HomeMy WebLinkAboutNorth Western National Life Insurance Company; 1986-05-15;. ‘.
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. . PLAN SPONkR: THE C.- OF CARLSBAD
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. EFFECTIVE DATE: JANUARY 1, 1986
GROUP POLICY NUMBER: GH-19235-0
SPLIT RISK AGREEMEN
This Agreement is between the Plan Sponsor named above and Northwestern
National Life Insurance Company ("NWNL") in consideration of the following:
1. NWNL has issued a group health insurance policy (the number of which
is listed above) ("Group Policy") to the Plan Sponsor.
2. The Group Policy forms a part of an employee welfare benefit plan
established by the Plan Sponsor.
3. The Plan covers and is reasonably expected to continue to cover at
least 200 Participants.
4. The Plan Sponsor wishes to accept liability for payments of the
benefits described in the Group Policy, subject to certain maximum
payment limits and minimum payment limits and minimum premiums
described in this Agreement.
5. The Payment of such benefits and minimum premiums will be in lieu of
the premium payments described in the Group Policy and any of its
Amendments.
6. The Plan Sponsor has requested NWNL to serve as its agent in the
payment of such benefits and NWNL is willing to do so in accordance
with the terms of this Agreement.
7. The establishment of the Group Policy requires the creation of
reserves from which to pay claims following the date of termination of
the Group Policy but incurred prior to such date and otherwise payable
under the Group Policy (“IBNR Reserve") and the Plan Sponsor wishes to
hold the IBNR Reserve.
Therefore, NWNL and the Plan Sponsor agree as follows:
1. EFFECTIVE DATE
This Agreement will be effective on the Effective Date shown above.
2. PARTICIPANTS COVERED
This Agreement applies to the classes of employees and their covered
dependents (herein called "Participants") described in the Group Policy
and any of its amendments.
3. PLAN SPONSOR'S LIABILITY FOR BENEFITS 1
a. The Plan Sponsor will be liable for the payment of Benefits Payable to
Participants under the Plan. NWNL will act as the Plan Sponsor's
agent in the payment of those benefits, subject to the terms and
conditions of this Agreement.
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b. Payments by the Plan Sponsor of the Benefits Payable to Participants
Under the Plan, and of any Accumulated Deficit repayments described in
this Agreement, and of the Minimum Premium described in Section 17 of
this Agreement, will be in lieu of the premium payments described in
the Group Policy and any of its Amendments. Upon the termination of
this Agreement, the premium payment obligations of the Plan Sponsor
will be as required under the then current Group Policy.
C. Payment of all Benefits Payable to Participants under the plan will be
made by NWNL's draft in the manner described in this Agreement. The
Plan Sponsor agrees to reimburse NWNL in accordance with the terms of
this Agreement subject to the Monthly Liability Limits described in
this Agreement.
d. If at any time in any Policy Month the payment of Benefits Payable to
Participants under the Plan plus the repayment or partial repayment of
any Accumulated Deficit exceeds the applicable Monthly Liability
Limit, NWNL will cease to be reimbursed for the payment of those
claims for benefits in excess of the applicable limit for the
remainder of that month. The Plan Sponsor remains liable for the
repayment of any Accumulated Deficit, plus interest, in accordance
with this Agreement. NWNL will resume reimbursement on the first day
of the next following Policy Month. Funds provided by the Plan
Sponsor each month for the operation of the Agreement will be applied
first to the reduction of the Accumulated Deficit, if any, and then to
the provision of Benefits Payable to Participants under the Plan.
4. NWNL AS PLAN SPONSOR'S AGENT
a. NWNL will, as agent for and on behalf of the Plan Sponsor:
(i) make final determination of the amount of benefits, if any, to
which a Participant may be entitled under the Plan, in accordance
with the terms and conditions described in the Group Policy, and
(ii) undertake and pay for the defense of any suit brought with
respect to any claim for benefits under the Group Policy and
settle any such suit when in its judgment it appears expedient to
do so.
b. The Plan Sponsor agrees to reimburse NWNL for the amount of benefit
payments included in any judgment or settlement, subject to the terms
and conditions of this Agreement. Benefit payments made in accordance
with the terms of any judgment or settlement shall be considered
Benefits' paid to Participants under the Plan for the Policy Month in
which such judgment or settlement is satisfied, provided that this
Agreement is then in full force and effect.
C. Any benefit payment made by NWNL in accordance with subparagraph (b)
above after the effective date of termination of this Agreement will
be reimbursed by the Plan Sponsor immediately upon written notification of the amount paid.
.
5. MONTHLY LIABILITY LIMITS
a. For the first Policy Month of the first Policy Year the Monthly
Liability Limit will be the Adjusted Expected Monthly Claims for that
month. Any resulting Accumulated Deficit or Accumulated Hypothetical
Surplus will be carried forward to the second Policy Month of the
First Policy Year.
b. For the second and each subsequent Policy Month, the Monthly
Liability Limit will be determined as follows:
(i) If there is an Accumulated Deficit, the Monthly Liability Limit
will be the lesser of:
(a) The sum of Actual Paid Benefits in that Month plus
Accumulated Deficit to the beginning of that Month; or
b) Adjusted Expected Monthly Claims for that Month.
(ii) If there is an Accumulated Hypothetical Surplus, the Monthly
Liability Limit will be the lesser of:
(a) Adjusted Expected Monthly Claims in that Month plus
Accumulated Hypothetical Surplus to the beginning of that
Month; or
(b) Actual Paid Benefits for that Month.
c. Individual claims for Benefits Payable to Participants Under the Plan
paid during any Policy Year will be pooled at the level described in
Section 17 of this Agreement. Claims paid on behalf of any
Participant in excess of the pooling level will not be considered in
the calculation of Monthly Liability Limits.
