WALMART INC.
TEXAS INJURY CARE BENEFIT PLAN
(Effective March 1, 2012)

00??

OFFICIAL PLAN DOCUMENT


Ra? 

 

TABLE OF CONTENTS
Page

ARTICLE I - DEFINITIONS ..1
1.1 "Acdden? "1
1.2 "Adverse Benefit Determination" ..1
1.3 "Appeals Committee" ..1
1.4 "Approved Facility" ..2
1.5 "Approyed Physician" ..2
1.6 "Associate" .. 2
1.7 "Beneflolary" .. 2
1.8 "Claimant" ..2
1.9 "Claims Administrato?'  .. 3
1.10 "Company" ..3
1.11 "Course and Scepe of Employment" .. 3
1.12 "Covered Charge? ..4
1.13 "Covered Associate" .. 9
1.14 ?Cumulative Trauma? .. 10
1.15 "Custodial Care" ..10
1.16 "Death Benefits" .. 10
1.17 ?Determination? .. 10
1.18 "Dlsabled" or ?Usability? .. 10
1.19 "Dismemberment Bene?ts" .. 10
1.20 "Emergency Care? ..10
1.21 "Employer" .. 10
1.22 "First Aid" 11
1.23 "Gross Mleconduet" .. 11
124 "HmnetbaM1Cme" .41
1.25 "Home Health Care Agency" .. 11
I26 thuy' .x ?11
1.27 "Maximum Bene?t leit" .. 15
1.28 ?maximum Rehabilitative .. 15
1.29- "Medical Bene?ts" .. 15
1.30 "Medlcally Necessary" .. 15
1.31 "Medical Rehabilitation Hospital? .. 16
1.32 "Medlcare" .. 16
1.33 '14o?ce"or"No??ca?on" ..16
1.34 "Occupational Disease? .. 16
1.35 "Partial Disabllity" .. 17
1.36 ..17
1.37 'TWan" ..17
1.38 ?Plan Administrator? .. 17
1.39 "Plan Year" .. 17
1.40 "Post-Service Claim" ..17

141 "Preexisting Condition? .. 17

I

New 12/2211!

1.42 "Pre-lnjury Pay" .. 17
1.43 "Pre~Service Claim" .. 18
1.44 "Receipt, Safety Pledge and Arbitration Acknowledgement? .. 18
1.45 "Relevant" .. 18
1.46 "Representative" .. 18
1.47 "Skilled Nursing Care" .. 18
1.48 "Skilled Nursing Facility" .. 19
1.49 "Temporary Alternate Duty" .. 19
1.50 "Totally Disabled? or "Total Disability? .. 19
1.51 "Urgent Care Claim? .. ..20
1.52 "Usual and Customary?..- ..20
1.53 ?Violent ..20
1.54 ?Wage Replacement Benefits" ..21
ARTICLE II - ELIGIBILITY AND NATURE OF PAYMENTS .. 21
2.1 Eligibility 
2.2 Nature of Payments. .. 21
ARTICLE - BENEFITS 21
3.1 Wage Replacement Bene?ts .. 21
3.2 Death Benefits. .. 23
3.3 Dismemberment Bene?ts .. 24
3.4 Medical Benefits..; ..25
ARTICLE IV - ADDITIONAL REQUIREMENTS AND LIMITATIONS ON BENEFITS .. 25
4.1 Reporting. .. 25
4.2 Medical Management .. 28
4.3 Suspension Or Termination of Benefits. ..29
4.4 Final Compromise And Settlement. .. 31
ARTICLE - ADMINISTRATION .. 31
I 5.1 Plan  .. 31
5.2 Funding Policy and Method .. 32
ARTICLE VI - CLAIMS PROCEDURES .. 33
6.1 Filing a Claim for Benefits. .. 33
6.2 Claims Review. .. 34
ARTICLE VII - COORDINATION OF BENEFITS AND SUBROGATION .. 41
7.1 Reduction in Benefit Payments. .. 41
7.2 Coordination Of Benefits. .. 41
7.3 Subregation and Reimbursement Rights. .. 42
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Page

7.4 Notice Of Legal Proceedings. ..43
7.5 Assignment Of Rights. .. 44
ARTICLE TERMINATION AND AMENDMENT .. 44
ARTICLE IX - GENERAL PROVISIONS .. 45
9.1 Inability to Make Payment ..: ..45
9.2 Claims Administrator and Appeals Committee Indemnity. ..: .. 45
9.3 Provision ..45
9.4 Employment Noncontractual ..45
9.5 Discharge for Benefit Payments .. 45
9.6 Participation By Affiliates .. 46
9.7 Plan Documents Control. .. 46
9.8 Construction .. 46
9.9 Separabllity. ..46
9.10 Applicable Law ..46
9.11 . Application of Health Insurance Portability and Accountability Act .. 46
9.12 Application of Patient Protection and Affordable Care Act. ..46
9.13 Application of Other Group Health Plan Requirements ..46

APPENDIX A: ARBITRATION OF CERTAIN INJURY-RELATED DISPUTES

APPENDIX B: PARTICIPATING EMPLOYERS
APPENDIX C: COBRA CONTINUATION COVERAGE NOTICE

APPENDIX D: SAFETY PLEDGE AND ARBITRATION
ACKNOWLEDGEMENT

?Cop3n?hi our? Paramecium 

Rev. 

WALMART STORES, 
TEXAS BENEFIT PLAN

This Wairnart Stores, inc. Texas injury Bene?t Plan (the "Pian") is made and executed in
Bentonvilie, Arkansas by Walmart Stores, inc. a Delaware corporation (the "Company").

WITNESSETH THAT:

. WHEREAS, the Company has rejected coverage for its Texas associates under the
Texas Workers' Compensation Act. effective March 1, 2012; and

WHEREAS. the Company desires to establish an employee welfare bene?t plan
subject.to the Employee Retirement income Security Act of 1974, as amended 
effective March 1, 2012, to provide a means by which the Company and other adopting
employers can protect themselves from certain liabilities as nonsubscribers to the Texas
workers' compensation insurance system by providing non?fringe disability, death,
dismemberment and medical benefits with respect to any covered injury sustained by
Texas associates in the course and scope of employment;

NOW, THEREFORE, in consideration of the premises, the?Company hereby
establishes this Plan to provide benefits and be administered in accordance with the
following: 


I DEFINITIONS

1.1- "Accident" means an event involving factors external to the_Participant
a: .

was unforeseen, unplanned. and unexpected:

occurred at a specifically identi?able time and place;

(0) occurred 6191-. .
resulted in physical injury (or mental or emotional injury. in the event of
a Violent Crime) to the Participant.

1.2 "Adverse Bene?t Determination" means a denial, reduction or termination
of, or a failure to provide or make payment (in whole or in part)? for, a Plan bene?t. For
example, this includes denial, reduction, or termination of bene?ts based upon a
participant?s ineligibility to participate in the Plan, application of any utilization review;
(0) a medical service being experimental or investigationai or not Medically Necessary or
appropriate, or the Participant is no longer Disabled.

1.3 "Appeals Committee" means the individuals or entity appointed by the
Company to make Determinations on appeal of benefit claims on behalf of the Company
and all other Employers.

?Copyriqhi 2012 1
Rev 

 

1.4 "Approved Facility" means a hospital, other medical care facility or medical
service or supply provider either expressly approved by the Claims Administrator, included
on an approved list of facilities adopted by the Claims Administrator, or otherwise approved
in writing by the Claims Administrator upon the request of a Participant. Where the
authorized prescription. medical supply or service ls available at a Walmart or Sam's Club
location convenient to the Participant, Walmart or Sam's Club is the exclusive Approved
Facility for such authorized prescription, medical supply or service. The Claims
Administrator reserves the right to add to. delete from, or otherwise amend any list of

. Approved Facilities at any time.

