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ACTIVE FUND
Supplemental Benefits
Supplemental Benefits Provided
In addition to those benefits provided by the City
of New York, the Health and Welfare Fund of the Patrolmen's Benevolent
Association provides benefits that augment the basic coverage, but
vary according to what basic program the member selected. Some
supplemental benefits are provided through the purchase of a rider
from the various carriers involved and some are provided on a self-insured,
self-administered basis.
The Patrolmen's Benevolent Association of the City
of New York, Inc. and the Health and Welfare Fund provides an extensive
Term Life Insurance program for every active member in the amount
of $120,000.
Designation Of Beneficiary(s)
Every Police Officer, when appointed to the force,
is required to complete various enrollment cards/forms designating
the beneficiary(s) of the life insurance policies. To change the
designated beneficiary(s), new cards and/or forms must be completed
by the member and filed with the member's records. These enrollment
forms may be obtained from the PBA or PBA Funds Office.
Should the member wish to verify the current beneficiary(s)
of record, the member must contact the PBA or PBA Funds Office and
request the information in writing. The information will be mailed
to the member's address of record. Beneficiary(s) information will
not be provided via the telephone, or to persons other than the
member.
Members are advised that changing the beneficiary
designation of the Life Insurance Program in NO WAY affects the
New York City Pension beneficiary designation, nor does it affect
any designation through the MetLife Insurance program, the Health
and Welfare eligible dependent records, or any other program with
which the member is enrolled.
Living Benefit Option
The Living Benefit Option allows a covered member
with a limited life expectancy to be paid part of the group life
benefit, up to a maximum of 50% of the face amount of Insurance,
but not to exceed $50,000 (members should consult their tax advisor).
Members are free to spend the proceeds as they wish—on
travel, family, expenses, etc. The death benefit payable to the
member's beneficiary upon the member's death will be reduced by
any benefits paid under the Living Benefit Option. This benefit
is available once in the member's lifetime, and is only payable
in a lump sum.
Please note that:
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If insurance was assigned by the employee previously, this
option may not be elected.
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The insured must claim this benefit voluntarily. If the insured
is required by law or government agency to exercise this option,
the claim will be denied.
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The consent of the beneficiary is not required when the insured
elects the Living Benefit Option.
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The life insurance amount will be reduced by the amount paid
under the Living Benefit Option.
Life Insurance After Termination
Life insurance coverage terminates when a member is
no longer an active police officer. In most cases a member may
apply for a personal policy under the Conversion Privilege within
thirty-one (31) days after his or her life insurance ceases. If
a person dies during the thirty-one (31) days and before the personal
policy goes into effect, the amount payable under the group contract
is limited to the maximum amount that could have been converted
under a personal policy.
Co-Payment Benefits
Effective January 1, 1999, a co-payment benefit will be available
for all members under which the Health and Welfare Fund of the Patrolmen's
Benevolent Association will reimburse the member directly for co-payments
incurred by the member and/or his or her eligible dependents for
any office visits under the member's City of New York basic health
insurance. The Fund will not reimburse the co-payment for diagnostic
care (lab and x-rays).
For those members enrolled in the GHI-CBP program, the member is
required to submit to the PBA Funds Office a copy of the GHI Explanation
of Benefits detailing the fact that an office visit occurred. No
other form of documentation will be accepted.
For those members enrolled with HMO and Point of Service subscribers,
the member is required to submit a copy of cancelled check(s), both
front and back, for each office visit, or a copy of the credit card
receipt. To assist in processing your claim promptly, please provide
the member's name, member's social security number, patient's name,
relationship to the member, and the type of care rendered.
No receipts directly from the participating provider shall be accepted.
Each member should submit his or her documentation as it is received.
Claims for reimbursement received more than one (1) year
after the office visit will be rejected.
The PBA Health and Welfare Fund provides the following
benefits on a self-insured and self-administered basis:
For the benefits provided on a self-insured and self-administered
basis, the following applies:
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Reimbursement of $35.00 of the GHI deductible:
When a member uses the services of non-participating GHI providers,
payments are subject to an annual deductible of $175.00 per
individual and $500.00 per family. The PBA Health and Welfare
Fund will reimburse up to $35.00 per family member when the
member submits the GHI voucher(s) showing the $175.00 deductible
has been met, and up to $100.00 per family should the full $500.00
deductible be met.
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Reimbursement of the $25.00 co-payment
for hospital emergency room treatment: Under the basic City
of New York Empire Blue Cross/Blue Shield program there is a
$25.00 co-payment for covered hospital emergency room charges.