6. DEFICIT CARRYFORWARD
a. At the end of any Policy Year, any Accumulated Deficit then existing
(plus interest on the daily deficit balance) will be carried forward
to the next Policy Year. The rate of interest shall be determined by
NWNL from time to time to be applicable to contracts of this class
which rate shall in no event be higher than that rate permitted by law
at the time it is charged.
b. The Accumulated Deficit will be recovered in subsequent Policy Years
in accordance with the terms of this Agreement. Upon termination of
this Agreement, however, the Plan Sponsor shall have no liability to
NWNL for the repayment of any Accumulated Deficit then existing.
7. CLAIM DRAFTS AND REIMBURSEMENTS
a. Claim drafts will be drawn on an NWNL Draft Account (called NWNL
Account) with the Norwest Bank, N.A., of Minneapolis, Minnesota.
b : The- Plan Sponsor will establish a demand account for the Plan (called
Plan Account) at the bank of its choice. The Plan Account will be the
account from which funds will be drawn to reimburse NWNL for all !
drafts NWNL issues to provide payment of Benefits Payable to
Participants under the Plan, to provide for the reduction of
Accumulated Deficit and for any other reimbursement of NWNL under this
Agreement. The Plan Sponsor will authorize its bank to allow
withdrawals of funds by NWNL to NWNL's account by use of depository
transfer checks or automated clearing house entries.
C. Drafts for payment of Benefits Payable to Participants under the Plan
will be released daily by NWNL. Reimbursement for such drafts,
however, will be delayed in accordance with the following:
(i) The Plan Sponsor shall designate a specific day of each week
upon which reimbursement shall be made.
(ii) Reimbursement on that day each week shall be for the seven day
period ending zero, seven, fourteen, twenty-one, or twenty-eight
days earlier, as specified in Section 17 of this Agreement.
Notwithstanding subparagraph 7.d., interest will not be charged on the
basis of the delay of reimbursement in accordance with this subparagraph 7.~.
d. Interest will be payable by the Plan Sponsor on the daily deficit at
the rate of interest determined by-NWNL from time to time to be
applicable to contracts of this class (which interest rate shall in no
event be higher than that rate permitted by law at the time it is
charged). For purposes of this Agreement, the daily deficit
represents the difference between the amounts advanced by NWNL for
Benefits Payable to Participants under the Plan, plus any Accumulated
Deficit carried forward but not yet recovered and the amounts
reimbursed by the Plan Sponsor, computed by NWNL each calendar day.
Any interest payable will be withdrawn by NWNL from the Plan Account
on the first business day of the next following Policy Month.
Interest payments shall be included in the computation of Actual Paid
Claims for purposes of determining Monthly Liability Limits in
accordance with Section 5 of this Agreement for the Policy Month in
which the interest is recouped.
e. It is the Plan Sponsor's responsibility to maintain funds in its Plan
Account in an amount adequate to fully reimburse NWNL for all amounts
due under the terms of this Agreement. In the event that the Plan
Sponsor does not supply funds sufficient for the payment of benefits
for which it is liable under this Agreement, NWNL may, at its option,
arrange for payment of benefits on behalf of the Plan Sponsor, subject
to reimbursement in accordance with this Agreement. In no event will
NWNL make such benefit payments beyond the end of the Policy Month in
which the Plan Sponsor fails to supply funds.
8. TERMINATION bF AGREEMENT
a. In the event the Plan Sponsor fails to comply with any provision in
this Agreement, NWNL may, at its election, terminate this Agreement
immediately. Termination will become effective on the date specified
in NWNL's notice of termination to the Plan Sponsor.
b. Failure of the Plan Sponsor to provide funds to its bank to reimburse
NWNL in accordance with this Agreement will result in termination of
the Agreement on the date specified by NWNL.
C. If any state or other jurisdiction enacts a law which prohibits the
continuance of this Agreement or the existing law is interpreted to
prohibit the continuance of this Agreement, the Agreement will
terminate automatically on the date of enactment or interpretation.
d. Either party may terminate this Agreement by gi.ving the other party at
least sixty (60) days written notice stating when, after the date of
such notice, such termination will become effective.
e. The parties recognize that the terms and conditions of this Agreement
are based upon the Plan Sponsor's representation that its Plan covers
and is reasonably expected to continue to cover 200 or more
Participants. Consequently, the Plan Sponsor agrees that this
contract may be terminated at NWNL's option on the next following
anniversary of its effective date if the enrollment of the Plan during
any Policy Year drops below 200 Participants, unless the Plan Sponsor
agrees to amend this Agreement to contain those terms generally
contained in NWNL's Split Risk Agreement for plans covering fewer than
200 Participants.
9. CLAIMS FOR BENEFITS FOLLOWING TERMINATION
a. Following termination of this Agreement, the Plan Sponsor shall be
liable for all claims for Benefits Payable to Participants incurred
prior to the effective date of termination of this Agreement.
b. The parties recognize that the Plan Sponsor intends, upon termination of this Agreement, to transfer the administration of its Plan to an
Administrator other than NWNL, and that the administration will
include the review and payment of the claims for benefits described
in subparagraph a above. Notwithstanding the foregoing, however, the
Plan Sponsor agrees that it will not transfer the administration of
those claims for benefits described in subparagraph a unless
(i) Transfer of administration is to a Third Party Administrator
approved by NWNL; and
(ii) The Plan Sponsor agrees to indemnify and hold NWNL and its
officers, directors and employees harmless from any and
every loss, demand, right or cause of action of any kind or
I character which may be asserted against NWNL and/or NWNL
directors, officers, and employees including but not limited
to any expense, loss, damage (including punitive damages),
cost or attorney's fees NWNL and/or NWNL directors,
officers, and employees may incur in connection with the
transfer of administration; and
(iii) The Plan Sponsor agrees to provide reasonable security for
its promised indemnification.