1.5 "Approved Physician" means a person duly licensed under applicable state
law as a Medical Doctor or Doctor of Osteopathy and either expressly approved by the
Claims Administrator, included on an approved list of physicians adopted by the Claims
Administrator, or otherwise approved In writing by the Claims Administrator upon the
request of a Participant. The Claims Administrator reserves the right to add to, delete
from, or otherwise amend any list of Approved Physicians at any time.

1.6 "Associate" means any person who is employed in the regular business of,
and receives his or her pay by means of a salary, wage or commission directly from, an
Employer and for whom an Employer files a Form W-2 with the internal Revenue Service.
This term does not include an independent contractor or third-party agent.

1.7 "Beneficiary" means the person or persons determined in the following
priority: -- 

if there is an Spouse, all Death Benefits shall be paid to the
Eligible Spouse.

If there is no Eligible Spouse, Death Bene?ts shall be paid in equal
shares to the Eligible Children. if an Eligible Child has predeceased the Participant,
Death Benefits that would have been paid to that child if he or she had survived the
Participant shall be paid in equal shares per stirpes to the children of such deceased

child.

If the Participant is not survived by an Eligible Spouse or Eligible Child.
any Death Benefits shall be paid to a surviving dependent (as determined in
accordance with the support criteria set forth in section 152- of the internal Revenue
Code and such other rules as the Claims Administrator may prescribe) of the
Participant who is a parent, sibling, or grandparent of the deceased Participant. if
more than one of those dependents survives the Participant, any Death Benefits
shall be divided among them in equal shares.

if the Participant Is not survived by an Eligible Spouse, Eligible Child.
or dependent who Is a parent. sibling, or grandparent, the Death Benefits shall be
payable to the Associate Critical Needs Trust for the benefit of Company associates.

For purposes of this Section:

(1) ?Eligible Spouse" means the surviving spouse of the deceased
Participant, recognized by a marriage certi?cate issued under the laws of the

@Ccpy?ghtmi? Partnan 2
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State of Texas or similar government authority, or by a Texas court decree of
common law marriage (obtained at such person's sole initiative and
expensei

(2) "Eligible Child"_ means a surviving child of the deceased
Participant, whether by blood. marriage. or legal adoption, if the child is:

(A) under 18 years of age;

(B) enrolled as a full~t me student in an accredited
educational institution and is less than 25 years of age; or 

(C) because of a physical or mental handicap, a dependent
(as determined In accordance with the support criteria- set forth in
section 152 of the Internal Revenue Code and such other rules as the
Claims Administrator may prescribe) of the deceased Participant at the
time of the Participant?s death.

1.8 . "Claimant" means a Participant, a medical provider seeking payment for a
service or supply, a Bene?ciary, or a Claimant?s Representative, as applicable.

1.9 "Claims Administrator" means the individual. individuals or entity appointed
by the Company to make initial Determinations of bene?t claims under this Plan on behalf
of the Company and all other Employers.

1.10 "Company" means Waimart Stores, Inc., a Delaware corporation whose
corporate headquarter is located in Bentonvilie, Arkansas. or any successor thereto.

1.11 "Course and Scope of Employment" means an activity of any kind or
character for which the Participant was hired and that has to do with, and originates in. the
work, business. trade or profession of an Employer, and that is performed by a Participant
in the furtherance of the affairs or business of an Employer. The term includes activities
conducted on the premises of an Employer or at other locations designated by an
Employer. This term does not include:

a Participant's transportation to and from his or her place of
employment,unless(1) the transportation. is furnished as part of the Participant's
employment arrangement or is paid for by an Employer; provided, however,
that this exception does not include commuting to or from the Participant's
usual place of employment; 

(2) the means of the transportation are under the control of an
Employer; or? -

(3) the Participant is directed in his or her employment to proceed
from one place to another place. Commuting to the place where the
Participant begins Employer business and commuting away from the place
where the Participant ceases Employer business shall not be covered if such

3
Rev. 1202)?

 

I transportation is not paid by the Employer or otherwise under Employer
control. 

travel by the Participant in furtherance of the affairs or business of an
Employer if such travel is also in furtherance of personal or private affairs'of the

Participant, unless:

(1) the travel to the place where the injury occurred would have
been made even had there been no personal or private affairs of the
Participant to be furthered by the travel; and

(2) the travel would not have been made had there been no affairs
or business of the Employer to be furthered by the travel.

(0) a Participant's transportation not under dispatch or other activity not
under dispatch;

any injury occurring before the Participant clocks in or otherwise begins 
work for an Employer or after the Participant clocks out or otherwise ceases work for

an Employer.

any injury occurring while the Participant is on a work break, unless:

(1) the injury occurs while the Participant is on a work break on
Employer's premises;

(2) such work break was authorized by his or her supervisor (or
was otherwise permitted consistent with the Participant's job description); and

(3) the Participant has not clocked out or otherwise ceased work or
concluded his or her shift for an Employer. 

1.12 "Covered Charge" means the cost to a Participant of a service or supply
described in this Plan below. which service or supply is Medically Necessary. based on the
nature of the injury, as and when provided, and (1) cures or relieves the effects naturally
resulting from the injury; (2) promotes recovery; or (3) otherwise enhances the ability of the
Participant to return to or retain employment. Such services and supplies are also subject
to the medical management provisions of Section 4.2. For purpoSes of this Plan, the words
"service" or "supply" include. but are not limited to. any related treatment. medication.

technique or'method.
First and Continuing Treatment.

(1) The first Covered Charge'must-be. received from an Approved
Physician and incurred the date?ief the injury (unless
the Claims Administrator cause exists): and

. (2) No further amount shall be considered a Covered Charge if the
Participant does not receive medical treatment from an Approved Physician
or Approved Facility (or scheduled treatment with an Approved Physician or
Approved Facility has not been approved by the Claims Administrator) for a

2012 PartnetScuch 4
REV 

period of more than 60 days. This subsection (2), however, shall not apply to
any Covered Charge for testing and any follow up vaccination with respect to
an injury that involves a potential occupational exposure to a bloodborne
pathogen.

Approved Provlder and Pro-Authorization Requirements. The cost
of a service or supply shall be a Covered Charge only if:

circumstances). _pre~approval may include authorization for multiple
visits to an Approved Physician or Approved Facility. and must be in writing,
or by electronic notice (except as otherwise specified below or in Article Vi
herein); or.

(2) treatment is provided as Emergency Care; and

the Claims Administrator receives notification of such
Emergency Care within the later of 24 hours of the Participant?s receipt -
of such care or the next business day; and

(ii) after receiving primary Emergency Care, subsequent
treatments are provided by. or at the direction of. an Approved
Physician or Approved Facility in accordance with paragraph (1)
above. -

(0) Covered Medical. Subject to the restrictions and limitations set out
elsewhere in this Plan, Covered Charges shall include the cost of the following:

(1) Approved Physician visits - at an Approved Facility (including
charges for an emergency room), Approved Physician?s office, or in the case
of Home Health Care, at the Participant's home, including second opinion
services requested by the Claims Administrator (in accordance with Section
and charges'for a registered nurser'" 

(2) Medical supplies approved by the treating Approved Physician,
including the following:

(A) Prescription drugs (generic. unless tradetname drugs are
requested by an Approved Physician) and over~the~counter drugs
such as analgesics prescribed by an Approved Physician;

(B) Blood and other ?uids (other than allergy. insulin, and
similar drugs) injected into the circulatory system (but only to the
extent not available through any refund or allowance by a blood bank
or similar organization); 

(C) Oxygen and its administration;

2012 Partnan 5
Rev 12am?

 

(D) Upon the written advice or prescription of an?Approved
Physician and only if obtained from an Approved Facility. rental or
purchase of a wheelchair. assisted breathing apparatus, or other
mechanical equipment necessary for the treatment of respiratory
paralysis, and similar internal or external durable medical equipment
designed primarily for therapeutic purposes;

Surgical dressings, bandages, splints, casts, crutches,
syringes, needles, trusses, and braces dispensed by an Approved
Physician or Approved Facility; and

(F) Other items approved by the Claims Administrator;

(3) Ambulance services professional ground ambulance service,
or if no other means of transportation can reasonably suf?ce to deliver the
individual to the closest appropriate Approved Facility, air ambulance,
regularly scheduled railroad, or airlines;

(4) Eyeglasses or contact lenses - one pair per injury up to $400,
Inclusive of professional of?ce visit charges, but excluding routine 
examinations; and -

(5) External hearing aid up to $600 per ear, inclusive of

professional office visit charges.

