/Certificate.
"No Fault Law" means a motor vehicle liability law or other similar law which requires that benefits be provided for personal injury without regard to fault.
"Occupational Injury" means an injury which happens in the course of any work performed by the Covered Person for wage or profit.
"Occupational Sickness" means a sickness which entitles the Covered Person to benefits under a worker's compensation or occupational disease law.
"Personal Benefits" mean the benefits which are provided on account of a Member under This Plan.
"Policyholder" means Trustees of the Board of Higher Education/Massachusetts Teachers Association Health and Welfare Trust Fund.
"This Plan" means the Group Policy which is issued by us to provide Personal Benefits and Dependent Benefits.
"We", "us" and "our" mean Metropolitan.
"You" and "your" mean the Member who is a Covered Person for Personal Benefits. They do not include a Dependent of the Member.