. . C. Should the conaitions for transfer of administration not be met, NWNL
shall continue as administrator and the procedures and obligations
described in this Agreement, to the extent applicable, (including but
not limited to the payment of reasonable administration fees) survive
the termination of this Agreement and remain in effect during the
remaining administration.
10. TAXES AND OTHER ASSESSMENTS
The Plan Sponsor will pay NWNL, within a reasonable time after assessment,
any tax or charge assessed against NWNL which may be incurred by reason
of:
a. A ruling or other determination by any Insurance Department or other
governmental authority that the amount of claim payments made in
accordance with the Plan is subject to the premium tax provisions of
the applicable statutes, including any retroactive assessments.
b. A change in any charges imposed on NWNL by any public body, inclusive
of Federal or State Income Taxes, which affect this Agreement.
11. LIMITATIONS ON LIABILITY
NWNL shall use ordinary care and reasonable diligence in the performance
of its duties under this Agreement and neither NWNL nor its directors,
officers, or employees shall be liable for any loss resulting from any
mistake or other action taken in accordance with this standard. The Plan
Sponsor agrees to indemnify and hold harmless NWNL and any and all NWNL
directors, officers, or employees of and from any and every loss, demand,
right or cause of action of any kind or character which may be asserted
against NWNL and/or NWNL directors, officers, and employees including but
not limited to any expense, loss, damage (including punitive damages),
cost or attorney's fees NWNL and/or NWNL directors, officers, and
employees may incur in connection with the performance of this Agreement,
unless the liability therefore was direct consequence of a lack of
ordinary care or reasonable diligence on the part of NWNL or any of its
directors, officers, or employees.
12. DIVIDEND OFFSET
Notwithstanding any other provision of this Agreement and in lieu of any
right to receive dividends in cash or otherwise, the Plan Sponsor agrees
that NWNL may apply any positive dividend arising under any group
insurance policy issued by NWNL to the Plan Sponsor to the reduction of
any amount due under the terms of this Agreement, including but not
limited to the payment of any Accumulated Deficit, the reimbursement of
Benefits Payable to Participants under the Plan, and the payment of any
Minimum Premiums.
13. INFORMATION REQUIRED
The Plan Sponsor agrees to furnish NWNL all information which NWNL may
from time to 'time reasonably require, The Plan Sponsor shall notify NWNL
immediately as to any modification of the Plan or the termination thereof.
NWNL shall not be responsible for any delay or nonperformance of its
functions under this Agreement which is caused or contributed to in whole
or in part by the failure of the Plan Sponsor to timely furnish any
required information.
14. LAWS GOVERNING AGREEMENT
This Agreement will be construed and enforced according to the laws of the
State of Minnesota.
15. AGREEMENT COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of
which will be deemed an original, and these counterparts will constitute
but one and the same instrument,
16. DEFINITIONS
a. "Pl an" means only that portion of the Plan Sponsor's employee benefit
Plan which is described in the Group Policy and any of its amendments.
Benefits provided under the Plan Sponsor's employee benefit plan which
are not described in the Group Policy or any of its amendments are not
included within the term "Plan" unless NWNL specifically agrees to
include them.
b. "Benefits Payable to Participants Under the Plan" means those benefits
for which coverage is described under the Group Policy and any of its
amendments.
C. A "Policy Year" under this Agreement shall coincide with a Policy Year
as that term is defined in the Group Policy except that the first
"Policy Year" shall commence with the Effective Date of this Agreement
and the last "Policy Year" shall terminate upon termination of this
Agreement.
d. A "Policy Month" under this Agreement shall coincide with a Policy
Month as that term is defined in the Group Policy except that the
first "Policy Month" shall commence with the Effective Date of this
Agreement and the last "Policy Month" shall terminate upon termination
of this Agreement.
e. Benefits become "due" under this Agreement upon receipt by NWNL of
proof, in accordance with the provisions of the Group Policy
pertaining to proof of loss, in substantiation of a valid claim for
such benefits.
f. "Accumulated Deficit" means the excess of accumulated Actual Paid
Benefits in each Policy Month within the current Policy Year plus any
Accumulated Deficit from any previous Policy Year carried forward (but
excluding any Accumulated Deficit carried forward which is subject to
a provision for its separate repayment) over the accumulated Adjusted Expected Monthly Claims for such Policy Months.
9* "Accumulated Hypothetical Surplus" means the Hypothetical amount used
in connection with the determination of Monthly Liability Limits.
Accumulated Hypothetical Surplus represents the excess of accumulated
Adjusted' Expected Monthly Claims for each Policy Month within the
current Policy Year over the Actual Paid Benefits for such Policy
Months plus any Accumulated Deficit carried forward from any previous
Policy Year (but excluding any Accumulated Deficit carried forward
which is subject to a provision for its separate repayment).
Accumulated Hypothetical Surplus will be carried forward between
Policy Months but not between Policy Years. The "Accumulated
Hypothetical Surplus" does not represent a sum to be paid by NWNL to
the Plan Sponsor and will not be construed to constitute a liability
of NWNL. *
h. “Actual Paid Benefits" means the amount
which drafts have been drawn by NWNL
such benefits.
of benefits under the Plan for
in satisfact ion of claims for
i. "Covered Unit" means the number of covered employees and covered
dependents under the Plan during any Contract Month, which is used for
purposes of calculating the Expected Claims Rate. If the Group Policy
provides Accident and Sickness insurance (as defined in the Group
Policy) the term "Covered Units" also means each $10.00 of Accident
and Sickness coverage provided thereunder.
j. "Expected Claims Rate" means the amount of Expected Claims per month
per Covered Unit. The initial Expected Claims Rate(s) is (are) stated
in Section 17 of this Agreement. NWNL will redetermine the Expected
Claims Rate on each anniversary of the Effective Date of this
Agreement and on the Effective Date of each amendment to the Group
Policy.
k. "Expected Reserve Rate" means the amount of reserves required to be
maintained per month per Covered Unit. The Expected Reserve Rates are
as stated in Section 17 of this Agreement. NWNL will redetermine the
Expected Reserve Rate on each anniversary of the Effective Date of
this Agreement and on the Effective Date of each amendment to the'
Group Policy.