(6) Admission to an Approved Facility on an Inpatient or outpatient
basis, including semi-private room and board, ambulatory day surgery.
anesthesia and its administration, and similar services; 

(7) Diagnostic tastings. including x-ray examinations, laboratory
tests. MRI, CAT Scan, nuclear medicine, radiology and pathology (including
interpretive services) and similar testing: 

(8) Speech, occupational and physical therapy provided by an

Approved Physician or a licensed speech therapist, licensed occupational
therapist or licensed physical therapist; provided, however, that such services
shall be subject to case management approval regarding the number of
visits, the types. and ambunt of services provided during such visits;

inpatient rehabilitation services ?provided in a Medicai?

Rehabilitation Hospital: provided, however, that such services shall be
subject to continued stay review by the Claims Administrator and case
management approval regarding the types and amount of services provided;

(10) Limited or temporary pain management services (for example,
epidural steroid injections), but not including pain management programs;

(11) Surgery that restores a reasonable, normal preuln'jury
functioning; -

Partne'Scuce 6

Rev. $2122)?

(12) Services of a dentist or licensed oral surgeon - services for 

treatment and repair of broken teeth, fractures and dislocations of the jaw. or
the replacement of teeth (excluding temporomandibuiar junction dysfunction
services) when the injured Participant seeks treatment as soon as possible
after the injury;

(13) Home Health Cars (with respect to physical needs only) up to
75 visits per Plan Year and up to eight hours per visit for the ?rst two weeks
of Home Health Care and up to four hours per visit thereafter;

(14) Skilled Nursing Care. provided that an Approved Physician
monitors the progress of the Participant at least once during each 30-day
period of confinement;

(15) Orthotlcs, arch supports. corrective shoes, special bras or
girdles, corrective appliances, prostheses, or any similar item;

(16) Organ and tissue transplant services not otherwise covered by
some form of expense payment program. excluding the donor's
transportation costs. organ procurementcosts and the donor's surgical
expenses; .

(17) Charges for telephone consultations with the Participant;
Participant?s Representative, Approved Physicians or other health care
providers;

(18) . Mental health services (to the extent not otherwise covered by
an Employer's EmpioyeeAssistance Program). but only when such services
are provided for mental 'or emotional damage or harm resulting from a
Participant who is the victim of. or witness to, a Violent Crime occurring
during such Participant's Course and Scope of Employment. This coverage
shall apply solely to Medical Bene?ts coverage and shall not result in any
payment of Wage Replacement Bene?ts or other bene?ts under this Plan;

(19) Services rendered primarily for training, testing, evaluation.

counseling, or educational purposes; and

(20) Reasonabletravei, meal and lodging expenses related to.

medical treatment that requires travel greater than 50 miles from the
Participant's residence (one way), as interpreted by the Claims Administrator
for application under this Plan and approved by the attending Approved
Physician. Mileage will be reimbursed at the internal Revenue Service
identified "Medical Purposes" rate. as periodically updated.

Non-Covered Medical. Any. provision of this Plan to the contrary

notwithstanding, Covered Charges shall not include the cost of the following:

(1) Charges incurred prior to the Participant's date of participation
in the Plan, or prior to the Participant's date of injury;

20i2 Parmancuce 7

Rev. 1202i?

 

(2) Charges rendered after the Participant's Medical Benefits under
the Plan terminate; 

(3) Expenses which are not Medically Necessary. as determined by
the Claims Administrator; . -

(4) Charges incurred more than 60 days after the date of the
Participant's last Covered Charge (except as otherwise specified herein);

(5) Expenses that exceed any fee schedule adopted by the Claims
Administrator or the Usual and Customary charge for the same or similar
treatment; services or supplies in the Employer's geographic area;

- (6) Services or supplies payable by anygovernment or subdivision
or agency thereof. or any other applicable third~party payer;

(7) Services or supplies which are experimental. investigative. or
for the purposes of research. including, but not limited to. services and
supplies that have not been approved by the American. Medical Association.
the Food and Drug Administration. the appropriate medical specialty society.
or the appropriate governmental agency, all phases of clinical trials. all
treatment protocols based upon or similar to those used in clinical trials. or
any treatment not generally accepted by the physician?s profession In 'the
United States as safe and effective for diagnosis and treatment;

(8) Services or supplies performed or provided while the Participant
is not covered by the Plan;

(9) Services or supplies for which the Participant is not legally
1* obligated to pay. or for which no charge would be made in the absence of the

Plan:

(10) Services for the evaluation or treatment of mental or
damage or harm. except to the extent provided above under
subsection 

(11) Services or supplies for personal comfort or convenience. such
- as a private room. television. telephone. radio. guest trays. and similar items;

(12) Fraudulent claims or claims not ?led in good faith as determined
by the Claims Administrator;

(13) Canceled appointment charges;
(14) Self?administered services;

(15) Services or supplies to which the Participant?s condition is
persistently nonresponslve; .

(16) Services or supplies relating to Preexisting Conditions, except
to the Iimitedextent (if any) that an Approved Physician clearly confirms an

6300;11an 201? PartcorScuaa 8
Rev. 12mm

identi?able and signi?cant aggravation?ncurred in the Course and Scope of
Employment) of a Preexisting Condition: provided, however, that:

(A) coverage for such aggravation will be provided only if
and to the extent that the Approved Physician -

con?rms that the Preexisting Condition has been
previously repaired or rehabilitated, and

(ii) prescribes services or supplies that are Medically
Necessary to treat such aggravation and likely-to return the
Participant to pre-lnjury status; and

(B) no coverage will be provided if the Preexisting Condition
was a maiorconiributing cause of the injury;

(17) Acupuncture, behavior- modification, pain management

programs, hypnosis, biofeedback, other forms of self-care or self-help training
or any related diagnostic testing, or any service or supply ancillary to any of
these treatments; .

we (18) Chiropractic or spinal manipulation services;
e419) Substance abuse services;
(20) Custodial Care;

(21) Charges for the purchase, rental or repair of bedding. or
environmental control devices. including, but not limited to, an air conditioner.
humidifier. dehumidi?er, or air puri?er; and charges for Jacuzzis, saunas,

vans, or structural changes to the Participant's residence or moving
expenses; - 

(22) Charges for services performed by:
(A) a person who normally lives with the Participant;
(B) the spouse of'the' Participant; 
(C) a parent of the Participant or of the Participant?s spouse;
(D) a child of the Participant or of the Participant's spouse; or

(E) a brother or sister of the Participant or of the Participant's
spouse; or .

(23) The cost of any other service or supply not speci?ed in
subsection or above.

1.13 "Covered Associate? means an Associate whose employment with the
Employer is principally located within the State of Texas. For driver Associates, "Covered

?COP'r?9hl2012 Perma?Sourm 9
Rev. 12122)?

Associate? means an Associate who Is dispatched out of a distributiOn center?located in the
State of Texas. -

1.14 "Cumulative Trauma" means damage to the physical structure of the
Participant's body occurring as a result of rapid, repetitious, physically traumatic activities
that occur in the Course and Scope of Employment. The term ?Cumulative Trauma" does
not mean fatigue. soreness or general aches and pain that may have been caused,
aggravated. exacerbated or accelerated by the Participant?s Course and Scope of
Employment. Any provision of this Plan to the contrary notwithstanding. no bene?ts will be
payable with respect to Cumulative Trauma unless the Participant has completed at least
180 days of continuous, active employment with an Employer and has been regularly
engaged in a Course and Scope of Employment with the Employer involving rapid,
repetitious. physically traumatic activities.