The PBA Health and Welfare Fund will reimburse the member this
co-payment when the member submits the Empire Blue Cross/Blue
Shield Explanation of Benefits showing the co-payment and a
copy of the itemized hospital statement.
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PBA Catastrophic Benefit: This benefit
is designed to assist those members who have used non-GHI participating
providers and who have incurred, or are reasonably expected
to incur, in a calendar year an out-of-pocket expense of $1,250.00
($1,500.00 if the member is not enrolled in the Hi-Option rider)
for GHI covered services for eligible family members. The member
must be able to provide itemized bills and original GHI Explanation
of Benefits for all charges being submitted. When the member
believes his or her out-of-pocket expenses for a calendar year
will exceed the catastrophic deductible ($1,250/$1,500), the
member should:
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Contact the PBA Funds Office and request a Catastrophic
Benefit Claim Form.
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Complete the catastrophic claim form, including the year
for which the claim is being filed, the member's information,
the spousal information (if the member is married, the member
must complete the spouse's information), the patient information
(complete for all patients, including the member and/or
spouse since this benefit is per family per calendar year
and includes any bills with a balance for all eligible family
members).
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Sign and date the front of the Claim form.
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Sign and Date the Authorization to Release Information
located on the back of the claim form.
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Attach copies of all itemized provider bills received to
date. Itemized bills must contain:
(1) Provider's name
and address
(2) Provider's Tax
ID number
(3) Date of Service
(4) Type of Service
(5) CPT code for
the Service
(6) Provider's Fee
for the service with the remaining balance due after the
insurance payment
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Attach all GHI Explanation of Benefits (EOB).
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If the member, patient and /or spouse has other medical
coverage, attach copies of the Explanation of Benefits,
including rejections, if applicable.
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Mail the completed claim form with the bills and vouchers
to:
PBA Funds Office
Catastrophic Benefit Claims
40 Fulton Street, Second Floor
New York, NY 10038
- Submit additional bills and vouchers as they are received.
The bills should be directed to the Catastrophic Department
and have the Member's name and Social Security Number on them.
It is not necessary to submit an additional catastrophic claim
form.
The PBA Funds Office will review the information submitted
and will request any additional documentation needed to process
the claim. Payment will be based on a fee schedule set by the
Trustees and payment will be sent directly to the member, with
a statement showing the service being covered and the balance
that is the member's responsibility.
The PBA Health and Welfare Fund, on a self-insured
and self-administered basis, provides the following benefits:
- Durable Medical Equipment
Where certain conditions may require the use of durable
medical equipment, such as wheelchairs, artificial limbs, orthopedic
appliances, etc., the PBA Health and Welfare Fund provides a benefit
toward the cost of these items. The benefit covers the cost of
such durable equipment, but not to exceed eighty percent (80%)
of the reasonable and customary charges. There is a maximum of
$1,000.00 in a twelve (12) month period and a lifetime maximum of
$3,500.00 per family.
To file for the medical equipment benefit you must
obtain a Medical Equipment Claim form from the PBA Funds Office.
The completed claim form and an itemized bill should be returned
to the PBA Funds Office.
Legal Services The
Legal Services Fund of the Patrolmen's Benevolent Association of
the City provides job-related legal and civil legal representation
to active police officers.
Legal Services Provided
Active members of the Health and Welfare fund are
afforded legal services arising out of activities in the scope of
their employment as a police officer, subject to the terms and conditions
of the PBA's Constitution and By-laws, including:
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Defense of criminal charges
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Disciplinary proceedings
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GO-15's in EEO proceedings
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Trial Room
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OATH
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CCRB
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Allegations and investigations
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The handling of administrative law matters
and appeals, where warranted
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Article 78 proceedings and appeals, where
warranted
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Counseling on Pension, Disability, and
Retirement matters
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Counseling on grievances
Also, subject to the terms and conditions of the PBA's
Constitution and By-laws, the Fund's attorneys will provide legal
defense in certain civil proceedings brought against a covered member
in State and Federal Courts. These cases stem from a member having
taken police action within the scope of his or her duties or otherwise
having acted lawfully as a police officer, when the City of New
York fails or otherwise refuses to provide a legal defense.
Provider of Legal Services
Covered legal services are provided as of May 1, 1998,
by the firm of:
Worth, Longworth, & London, LLP
111 John Street
New York, NY 10038
Application for Legal Benefits
When the services of any attorney are needed to assist
in any of the covered services, the member should telephone his
or her PBA board member at the PBA office at (212) 233-5531 or the
PBA General Counsel's office at (212) 298-4144.
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