1. The Expected Monthly Claims for each Policy Month is the sum of the
following:
(1) The Expected Claims Rate times the number of employees covered
for Medical and Dental during the second preceding Policy Month;
provided that for the first and second Policy Months of the first
Policy Year, that the Expected Claims Rate will be based upon the
number of employees insured during the first Policy Month.
(2) The Expected Claims Rate times the number of dependents covered
for Medical and Dental during the second preceding Policy Month;
provided that for the first and second Policy Months of the first
Policy Year, that the Expected Claims Rate will be based upon the
number of employees insured during the first Policy Month.
m. "Adjusted Expected Monthly Claims" means the Expected Monthly Claims
for any Policy Month multiplied by the Monthly Claims Cap Factor
stated ir Section 17 of this Agreement.
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17. SPECIFICATIONS
a. Some or all of the specifications contained in this Agreement may be
changed by NWNL on each anniversary of the Effective Date of this
Agreement and on the Effective Date of any amendment to the Group
Policy. Consent of the Plan Sponsor to such changes will not be
required. NWNL will notify the Plan Sponsor of changes in the
specifications in writing and such notification will become part of
this Agreement, effective on the date specified in the notification.
b. The Minimum Premium for each Policy Month is the sum of the following:
1) $9.63 times the number of employees insured for Medical.
$1.98 times the number of employees insured for Dental.
2) $22.61 times the number of one dependent units insured for Medical.
$ 5.13 times the number of one dependent units insured for Dental.
$29.82 ",Q-i;;a;he number of multiple dependent units insured for
$ 6.49 times the number of multiple dependent units insured for
Dental.
C. The Expected Claims Rates are:
1) $34.60 per Policy Month per employee insured for Medical. -
$ 7.11 per Policy Month per employee insured for Dental.
2) $ 81.22 per Policy Month per one dependent unit insured for Medical.
$ 18.47 per Policy Month per one dependent unit insured for Dental.
$107.11 per Policy Month per multiple dependent unit insured for Medical.
$ 23.37 per Policy Month per multiple dependent unit insured for Dental.
d. The Expected Reserve Rates are:
11 $12.98 per Policy Month per employee insured for Medical.
$ 2.67 per Policy Month per employee insured for Dental.
2) $30.43 per Policy Month per one dependent unit insured for Medical.
$ 6.94 per Policy Month per one dependent unit insured for Dental.
$40.26 per Policy Month per multiple dependent unit insured for Medical.
$ 8.68 per Policy Month per multiple dependent unit insured for Dental.
e. The level at which claims for Benefits Payable to Participants under
the Plan paid during any Policy Year will be pooled is $50,000
annually,
f. The Monthly Claim Cap Factor is 100%.
90 Claim drafts shall be reimbursed each Friday for the seven day period
ending seven days prior to the date of reimbursement.
h. The AnnAal Deficit Limitation Factor is 25%.
i. The IBNR Expense Factor is 7.5%.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement by their
respective officers duly authorized to do so.
Dated at
fh
this /.// day of , 1986.
Title u
BY
Title
NORTHWESTERN NATIONAL LIFE
INSURANCE COMqPNY
, .::. L ,
RESOLUTION NO. 93-159
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CARLSBAD, CALIFORNIA, CONFIRMING THE AMENDMENT OF
THE CR-Y’S CONTRACT WITH NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY TO AN “ADMINISTRATIVE
SERVICFS ONLY 9, PLAN.
WHEREAS, effective January 1, 1986, the City of Carlsbad
7 contracted with Northwestern National Life Insurance Company
8 (NWNL) to be the claims payor for the City’s group comprehensive
9
1o medical plan (Plan); and
11 WHEREAS, the above Plan was established as a “split risk
12 agreement” plan where’ the administrative fees are determined
13
14 before the Plan year begins, based on estimated claims, and include
15 a premium fee; and
16 WHEREAS, under an “Administrative Services Only” (ASO)
17 plan, a self-insured plan, the City does not have to pay a premium
18
1g fee, and most of the administrative fees are based on actual claims
20 paid; and
21
22
WHEREAS, by amending the contract with NWNL to an AS0 Plan,
23 the City reduces its administrative expenses for the group Health
24 Plan.
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NOW, THEREFORE, BE IT RESOLVED by the City Council of the
City of Carlsbad, California, as follows:
1. That the above recitations are true and correct.
2. That the City Council confirms the amendment to the
City’s contract with NWNL to an Administrative Services Only
agreement effective April 1, 1992.
3. That the City Council authorizes the attached
amendments and riders to the contract with NWNL contained in
Exhibit 3.
> ,
i (
1:
PASSED, APPROVED, AND ADOPTED at a regular meeting of the
Carlsbad City Council held on the 25th day of Mav 8
i 1993, by the following vote, to wit:
i AYES: Council Members Lewis, Stanton, Ku lchin, Nygaard, and Finnila
NOES: None
ABSENT: None
ATTEST:
4LETHA L. RAUTENKRANZ, City Cle
SEAL)
EXHIBIT 3
Copies of Amendments and Riders to the Group Health Contract
with Northwestern National Life Insurance Company.
a)
b)
a
d)
e)
f)
cl)
5i.skm a)
W
a
d)
Dated September 30, 1986; effective January 1, 1986: amend
Plan to pay 90% benefit for certain services not available
through the Preferred Provider Organization (PPO).
Dated April 8, 1987; effective January 1, 1987: amend Plan to
provide modified family deductible of $300.