1.15 "Custodial Care" means care consisting of services and supplies provided
to an individual in or out of an institution primarily to assist him in daily living activities,
whether or not he or she is disabled. and no matter by whom recommended or furnished.
Room and board and Skilled Nursing Care are not. however. considered Custodial Care if
provided during confinement in an Approved Facility, and if combined with other necessary
therapeutic services. under accepted medical standards, which can reasonably be
expected to substantially improve the medical condition which resulted from an

Injury.
1.16 "Death Benefits" means any' benefit payable under Section 3.2.

1.17 "Determination" means a decision of the Claims Administrator or Appeals
Committee on whether benefits are payable to. or with respect to, a Claimant under the

Plan.

1.18 "Disabled" or "Disability" means a Total Disability or a Partial Disability.
1.19 "Dismemberment Benefits" means any benefit payable under Section 3.3.

1.20 "Emergency Care" means a service or supply provided with respect to a
medical condition manifesting itself by a sudden and unexpected onset of acute 
of sufficient severity that in the absence of immediate medical attention could reasonably
be expected to result in death, dis?gurement, or permanent disability. or (ii) result in
substantial impairment 'of' any bodiiy' ofg?an,? ?part.' or function; This Emergency Care
determination solely relates to satisfaction of the Plan's approved medical provider
requirements, and the consideration of an exception for Emergency Care. Urgent
Care Claims may not arise to the level Emergency Care. A Participant?s
decision to seek treatment from an urgent care clinic or hospital emergency room -
does not necessarily result in an Urgent Care Claim or Involve Emergency Cars.
That determination shall be made within the sole administrative discretion of the
Claims Administrator or Appeals Committee, with such advice and consultation from
an Approved Physician as the Claims Administrator or Appeals Committee deems

appropriate.

1.21 "Employer" means the Company and any other related trade or business
that adopts the Plan pursuant to Section 9.6.

?2091ri9hl2012 PartnerSoucn 10
Hay mum

1.22 -"First Aid" means on-site primary medical care rendered in accordance with
Employer policy.

1.23 "Gross Misconduct? means the Associate's gross misconduct within the
meaning of Section 49808 of the Internal Revenue Code. or any successor-provision of
law.

1.24 "Home Health Care" means the following care provided to the Participant on
the recommendation of an Approved Physician at the Participant?s home or a Home Health
Care Agency:

intermittent nursing care by ajn):

(1) Registered Nurse 

(2) Licensed Practical Nurse 

(3) Home Health Aide:

(4) Occupational Therapist;

(5) Physical Therapist or Licensed Physical Therapy Assistant;
Licensed Vocational Nurse or

(7) Licensed Speech Therapist; and

private duty nursing services of a R.N., L.V.N., L.P.N., or Certi?ed
Home Health Aid:

provided. however, that Home Health Care services shall not include services provided by
persons who ordinarily live in the same household as the Participant or who are related by
blood, marriage, or legal adoption to the Participant or the Participant's spouse.

1.25 "Home Health Care Agency" means any of the following: (I) a home health
care agency licensed by the State in which it is located, (ii) a home health agency as
de?ned by the Social Security Administration, or an organization which is certified by
the Participant's Approved Physician as an appropriate provider of Home Health Care and
Which: has a full-time administrator, keeps written medical records, and has at least one
RN. on start (or the services of an RN. ayaiiabie).

1.26 "Injury" means damage or harm to the physical structure of the body caused
solely as the result of either an Accident; (ii) Cumulative-Trauma, or an Occupational"
Disease. Such damage or harm must be incurred in, and directly and solely result from.
the Course and Scope of Employment.

Date of injury. Any provision of this Plan to the contrary
notwithstanding, in order to be subject to this plan document. the date of such injury
must be on or after March 1, 2012. For all purposes of this Plan, the date of injury
shall be either the date of the Accident resulting in the injury, (ii) the date that the
damage or harm, or thereof, were ?rst known to (or should have been
known to) the Participant or diagnosed by an Approved Physician as Cumulative
Trauma, or the date that the damage or harm, or thereof, were first
known to (or should have been known to) the Participant or diagnosed by an
Approved Physician as an Occbpational Disease. All injuries sustained by a
Participant that relate to an Accident, or related series ofAccidents, (it) exposure

1 1
R69. 

 

to an environmental or physical hazard that causes an Occupational Disease, or 
rapid, repetitious, physically traumatic activities that result in Cumulative Trauma
shall be considered a single lniury for purposes of the Plan.

Types of Non-Covered Injuries. Any provision of this Plan to the
contrary notwithstanding, the term Injury shall not include:

(1) any strain, degeneration, damage or harm to, or disease or -

condition of, the or musculoskeletal structure or other body part resulting
from use of a video display terminal or keyboard, poor or inappropriate

posture, the natural results of aging, osteoarthritis, arthritis, or degenerative
process (Including, but not limited to, degenerative joint disease,
degenerative disc disease, degenerative spondylosls/ and
spinal stenosls), or other circumstances prescribed by the Claims
Administrator which do not directly and solely result from the Participant's
Course and Scope of Employment;

(2) factors to which thegeneral public is exposed:

(3) diagnostic labels which imply generalized musculoskeletal
aches and pains in the absence of any demonstrable primary
pathophysiology. such as Fibrositis. Fibromyalgla, Myofascial 'Pain
Myositts, or Chronic Fatigue 

(4) except to the limited extent provided under the definition of
"Covered Charges," any mental injury. emotional distress, mental trauma or
similar injury to the mental or emotional state of a Participant, including
without limitation, any physical manifestations resulting from such mental or
emotional state, and any mental or emotional damage or harm that arises
primarily from a personnel action, including, but not limited to, a transfer,
promotion, demotion or termination of employment or other disciplinary
ao?on:



(5) damage or harm resulting from airborne contaminants not
commonly found in the Company?s normal working environment. including,
but not limited to. pollen, fungi, and mold;

damage or harm resulting from?job'stress?;
(7) any heart attack, stroke, or aneurysm (an "attack"), unless --
(A) the attack can be identi?ed as --
occurring at a definite time and place; and

(ii) caused by 'a speci?c event related to and
occurring in the Course and Scope of Employment:

(B) the preponderance of the medical evidence regarding
the attack indicates that the Participant's work rather than the natural

@cpy?gh'twl? PartnetSource 12
Rev. 1mm:

progression of a preexisting heart condition or disease was a
substantial contributing factor cfihe attack; and

(C) the attack was not triggered solely by emotional or
mental stress factors, unless it was precipitated by a sudden work?_
related stimulus;

(8) hernia, unless such hernia is an inguinal and/or umbilical hernia
that 

(A) appeared suddenly and immediately following the injury;
(B) did not exist in any degree prior to the injury: and -
(C) was accompanied by pain; or

(9) any Preexisting Condition, except to the limited extent (if any)
that an Approved Physician clearly confirms an identifiable and significant
aggravation (incurred in the Course and Scope of Employment) of a
Preexisting Condition: provided, however, that:

(A) coverage for such aggravation will be provided only if
and to the extent that the Approved Physician -

confirms that the Preexisting Condition has been
previously repaired or rehabilitated. and

(ii) prescribes services or supplies that are Medically
Necessary to treat such aggravation and likely to return the.
Participant to pre-injury status; and

(B) no coverage will be provided if the Preexisting Condition
was a major contributing cause of the injury;

Non-Covered injury. Circumstances. Furthermore, no benefits shall

be payable under the Plan if:


Rev 1202)?

the?Participant is not err Associate of the Employer, or the
person?s employment is not principally located In the State of Texas;

(2) the injury occurred while the Participant was in a state of
intoxication, or had otherwise lost the normal use of his or her mental or
physical faculties as a result of the use of a drug or alcohol. Such
intOxication or loss of faculties may be established on the basis of the facts
and circumstances of the injury, the testimony of witnesses, admissions or
statements of the Participant, or cn'such other basis as the Claims
Administrator may determine. For this purpose, the Participant shall be
deemed to have been in a state of intoxication at the time of the injury if the
drug or alcohol test required by the Employer following the injury finds a
violation of the Employer?s substance abuse policy;

amaScuce 1 3

 

(3) the injury is treatable by medical care that Is reasonable and of
a form that an crdinaryprudent person in the same or similar circumstances
would undergo and the Participant has not availed himself or herself of such
treatment; -

(4) the injury was caused by the Participant's willful intention and
attempt to injure himself or herself or to injure another person, whether the
Participant was sane or insane;

(5) the injury occurred while the Participant was employed in
violation of any law;

(6) the Participant?s horsepiay, scuffiing, ?ghting, or similar
inappropriate behavior was a proximate causeof the injury; .

(7) the Participant's long-term cell phone use, or second?hand
smoke was a proximate cause of the injury;

the injury was incurred while the Participant was "on
suspension,? "laid off" by his or her Employer, on leave of absence for any
other reason, or otherwise outside cf'the Course and Scope of Employment;

(9) the injury arose out of an act of a third person intended to injure
the Participant because of personal reasons and not directed at the
Participant as an Associate of, or because of his or her employment by, an
Employer;

(10) the injury arose out of a Participant?s participation In an off-duty
recreational, social, charity, or athletic activity not constituting part of the
Participant's work-related duties, except where these activities are expressly
required in writing by an Employer (more than an invitation or request to
participate or attend);

the injury arose out of an act of God, unless the Participant's
employment by an Employer exposes such Participant to a greater risk of
injury from an act of God than ordinarily applies to the general public;

X12) the. alleged Injury" is feigned" or'an attempt to defraud the
Employer; -

(13) the injury arose out of the Participant's participationin:
(A) a riot or act of civil disturbance;
(B) a war, declared or undeclaredterrorism;

(D) any illegal act;

@Com-rght 2012mman 14
Rev 1322111

(E) a felony or an assault, except an assault committed in
defense of an Employer's business or property; or

(F) service in the military of any country or any civilian non?
combatant unit serving with such forces;

(14) any damage or'harm arising out of the use of or caused by -
(A) asbestos, asbestos fibers or asbestos products; or

(B) the hazardous properties of nuclear material or biological
contaminants;

(15) the injury arose out of the injured Participant's participation in
the commission, or attempted commission, of any crime; 

(16) the Injury did not occur during the Participant's Course and
Scope of Employment; or 

(17) the injury was not timely reported (or requested information was
not timely provided) in accordance with the timeframes specified under Article
lV herein. 

1.27 "Maximum Bene?t Limit" means the total amount of all benefits payable to,
or with respect to, any Participant under the Plan with respect to an Injury. Payments
made for each form of bene?t'shaii be counted towards the Maximum Benefit Limit .
amount. The Maximum Benefit Limit for this Plan is $300,000; provided. however, that the
aggregate amount of the Maximum Benefit Limits with respect to claims of all Participants
arising out of a single Accident, or related series of Accidents. or Occupational Disease or
Cumulative Trauma exposure, shall no; exceed $1,000,000. Such aggregate amount may
proportionally reduce the Maximum Benefit Limit applicable to each Participant involved in
such Accident, related series of Accidents, or exposure, in such manner as the Claims

Administrator or Appeals Committee may determine.

1.28 ?Maximum Rehabilitative Capacity" means the earliest date after which,
based upon reasonable medical probability, further material recovery from or testing
improvement to an injury?can no longer reasonably be - -- -

1.29 "Medical Bene?ts" means any benefit payable under Section 3.4.

1.30 "Medically Necessary" means the services, procedures or supplies, which

are:
required, recognized, and professionally accepted nationally by
physicians as the usual, customary. and effective means of diagnosing or treating
the condition;
1b) the most economical supplies or levels of service that are appropriate
and available for the safe and effective treatment of the Participant; and
2012 PartnerSouee 1 5

121722!?

 

 not primarily for the convenience of a Participant, the Participant's
family. a physician. or a facility.

Even though a physician may have prescribed a particular treatment,-such treatment may
not be considered Medically Necessary within this de?nition or may otherwise be excluded
from coverage under the terms of this Plan.

1.31 "Medical Rehabilitation Hospital" means an Approved Facility that:

is licensed;

provides facilities for the diagnosis and inpatient rehabilitative
treatment of disease or injury with the objective of restoring physical function to the
fullest extent possible: Examples of conditions treated in a rehabilitation hospital
are: amputations, spinal cord injuries. head injuries, paraplegia and quadriplegta,
cerebrcvascular accident, paralysis; 

has facilities or a contractual agreement with another hospital in the
area for emergency treatment, surgery, and any other diagnostic or therapeutic
services that might be required during a con?nement;

provides all normal infirmary level medical services required for the
treatment of any disease or injury occurring during confinement;

has a staff of physicians specializing In physical medicine and
rehabilitation directly involved in the treatment program, one of whom is present at
all times during the treatment day; 

is accredited as a medical inpatient rehabilitation hospital by the Joint
Commission on Accreditation of Rehabilitation Facilities; 

is not a place for rest, the aged, drug addicts or alcoholics, a chronic
disease facility, a nursing home or sheltered workshop; and -

does not provide as its primary purpose custodial care, treatment of
mental disorders. special education, vocational counseling. job training, or social
adjustment services,_ Any identi?able charges for educational, vocational or social
adjustment services are not covered under the Plan, unless otherwise provided as a-

Covered Charge.

1.32 "Medicare" means Title of the Social Security Act, as amended, and
the regulations promulgated thereunder.

1.33 "Notice" or "Notification" means the delivery or furnishing of information to
.an individual in a manner that satisiies the standards of 29 CFR 2520.104b??i 

1.34 "Occupational Disease" means a condition marked by a pronounced
deviation from the normal healthy state of a Participant arising out of such Participant's
assigned duties in his or her Course and Scope of Employment. Occupational Disease
includes other diseases or infections that naturally result from the work-related disease.
Occupational Disease does not include ordinary diseases of life to which the general public

PartnerSouDB' '16
Hay imam . .

is exposed outside of a Participant's assigned duties in his or her Course and Scope of
Employment.

1.35 ?Partial Disabliity?i means a medically demonstrable anatomical or
physiological abnormality caused by an injury that results in the Participant being -

unable to fully perform the normal duties for which he or she was
employed;

under the regular care of an Approved Physician:
released to Temporary Alternate Duty by such Approved Physician; and

working for the Employer in such a Temporary Alternate Duty position
approved by the Employer.

The existence-of a Temporary Alternate Duty position provided in conjunction with benefits
under this Plan does not imply or create a permanent Temporary Alternate Duty position for
purposes of the American with Disabilities Abt -

1.38 '_'Participant" means a Covered Associate who satisfies the eligibility
requirements of Article ii.

1.37 "Plan" means the Waimart Stores, inc. Texas injury Care Bene?t Plan as
herein set forth and as it may from time to time be amended.

1.38 "Plan Administrator" means the Company.

1.39 ?Plan Year" means a 12 calendar month period beginning each February 1
and ending the following January 31; provided, however, that the initial Plan Year shall be
the period beginning March 1. 2012 and ending January 31. 2013. 

1.40 "Post-Service Claim? means any claim for a Medical Bene?t that is not a
Pre-Service Claim. 

1.41 ?Preexisting Condition? means any Participant illness, injury, disease,
impairment, or other physical or mental condition, whether or network-related, which
originated orexisted?p'riortothe dayoflnjury. 

1.42 "Pra-lnjury Pay" means 

(3) for salaried Participants, regular biweekly salary from an Employer at
the time of the injury;

for hourly Participants, the avorage earnings from an Employer for the
12 consecutive weeks immediately preceding the date of Injury; provided, however,
that if such a Participant has worked for an Employer for less than 12 consecutive
weeks. or it his or her earnings as of such date cannot be reasonably determined (in
the judgment of the Claims Administrator), such 12-week average will be based
upon the earnings received over such period by a similar associate of the Employer.