Dated April 15, 1987; effective January 1, 1987: amend Plan to
provide a $1 million lifetime Major Medical benefit.
Dated May ‘21, 1987; effective January 1, 1987: amend Plan to
set up Account #6 for COBRA Claims.
Dated January 6, 1989; effective January 1, 1989: change split
risk pooling level from $50,000 to $75,000.
Dated January 22, 1990; effective January 1, 1990: the Police
Unit is no longer covered for Health benefits through NWNL.
Dated March 9, 1992; effective April 1, 1992: cancels split
risk contract and replaces it with ASO/Excess Risk plan.
Effective January 1, 1986; NR-07886: modifications of
provisions affecting “pre-existing conditions” and “takeover
deductible and out-of-pocket expenses.”
Effective January 1, 1986; NR-07887: modifications of the
provisions affecting “employee’s insurance“ and “dependents’
insurance.”
Dated March 31, 1989; effective January 1, 1989: policy is
nonparticipating as a result of NWNL’s conversion to a stock
life insurance company.
Effective July 1, 1991; NC-287: modifications’ of provisions
affecting “Basic Life Insurance” and “Supplemental Life
Insurance;” insurance will decrease to 65% on the employee’s
65th birthday.
Group
Group
T . IO. Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 55440
Request for Amendment of Group Policy(ies)
(Prepare in Triplicate)
Please be complete and specific in your request.
Policyholder City of Carlabad
Policy Number(s) CH-19235-o
ECfective Date for Amendment(s) January 1, 1986
( If possible. the effective date should be the first day of a policy month)
Route So.
Request is hereby made to Northwestern National Life Insurance Company for the following revizion(s) to the Group Policy(ies) indicated above:
Please amend our policy to pay PPO benefit (90%) for the following, since
these services are not currently available through the PPO:
Ambulance Podiatrist -. .
Psych/Marriage Counselor Nutritionist
Physical Therapy
Dental - (m, X-Ray, La) ‘j,r’,l’. ‘1 - r*i a-
Ophthalmologist (treatment of diseases only, not standard exm 6 lens prescription)
Durable Medical Equipment Acupuncture - by an M.D. only
Prescriptions
Services received by all providers outside of San Diego County are also covered
at PPO benefits.
If both PPO hospital 6 physician are used, all ancillary services are covered aa
PPO benefits as well.
Dated
(If additional space is needed, please use reverse side)
,194&. Group Policyholder City of Carlsbad
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) to accnm- plish the requested revisions, provided it deems the result to be legal, appropriate for the type of insurance plan involved and acceptable based on ita underwriting requirements, subject to necessary adjustment. II any, in premium rates. In case of problem, we till contact you promptly.
To: Northwestern National Life Insurance Company BOX 20 - Minneapolis, Minnesota 55440
Request for Amendment of Group Policy(ies)
(Prepare in Triplicate)
Please be complete and specific in your request.
Route So.
--. Insurance Company’:
use only
ftY-I
Group Policyholder City of Car&bad
Group Policy Number(s) GH-19235-o
Effective Date for Amendment(s) Januaw lr 1987 ( If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revision(s) to the Group Policy(ies) indicated above:
.
please amend pla;to provide a modified family deductible of
$300.
Dated
(It additionaLspace is needed, pleaae use reverse side)
, 19 82 Group Policyholde
BY
Tit1 LEL cl> I ~Ec7-c
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) tp accom- plish the requested revisions, provided it deems the result to be legal, appropriate for the type of Insurance plan involved and acceptable based on ita underwriting rquirements, subject to necessary adjustment, if any, in premium rates. In case of problem, we will contact you promptly.
Roure So. To: Northwestern National Life Insurance Company Box 20 - Minneapolis, &Minnesota 55140
Request for -4mendment of Group Policy(ies)
(Prepare in Triplicate)
Please be complete and specific in your request.
-- _-
Insurance Company’;
use only
Group Policyholder The City of Carlsbad
Group Policy Number(s) GH-1923 5-O
Effective Date for Amendment(s) January 1, 1987
( If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revision(s) to the Group Policy(k) indicated above:
Please amend the plan to provide a Sl,OOO,OOO lifetime Major
Medical benefit for all covered employees.
Da ted-A@ 1 15
(If additional space b needed, please use reverm side)
( 19-8L. he City of Catlsbad
Title Personnel Director
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) t? accom- plish the requested revisions, provided it deems the result to be legal, appropriate for the type of msurnnc.e plan involved and acceptable based on its underwriting requirements, subject to necessary adjustment. II any, in premium rates. In case of problem, we will contact you promptly.
Route No. To: Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 35140
Request for Amendment of Group Policy(ies)
(Prepare in Triplicate)
Please be complete - ’ specific in your request.
- --
Insurance Company’5
\ . use only I__- - s-1 1
Group Policyholder C; af
Group Policy Number(s) GH-19235-0
Effective Date for Amendment(s) l/l/87 ( If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revision(s) to the Group Policy ties) indicated above:
Please amend plan to have Account 116 set up for COBRA Claims.-,
(If additional space is needed, pleaw’use reverse side)
Dated- May 21 ,19x-.
Title” crsonnel Director
PLEASE NOTE: Northwkstem National Life Insurance Company will provide amendment(s) to accom- plish the :‘: quested revisions, provided it deems the result to be legal, appropriate for the type of insurance plan involved and acceptable based on its underwriting requirements, subject to neceswry adjustment. rf any, in premium rates. In case of problem, we will contact you promptly.
. -
1200 ELM AVENUE CAALSBAD. CA 920081989
PERSONNEL DEPARTMENT
ELEPhObE
1619) O&i852
January 9, 1989
CAREN FRIEDMAN
Group Field Representative Northwestern Nationial Life 18400 Von Karman Ave., Suite 730 Irvine, CA 92715
Dear Caren:
The City of Carlsbad has agreed to increase their pooling level from $50,000 to $75,000. This will be effective January 1, 1989. According to your figures, the rates will increase by 24.69. In addition, here is yotir copy of the axnendment to the split risk agreement.
Please call me if you need additional information.
Sincerely,
MARSHA PAYNE Acting Person..al Director
jm
Enclosure
.-
MASTER AMENDMENT REQUEST FOR REVISED SPLIT RISK AGREEMENT
The City of Carlsbad GH - 19235-o
Plan sponsor Group Number
Effective l/1/89 the Plan Sponsor requests Northwestern National Life Insurance CAmpany, ("ML") to amend and restate in its entirety the Split Risk Agreement previously made between the parties to incorporate, among otherr, the following summarized changes and provisiona.
1.
2.
3.
4.
5.
Interest on deficit8
Interest charged on deficits will be paid by the Plan Sponsor ar,d will not be subject to inclusion in the maximum monthly reimbursement level or any other limitation.
Mimimum monthl,v claim8 cae
A minimum monthly claim8 cap will be eatabllshed by NWNI, at the time of renewal or amendment underwriting. NWNL may reimburse itself for claim8 up to thi8 limit regardless of other fluctuation in tha determination of monthly claim8 limitationa. . _
Two month employee/dependent count laq
For purpose8 of setting the maximum monthly claim8 cap, the employee/dependent count will come from the second preceding plan month.
Calculation of Reserves
Reserves will ba calculated by multiplying 12 timaa the reserve rata8 times the greater of the following employee/dependent counts in the' last policy year.
* Number at the beginning of the year; * Number at the end of the year; * Average number during the year.
Termin&on CMtionm
At termination, a retro8pective premium in the amount of the reaemm will be transferred to WNL. NWNL will a88ume all liability for incurred but not reported claims.
The Plan Sponsor may retain tha resewes and assume liability for all run-off claims if the following conditions are met:
* the plan sponsor pays NW& any outstanding accumulated deficit; * in approved claimr adminirtrator handles the claims;
* The plan rrponror giver NW!Wan accepttile hold-harmle88 agreement; * NWNL l gree8.
.-
6. Claim Liability Options (Choose A or B)
'3 A Plan Sponsor to repay deficits - recovery in future months/years with remaining deficit due on termination. Monthly claims cap and deficit limitation must be qreater than of equal to 120%. (Choose one)
\:! 100% monthly claims cap / 20% deficit limitation
c! monthly claims cap (minimum cap of 100%) / deficit limitation
\J B . Deficit to be recovered in future months/years only as monthly claims cap allows. Monthly claims cap, deficit I' limitation, and year-end payment (if any) must be greater than or equal to 125%. (Choose one),
'3 110% monthly claim8 cap / 15% deficit limitation
n 1107hrorithly claims cap (minimum cap of 110%) / m deficit limitation
q .
100% monthly claims 'cap / 10% year end payment / 1 y. deficit limitation
'1
end monthly claims cap (minimum cap of 100%) / 10% year payment / - deficit limitation
7. Insulated deficits
For those plan sponsors in a deficit position when they increase their monthly claims caps from 100% (or 105%) to 110% or more, NWNL will continue to recover existing deficit8 on the First of each month subject to the deficit carry-forward limitations and the new monthly cap.
8. Dividend Offset
If the Plan Sponsor is in a deficit (either insulated or not) and is entitled to a dividend on any other coverage, NWNL will apply tit dividend to the accumulated Split Risk deficit.
NWNL will promptly prepare an amended and restated Split Risk Agreement, th@ tetmr and condition8 of which shall constitute the contract between the parties, for delivery to the Plan Sponsor. By it's signature hereunder, the Plan Sponsor agrees that, in the ab8enSe of any written notification to NWNL of objection8 made within thirty days of its receipt of the amended and restated Agreement, the contract as amended and restated shall become effective on the date specified therein without further action or signature of either party.
Plan Sponsor
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1c
~.onal Lfia Ia8Uf MCI company Box 20 - Ipour, laaalasota 55440 - .
EQquut for Amudmuit of omlp Poli8ytLu)
(Prapua fa Ikiplio8ta)
Plum bo caaplato aad 8pcraifia in your roquut.
P.8PEl &nItr No.
Group Polfc~holtiar Pifrot
Group Policy NUM&r(r) =-la&g
Zffautivo D&r for Amandmaat<r) (If porrlblr, thQ l CfoCtfvI data I 9i!iikm. first dry of a policp month)
. Rqllut fa hur % rQvision(r) to t rn8.d~ to Northuutun National Lffr Iarutaaca Company for the following Q Group Poliuyc fu) fladia8tad SbovQr
PraAsx ma tdorthwutua Natimrl Lifm Iamr~rca Company will pzovido amadmat(a) to &au "k lids tha toqttutd rwiabnm, provided it doma the tomalt to bo loyal, rppropriato fcgt t 0 of faaumaca plm i~~01ved (Ipd raaagtrbh burd on ik nndazwzitiag require- IMUt8, S P jaat to lamcucr~) adj~tmaat, if any, ix premium ratu. Ia CUE at problw, we will ccrat8at prr prorptly.
.
NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY HOMl OCClCl * MINNlAPOLIS. YlNNlSOTA
cERTrFrcArEBooKLETRIDER
city of c8rl8bd
GH-192354
Certain provisions in your certificate may be modified if you and your dependents were insured on
the effective date of the Group Policy, January 1, 1966. These provisions are:
The pre.existing conditions provision in your certificate may not apply to you or your insured depen.
dent if the Group Policy replaces the Policyholder’s previous group health insurance policy. The pro.
vision does not apply to you or your insured dependent if all of these are true: You or your insured dependent -
l was insured under the Policyholder’s previous policy on the day before the Group Policy’s Ef.
fective Date.
l becomes insured under the Group Policy on its Effective Date.
l incurs an expense that would have been covered under the previous policy but is not covered _ under the Group Policy because of the pre.eristing conditions provision.
l Incurs the expense on or after the Group Policy’s Effective Date.