Pathetsrouca 1 7
Re? 12122? 

 

"Pre~lnjury Pay" shall include pay for overtime and Participant contributions (through salary
reduction or otherwise) to a 401(k) arrangement, cafeteria plan. or other pre-taxsalary
deferral employee benefit plan. ?Pre-lnjury?Pay" shall not include any bonuses, benefits
(including,'but not limited to, Employer contributions toany employee bene?t plans or
matching contributions to a retirement plan) or other extraordinary remuneration.

1.43' "Pm-Service Claim" means any claim for Medical Benefits with respect to
which this Plan requires Claims Administrator approval in advance of obtaining medical

care.

1.44 "Receipt, Safety Pledge and Arbitration Acknowledgement" means the
form attached hereto. -

1.45 "Relevant" shall mean, with respect to the relation of a document, record or
other information to a Claimant's claim. that such document, record or other information:

was relied upon in making a benefit determination on the Claimant's
claim; - 

was submitted, considered, or generated in the course of making the
benefit determination, without regard to whether such document, record or other
information was relied upon in making the actual benefit determination;

(0) demonstrates compliance with the Plan's administrative processes and
safeguards required formatting the benefit determination; or

constitutes a statement of policy or guidance with respect to the Plan
concerning the denied, treatment option or bene?t for the Claimant's diagnosis,
without regard to whether such advice or statement was relied upon in making the 
benefit determination. -

The individual records or information specific to the resolution of one Claimant?s claim shall
not be considered relevant to another Claimant's claim.

1.46 "Representative" means a person that a Participant authorizes in writing to
act on his/her behalf. The Plan will also recognize a legally valid power of attorney or a court
or administrative agency order giving? a person authority to take an act on a Participant?s
behalf: In the case of an Urgent Care Claim. a physician with knowledge of the Participant?s
condition may act as the Participant's Representative.

1.47 "Skilled Nursing Care" means service provided in a Skilled Nursing Facility
by a R.N., L.P.N., or licensed vocational nurse (L.V.N.), provided that the care is Medically
Necessary and that the treating Approved Physician has prescribed such care. However,
no benefit will be payable under the Plan for the following expenses:

charges for-food. housing, or homemaker's services;

charges for the services of a person licensed or unlicensed who
ordinarily resides in the Participant's home or is a member of the family of either the
Participant or the Participant's Spouse;

18
Rev. 132211!

 charges for an illness or injury unrelated to the original hospital
confinement; or

charges that do not follow a hospital stay or are Incurred when the
Participant could otherwise receive services from private duty nursing at home.

1.48 "Skilled Nursing Facility" means a section, ward. or wing of a hospital, or a
free-standing health care facility, which:

provides room and board;
provides nursing care by or under the supervision of a nurse;

. (0) provides physical, occupational, and speech therapy furnished by the
facility or by others under arrangements made by the facility;

provides medical social services;

provides drugs, biotogicals, supplies, appliances and equipment
ordinarily furnished for use in such a facility;

provides medical services by staff Approved Physicians;

has an agreement with a hospital for diagnostic and therapeutic
services. the transfer of patients, and exchange of clinical records;

(it) provides other services necessary to the health and care of patients
that are generally provided by such facilities; and

is licensed or registered in accordance with local and state laws and
regulations. .

1.49 "Temporary Alternate Duty? means work which is either --

a temporary accommodation that allows an Associate to perform his or
her regular Job; or

(by an alternate, temporary job that complies with the Associate?s work
restrictions and Employer needs.

. 1.50 "Totally Disabled" or ?Total Disabilityil means a medically demonstrable
anatomical or physiological abnormality caused by an injury, and commencing within six
months from the date of injury, that causes the Participant to be -

temporarily Unable to perform the normal duties for which he orshe
. was employed;

under the regular care of an Approved Physician; and

temporarily unable to engage in Temporary Alternate Duty or any
other occupation for wage or profit.

PartrerScuca 19
Rev. 

 

1.51 "Urgent Care Claim? shall mean any claim for medical care or treatment
with reapect to which application of the time periods for making non~urgent Pro?Service
Claim Determinations generally, 15 days after the Claims Administrator's receipt of

the claim):

could seriously jeopardize the life or health of the Participant or the
ability of the Participant to regain maximum function: or

in the opinion 'of a physicianwith knowledge of the Participant?s
medical condition, would subject the Participant to severe pain that cannot be
adequately managed without the care or treatment that is the subject of the'claim.

The determination of whether a claim Is an Urgent Care Claim within the meaning of
subsection above shall be made by the Claims Administrator applying the judgment of a
prudent. layperson that possesses an average knowledge of health and medicine.
However. if a physician with knowledge of the Participant?s medical condition determines

that a claim is an Urgent Care Claim and clearly communicates such determination to the .

Claims Administrator, such claim shall be treated as an Urgent Care Claim for purposes of
this Plan. The characterization of a claim as an Urgent Care Claim solely impacts the
timeframes and other procedures for claims processing under ARTICLE VI, and in
no way changes this Plan's approved medical provider, prs-authorlzation, or other
medical management requirements. These requirements generally provide that (1)
except in the case of Emergency Care, no amount shall be considered a Covered
Charge unless treatment ls pre-approved by the Claims Administrator and furnished
by or under the direction of an Approved Physician or Approved Facility, and Mail
determinations. relating to the physical condition of a Participant, upon which the
payment of bene?ts Is based, must be made by an Approved Physician. Urgent Care
Claims may not arise to the level of involving Emergency Care. A Participant?s
decision to seek treatment from an urgent care clinic or hospital emergency room
does not necessarily result in an Urgent Care Claim or Involve Emergency Care. The
determination of whether a claim Involves Emergency Care shall be made within the
sole administrative discretion of the Claims Administrator or Appeals Committee,
with such advice and consultation from an Approved Physician as the Claims
Administrator or Appeals Committee deems appropriate.

"_'Usual and Customary" means a charge that is not more than the amount
charged when there is no not more than the prevailing chargeJn the
locality for a like serviCe or supply. A like service is one of the same in nature and
duration, requiring the same skill and performed by one of similar training and experience.
A like supply is one which is the same or substantially equivalent. Locality is the city or
town where the service or supply is obtained, if it Is large enough so that a'representative
cross-section of like services or sUpplies can be obtained. In large cities, it may be 'a
section or sections of the city, if the above criteria can be met. In smaller urban or rural
areas, locality may have to be expanded to include surrounding areas to arrive at a
representative cross-section.

1.53 "Violent Crime? means any act involving, or of the nature of, a violent crime,
including, but not limited to, armed robbery, that would result in severe shock to a
reasonable person. A

(Cowman i?artnerouros 
REV. I7f221?

1.54; "Wage Replacement Benefits" means any benefit payable under Section
3.1.

ARTICLE ii
AND NATURE OF PAYMENTS

2.1 Eligibility. Each Covered Associate shall automatically become a
Participant in this Plan as of the later of (A) 12:01 am. March 1. 2012. or (B) the time and
date of his or her employment as a Covered Associate. Except to the limited extent
provided under Article ill regarding the continuation of certain benefit payments, if a
Participant ceases to be a Covered Associate, he or she shall thereupon cease to

participate in this Plan; provided. however. that if such Participant is thereafter reemployed -

as a Covered Associate, he or she shall resume participating in, the Plan as of the time and
date of such reempioyment.

2.2 Nature of Payments.

No Admission of Liability: The Plan has been established and is'

maintained by the Employers to protect themselves from certain liabilities as
to the Texas workers' compensation insurance system. Payments
made under this Plan by an Employer shall not in any way constitute an admission
of liability or'responsibiilty by an Employer for an injury and any such liability or
responsibility is specifically denied.