When all of the above are true, we will pay a benefit equal to the lcucr of the total expenses covered
under -
l the previous policy, OK .
l the Group Policy, disregarding its preexisting conditions provlslon.
mkcover Deductible and Chatof-Fucket Expaua
If you or your insured dependent -
l was insured under the Policyholder’s previous policy on the day before the Group Policy’s Effec-
tive Date, and
l met any part of the deductible or incurred any out-of-pocket expenses under the policy the Group Policy replaced, we will use that part of the deductible and the out-of-pocket expenses towards meeting the deducti-
ble and the out-of-pocket expenses under the Group Policy.
,
Registrar
NORTHWESTERN NATIOh.--
LIFE INSURANCE COMPANY MOM1 Ofelcf . MINN1ACOLIS. MINNlSOTA
city of ctrlrbed
CH-19235-O
EMPLOYEE’S INsuRANcE
The following provision is added to the Employee’s Insurance section of your cettificate for Medical Insurance.
We waive the actively at work requirements of the Employee’s Insurance section of your certificate if
all of the followin conditions are met:
l You are eligible for insurance except for meeting the actively at work requirements on the Group
Policy’s Effective Date.
l You were insured under the group policy the Group Policy replaced on the day before the Group Policy’s Effective Date. If these conditions are met, your Insurance, Including any Dependents’ Medical Insurance, will start on the Effective Date of the Group Policy.
which txpemtt art covtrtd expalett?
For Medical Insurance, we pay benefits only for expenses that were covered expenses under the
group medical policy which the Group Policy has replaced.
How much do we pay?
Before you return to active work, the benefit amounts and limits will be the same as the benefits un- der the prior group policy. We reduce the amount we pay by any benefits still payable under the prior
group policy.
If you return to active work, we pay benefits according to the Schedule of Benefits and covered ex-
penses of your certificate.
when doa your Medlctl Inmutnct nap?
If you were not totally disabled on the day before the Group Policy’s Effective Date, then your insur.
ante stops according to the “When does your insurance stop?” section of your certificate.
If you were totally disabled on the day before the Group Policy’s Effective Date, your insurance stops
on the earlier of the following dates:
l For Major Medical Insurance, the end of the 12 month period following the date you became
totally disabled.
l For any other Medical Insurance, the end of the 90 day period following the date you became
totally dfsabled.
DEPENDEN’IWINSURANCE
The following provision is added to the Dependents’ Insurance section of your certificate for Medical
Insurance.
We waive the requirement in the Dependents’ Insurance section of your certificate that a dependent must not be confined in a hospltai in order to become insured, if 8I.l of the following conditions are
met:
l Your dependent is e!igible for insurance on the Group Poll@ Effective Date, except for being hospital confined.
l Your dependent ww insured under the group policy the Group Policy replaced on the day before the Group Policy’s Effective Date.
If these conditions are met, your dependent’s insurance will start on the Effective Date of the Group
Policy.
NR-07887-l
NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY
HOME OFFICE . MINNEAPOLIS MINNESOTA
CERTIFICATE BOOKLET RIDER
City of Carlsbad
CH-19235-O
Your certificate has been changed as follows. Please insert this rider in your certificate. This rider 1s
subject to all of the terms of the Group Policy.
I. Medical Insurance
A. The following provision under the Schedule of Benefits Major Medical Insurance “Maximum Life-
rime Benefit” section on page 4 is deleted.
*Your maximum lifetime benefit will decrease to S25,OOO on your 70th birthday.
B. The “Deductible” provision under the Schedule of Benefits Major Medical Insurance section on
page 4 is changed to read as follows:
neductfble
^or an accidental injury . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . none
)r Non.Emergency Surgery Expenses for opinions
.lade by the second and third doctor . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . , . . . none
. For Outpatient Preadmission Testing Expenses . . . . . . . . . . . . . . . . . . . . . . . . , . . . none
l For Home Health Care Services Expenses . . . . , . . . . . . . . , . . . . . . . , . , . . . . . . . . . none
. For Hospital Admission Expenses per admission
(if no preadmission certification is obtained) . . . . . . . . . . . . . . , . . . . . . . . . . . . . $250
. For all other covered ,expenses:
individual.............................................................. $100
family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300
l Accumulation Period (January 1 through December 31) . . . . . . . . . . . . . . . . . . , . 12 months
C. The “Family Deductible” provision under the Schedule of Benefits Major Medical Insurance
section on page 4 is changed to read as follows:
Vy Deductible
,rmount used to meet the individual deductible for each member of your family is also used
crds meeting the family deductible.
; consider the deductible met by you and all your insured dependents for the rest of a benefit
period if two or more insured members of your family meet the family deductible in that benefit
period. If one insured member of your family meets the individual deductible, we consider the de-
ductible met for that insured member.
The carry over deductible does not apply.
NR-104’55.1
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NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY
HOME OFFICE HlNNEACOLlS MINNESOTA
POLICY RIDER Issued by Northwestern National Life Inrurance Company (NWNL)
This Rider is made a part of your policy, effective the date of NWNL’s conversion to a stock life insur. ante company, or, if later, the effective date of your policy.
Your policy is revised as follows:
This policy is nonparticipating and will not be entitled to share in the surplus earnings of NWNL.
After each policy year this policy, for purposes of determination of a retroactive rate credit, if any, will be subject to experience rating with respect to the prior policy year. The experience rating plan 0' ‘VNL in effect at the time of the experience rating will be used. The experience rating plan wiU
L nto account those reserves and expenses which NWNL determines to be necessary and advis-
at NWNL, in its discretion, may combine the financial experience of this policy with the finan-
cia. experience of other group policies or coverages issued by NWNL to the policyholder. If a
retroactive rate credit results, it will be paid in cash to the policyholder.
Any conversion policy to which this policy refers is nonparticipating and wilI not be entitled to
share in the surplus earnings of NWNL.
NORTHWESTERN NATIONAL LIFE INSURANCE COMPANY
‘4 &-
resident
39924
Northwestern
National Life
Home Office l Minacapotis MN
CERTIFICATE BOOKLET RIDER
City of Cartsbad
GL-19236-S
Your certificate C-2847 has been changed. The page attached replaces the one presently included in your certif-
icate. Please insert the new page into your ceniticate. This rider is subject to all of the terms of the Group
Policy.
Page 3 is replaced.
This Certificate Booklet Rider is effective on the latest of the following dates:
- July 1. 1991.
- The effective date of your insurance.
l The date you return to active work if you are not actively at work on the date this Rider would otherwise start.
NC-2847
SCHEDULE OF BENEFITS
BASIC LIFE INSUFtANCE
ClaSS
Active Mayor, Council Members
and Elected Offtcials
Amount of Life Insurance*
s25,ooo
City Manager, Assistant City Managers,
Department Heads and all other
Management Employees
All Other Active Employees
Two times your Basic Yearly .
Earnings** to a maximum of $2OO,ooO.
but not less than $15,000.
One times your Basic Yearly
Earnings** to a maximum of~5200.000.
but not less than $15,000.
SUPPLEMENTAL LIFE INSURANCE
Class
Active Mayor, Council Members
and Elected Officials
Amount of Life Insurance*
$25800
Active Managers, Assistant Managers,
Department Heads and all other
Management Employees
All Other Active Employees
Two times your Basic Yearly Earnings**, but
the total amount of Basic and Supplemental Life
Insurance will not be over $400.000.+**
One times your Basic Yearly Earnings+., but
the total amount of Basic and Supplemental Life
Insurance will not be over $400.000.***
*Your amount of insurance will decrease to 65% on your 65th birthday.
**Basic Yearly Earnings means the basic yearly salary or wage you receive for work done for the Policyholder.
It does not include bonuses, commissions, overtime pay, uniform allowances, car allowances, “stand-by” or “call-
back” pay. educational incentive, or insurance rebate. To determine benefits, your amount of insurance is
rounded to the next higher $1,000 multiple, unless the amount equals a $l.ooO multiple.
***For amounts of Supplemental Life Insurance or a combination of Basic and Supplemental Life Insurance over
$235.000. you must give us proof of good health we accept, without expense to us.
DEPENDENT LIFE INSURANCE
ChSS Amount of Insurance
Spouse $1,500
Child (each)
l under 6 months
* 6 months but less than 19 years,
Student age 19 but less than age 24.
$100
$1,500
Effective July 1. 1991
To : Northwestern L -ional Life Insurance Company
Box 20 - Hinneapolis, tlinnesota 55440
Request for Amtnticnt of Group Policy(ies)
(Prepare in Triplicate)
Please be complete and specific in your request.
Route No.
Insurance Company use only
Group Policyholder CITY OF CARLSBAB
croup Policy Number(s) GL-19236-8
Effective Date for Amendment(s) 7/l/91 (If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revision(s) to the Group Policy(ies) indicated above:
Please amend the age reduction on our life plan as follows:
From:
65th birthday to age 70 NW?4L pays 65%
70th birthday and after NWNL pays $1000
TO:
65th birthday and after NW& pays 65%
(If additional space is needed, please use reverse side)
PLEASE NOTE I Northwestern National Life Insurance Company will provide amendment(s) to accomplish the requested revisions, provided it deems the result to be legal, appropriate for the type of insurance plan involved and acceptable based on its underwriting require- ments, subject to necessary adjustment, if any, in premium rates. In case of problem, we will contact you promptly.
C, dITE IT - DON’T SAY ‘ 1-!
To .--FL&L--___--- ..____-__
From Isabelle.F'?ulsen
-
Date May 23
0 Reply Wanted
ONo Reply Necessary
19 95
These pages were part of Agenda Bill j/12,251, Council Meeting of May 25, 1993.
PRINTED IN us1
- EXHIBIT 2
To: Northwestern National Life Insurance Company
Box 20 - Minneapolis, Minnesota 55440
Route No.
Home Office use only
Request for Amendment of Group Plan(s)
Please be complete and speczjk in your request.
Group Plan Name CITY OF CARLSBAD
Group Plan Number(s) AS0 24438-4
Effective Date for Amendment(s) 07/01/1995
(if possible, the effective date should be the first day of a plan month)
Request is hereby made to Northwestern National Life Insurance Company for the following
revision(s) to the Group Plan(s) indicated above:
Terminate vision benefits with NWNL for all claim accounts (except claim account 3 General)
resulting in an AS0 fee reduction of $.25 per employee per month for those terminated claim
accounts.
Add dental benefits for employees enrolled under the Kaiser plan (claim account 10). AS0 fees
will be $4.25 per dental only employee per month.
Add an annual $250 per family wellness benefit for all claim accounts (except claim account 3
General) to be administered through the Reimbursement Account Administration Department in
Minneapolis, MN.
(If additional space is needed, please use reverse side)
Dated
39279
July 3, 1995
Northwestern National Life Insurance Company Box 20 Minneapolis, MN 55440
Re: Amendment of Group Plan - City of Carlsbad
The Carlsbad City Council, at its meeting of June 27, 1995, adopted Resolution No. 95-189, approving an amendment with Northwestern National Life Insurance Company for group medical, dental and vision coverage for city employees.
Enclosed is a copy of Resolution No. 95-189 and a copy of the amendment to the agreement for your records.
KRK:ijp
Enclosures
1200 Carlsbad Village Drive l Carlsbad, California 92008-1989 - (619) 434-2808