No Collateral Source: Benefit payments under the Plan shall be
considered to be made by the Employer of a Participant and shallnot be considered
payment from a "collateral source? as that term has been de?ned under any
applicable rule. statute, judicial decision. or directive. All benefits paid under this
Plan shall be offset against any alleged liability of the Employer, its of?cers,
directors. or agents to a Participant or Participant's Beneficiaries, heirs, or assigns
due to an injury. - 




Participants shall be entitled to receive under this Plan the bene?ts described in this Article
ill with respect to any injury incurred in the Course and Scope of Employment by an
Employer, and (ii) during his or her participation in this Plan.

3.1 Wage Replacement Bene?ts.

Total Disability: From the ?rst full day of an injufeEiTPadicipant's Total
Disability, the Plan shall pay Wage Replacement Bene?ts equa to 90% of the injured
Participant's Pro-injury Pay. \a 

Partial Disability: From the first full day of an injured Participant?s
Partial Disability, the Plan shall pay Wage Replacement Bene?ts equal to 90% of the



@cpy?ght 2012 21
Rev mam:

 

portion 'of the injured Participant's Pro-injury Pay that the Participant is unable to earn
(due to the Approved Physician?s restrictions) while working Temporary Alternate Duty.

Bene?ts shall continue until the earliest of:

(1) if a Participant with a Partial Disability is released to Temporary -
Alternate Duty, but the Employer has no Temporary Alternate Duty position
available. and (it) an Approved Physician has not assigned permanent
restrictions and released the Participant to any other gainful employment, then
the Participant shall be considered to be Totally Disabled and Wage
Replacement Bene?ts shall be payable in the?manner speci?ed above under
subsection above.

(2) If a Participant with 3 Partial Disability has made a good faith
effort to comply with the treating Approved Physician's instructions and carry
out the Participant?s responsibilities in the Temporary Alternate Duty position.
but is either:

(A) again determined by an Approved Physician to be Totally
Disabled, or

(B) the Temporary Alternate Duty position ceases to be
available (for example, the position reaches its maximum duration) and
an Approved Physician has not assigned permanent restrictions and
released the Participant to any other gainful employment;

then the Participant will be considered to be Totally Disabled and Wage
Replacement Bene?ts shall be payable in the manner speci?ed above under
subsection above. .

Payment Terms and Other Limitations:

(1) An Approved Physician must make the determination regarding
whether a Participant is Totally Disabled or Partially Disabled, except to the
extent that such determination is made In conjunction with Emergency Care as
determined by the Claims Administrator.

(2) No Wage Replacement Bene?ts shall be payable without a
corresponding approved or pending request for Medical Bene?ts.

(3) Wage Replacement Bene?ts are calculated on a weekly basis,
and paid on regular paydays. Payments for portions of a week shall be
prorated.

(4) Only the Participant's normal, scheduled workdays shall be
considered in calculating bene?ts (based upon his or her employment status as
of the date of injury).

(5) Wage Replacement Bene?ts shall be reduced as described in

Article Vii.

When Wage ReplacementBene?ts Cease: Wage Replacement

@Copyrichl 2012  

?sv 

(1) the expiratiorgfgizg weeks from the date of the injury. This 120-

week maximum period for Wage Replacement Bene?ts is calculated
continuously from the date of the injury, regardless of whether or not the
Participant quali?es as Disabled at all times during such period or receives
Wage Replacement Bene?ts continuously throughout such period; 

(2) the date the Participant is certi?ed by the treating Approved
Physician to no longer be Disabled. without regard to whether the Participant
returns to regular or Temporary Alternate Duty on? that date;

(3) ?the date that the Maximum Bene?t Limit is met;

termination ?of both the Participant's status as a Covered
Associate egg all?other employment of the Participant with an Employer;
provided, however, that this paragraph (4) shall not apply if termination of
employment is solely due to 

(A) application of a duration limit in the Employers leave of
absence policy, or

(B) elimination of the Participant?s employment position;

(5) the date the Participant is placed in jail, is deported or detained by
or at the request of any government agency or foreign government, has left the
local area for an extended period of time, or is similarly unavailable for work;
provided, however, that, this paragraph (5) shall operate to cease Wage
Replacement Bene?ts only for such period of time that such Participant is
unavailable for work; or

(6) as othenvise provided under Section 4.3.-

3.2 Death Bene?ts. in the event that a Participant dies as the direct and sole
result of, and within 365 days the Plan shall pay such Participant's
Bene?ciary a Death Benefit equal 0 $250,000; pr vided, however that this benefit amount
shall be reduced to the extent nec ssakry to avgl exceeding the Maximum Bene?t Limit.
The Death Benefit shall be paid to the Participant's Bene?ciary as follows: 20% of the
Death Benefit shall be paid in a lump- sum- cash 
possible following the death of the Participant and the determination of the proper
Beneficiary; and (ii) the remainder of the Death Benefit shall be paid In 35 equal 
installments (without interest), commencing on the ?rst day of the month following the initial
lump sum payment. Death Bene?ts payable under this Plan shall be in addition to Medical
Benefits, Wage Replacement Bene?ts, and Dismemberment Bene?ts payable to, or with
respect to, the Participant; provided. however, that no interest in future Dismemberment
Bene?ts survives after a Participant's death which results in the benefits under
this Section 3.2. In additi'onto the Death Bene?ts setforth above, in flan shjalireimb?u se.



reasonable b'riai expenses to any person who incurs liability therefore: up\tg $12.00 :3

Reimbursed reasonable?burial expenses are not subject to the Maximum Benefit [imit- 

2012 Peru-?Source I 
REV. i202?! 

 

3.3 Dismemberment Bene?ts. In the event a Participant suffers a loss
described in the Schedule of Losses below as the direct and sole result of, and within 365
days of. an Injury, then the Plan shall pay the Participant an amount equal to the applicable
percentage from the schedule below times $250,000; provided, however, that this benefit
amount shall be reduced to the extent necessary to avoid exceeding the Maximum Benefit
Limit. The Dismemberment Benefit shall be paid as follows: 20% of the Dismemberment
Benefit shall be pald?ln a lump sum cash payment as soon as administratively possible
following the date offsets: and (ii) the remainder of the Dismemberment Bene?t shall be
paid in 35 equal installments (without interest), commencing on the first day of the
month following-the initial lump sum payment, .

SCHEDULE OF LOSSES

Loss ?of: Benefit Amount:
Both Hands - 100%
Both Feet 100%
Sight of Both Eyes 100%
one Hand and One Feet 100%
One Hand and Sight of One 100%
,One Foot and Sight of One 100%
Speech and Hearing 100%
One Hand 50%
One Foot 50%
Sight of One - 50%
Speech 50%
Hearing 50%
Finger or Toe (two joints) - . 10%
Finger or Toe (one joint) 5%

If the Participant suffers more than one Injury described above from
any one Accident, related series of Accidents, or Occupational Disease exposure or
Cumulative Trauma exposure only one of the applicable Dismemberment Benefits
listed above, the largest single amount, will be payable with respect to such

Accident or exposure.

Total and permanent loss of use of a member of the body is the same

as loss of such member. Prior to payment of the bene?t. loss of use must be

rtifled following the care of an Approved Physician for 12 straight months from the

the loss of use began. At the end of this time it must be medically determined
Approved Physician that the loss of use is total and not reversible.

Loss of Hand or Foot means the complete and permanent severance

above the wrist or ankle joint (or the total and permanent loss of use as

above). Loss of Sight means legally blind. Such loss correctable

case will not result in payment of a Dismemberment Benefit. Loss of

?e total and permanent loss of speech. Loss of Hearing means the
tloss of hearing in both ears.

24

 The above-described loss of "Finger or Toe (two joints)" must be at or
above the joint at the proximal end of the middle phalanx of the finger or toe; except
that for the thumb or great toe, such loss must be at or above the
metacarpophaiangeal joint. The above-described loss of "Finger or Toe (one joint)"
must be at or above the Joint at the distal end of the middle phalanx of the finger or
toe; except that for the thumb or great toe, such loss must be at or above the joint at
the distal end of the proximal phalanx.

Dismemberment Bene?ts shaii'be In addition to Wage Replacement
Benefits and Medical Benefits; provided, however, that payment of Dismemberment
Benefits will cease In the event of the death of the Participant which results in the
payment of Death Bene?ts.

3.4 Medical Benefits. Subject to the medical management and other provisions
of this Plan, the Plan shall pay Medical Bene?ts to, or with respect to, a Participant for an
Injury in an amount equal to all Covered Charges; provided, however, that Medical Bene?ts
shall cease upon the earliest of:  

the expiratIonicfriggweeks Eom the date of an injury;
reaching the Maximum Bene?t Limit;

(0) involuntary termination of employment of the Participant with an
Employer for Gross Misconduct; 

the Participant not receiving medical treatment from an Approved
Physician or Approved Facility (or scheduled treatment with an Approved Physician
or Approved Facility has not been approved by the Claims Administrator) for a
period of more than 60 days; or -

as otherwise provided under Section 4.3.

ARTICLE iV
ADDITIONAL REQUIREMENTS AND LIMITATIONS ON BENEFITS

4.1. Reporting; The Participant must report every incidents: fact that the
Participant believes results, or might reasonably be expected to result, in an injury in
accordance with the following requirements: 

Notice of injury: The Participant (or the Participant's Representative)
must provide verbal notice immediately after being Injured at work to his or her
supervisor then on duty, no matter how minor the Injury appears to be.

For injury due to an Accident, or for a known exposure? to an
Occupational Disease, verbal notice must be provided withirf22i hours of the
time of the injury. - 



(2) For an actual Injury due to Occupational Disease or Cumulative
Trauma, verbal notice must be provided within 24 hours after being medically

?Copyn9i1120i2 Partnc-rSmloa 
Rev. 12/22)?

 

A diagnosed with a work-related injury, or within 30 days after the Participant
should?have known of the work~reiated Injury, whichever is earlier.

No benefits will be payable under the Plan if notice is not provided as required above,
unless the Claims Administrator determines that good cause'exists for failure to give notice
. in a timely manner. -

Providing Required information: An injured Participant (or the 
Participant's Representative) must complete the incident report form and medical
authorization form within 24 hours after the injury is reported. These forms must be
submitted to the Participant's supervisor (or such other person as the Claims
Administrator may specify). The Participant must provide verbal, written. or recorded
statements, and provide such proof and demonstrations (relating to the injury or any
prior or subsequent damage or harm suffered by the Participant, in or out of the
Course and Scope of Employment), in such manner and within such periods. as the
Claims Administrator may from time-to-time direct. No bene?ts will be payable
under the Plan if all Information is not provided as required above. unless the Claims
Administrator determines that good cause exists for failure to provide such
information in a complete and timely manner.

4.2 Medical Management.

. Use of Approved Providers: Requirements for the use of Approved
Physicians and Approved Facilities are found in the "Covered Charge" de?nition of
this Plan. if necessary, the Claims Administrator will assist a Participant in
arranging for appropriate medical treatment from an Approved Physician or
Approved Facility. Participant does not have the right to select and have the Plan -
pay for his or her. choice of a primary care provider or provider of specialty medical

care. even if such a provider is an Approved Physician or Approved Facility.

Medical Determinations and Treatment: All determinations relating
to the physical condition of a ParticipantI upon which the continued payment of
benefits is based (for example, inability to return to work or results of a prior injury).
must be made by an Approved Physician. The Participant must follow fully and
completely the advice of, and the course of medical treatment prescribed by, the
treating Approved Physician, and must keep all scheduled appointments to fulfill the
prescribed medical treatment pian?._ The Claims Administrator may require-that the
Participant present an authorization and report form to the treating Approved
Physician or Emergency Care provider at the time of primary medical treatment.
The Employer may also require that the Participant submit to any form of drug
and/or alcohol testing in accordance with the Employer's substance abuse policy.
The Claims Administrator shall have the right to require the Participant to be
examined or reexamined by an Approved Physician (including. but not limited to an
autopsyI where not prohibited by law) as often as the Claims Administrator
determines to be reasonably necessary or appropriate during the pendency of a
claim for benefits under the Plan.

- initial Treatment and Derilal: Any provision of this Plan to the
contrary notwithstanding, an Employer may render First Aid. or the Plan may pay for
Emergency Care, pay Wage Replacement Benefits or pay for a medical evaluation

26
Rev imam

omissions of any health care provider.

or treatment of a Participant, and the Plan can still make a subsequent
determination that the Participant has not suffered a covered injury or otherwise
deny any or all further benefits under the provisions of this Plan.

Medical Provider Referrals: If the treating Approved Physician ?nds
it necessary to refer a Participant to another health care provider, the treating
Approved Physician must notify such Participant and-the Claims Administrator of his
or her desire to make the referral and the objectives of such referral. The Claims
Administrator will provide advance approval or disapproval of all referrals (and may
rescind any such approval at any time) based' upon such criteria as the Claims
Administrator may determine for the effective administration of the Plan. it is the
Participant's responsibility to determine the status of any such approval or
disapproval, and the expense of services or supplies relating to any disapproved
referral shall be solely the responsibility of the Participant.

No interference with Patient-Provider Relationship: Although
benefits under this Plan are conditioned on a Participant's use of only Approved
Physicians and Approved Facilities, a Participant remains entitled to seek any
medical care he or she deems appropriate from any provider of his or her choice at
his or her expense. However, expenses for each medical care shall not be payable
under the Plan and the Participant?s use of a non-approved physician or facility may
result in a complete denial or termination of Plan bene?ts. The Employers, Claims
Administrator, and Appeals Committee, and their agents and delegates, shall not
have any responsibility for the actual medical or other health care services provided
by any Approved Physician, Approved Facility or other designated health care
service provider. Health care providers are not agents of the Plan, Employer,
Claims Administrator. or Appeals Committee. The Plan, Employer, Claims
Administrator, or Appeals Committee are not liable or responsible for the acts or
The actual medical treatment or
rehabilitation 'of any Injury remains the sole prerogative and responsibility of the
attending Approved Physician and other health care providers based on their
independent Judgment for the provision of health care.

Professional Medical Review and Quality/Ef?ciency Features:
The Claims Administrator shall have the discretion to assign Approved Physicians
and other health care. providersor ?rms. to.a. order to 
coordinate and expedite medical treatment of the Participant, in consultation with
the treating ApprOVed Physician, (ii) facilitate such case management, quality, and
efficiency measures and procedures as the Claims Administrator deems
appropriate, based upon-particular facts and circumstances, and review the
propriety of any and all treatment, services, and supplies, including charges for such

treatment, services. and supplies. - Without limiting the generality of the foregoing, 

the following case management, efficiency, quality control and cost containment
features may be utilized under the Plan. at the direction of the Claims Administrator,
to help ensure that health care services are being effectively and efficiently
provided:

(1) Fee Schedules: Noisest shall be a Covered Charge to the
extent that it exceeds-the charge specified in any fee schedule approved or
adopted by the Claims Administrator. in the event such charge is not listed In

?Copy?qhi 20i2 Partners-cues 

itav 1?r22iit

 

such a'fee schedule. the charge shall not be considered a Covered Charge to -

the extent it exceeds the Usual and Customary charge.

(2) Alternative Health Care Facilities: Use of Approved Facilities
other than hospitals. Including surgicenters. Skilled Nursing Facilities, and
Home Health care Agencies;

(3) Concurrent Review: A review by designated health care
personnel that utilizes Approved Physician-developed criteria and standards
for determining the appropriateness of reimbursement for initial or continued
treatment or hospital confinement;

(4) Cost-Saving Techniques: Such techniques include not
admitting to hospitals on weekends whenever possible and obtaining second
opinions before surgery if deemed advisable by the'Approved Physician or
the Claims Administrator;

(5) Pre-Admisalon Evaluation: A review made by health care
personnel to. (I) determine whether each Approved Facility admission is
Medically Necessary. and (ii) evaluate the number of days for an inpatient
Approved Facility confinement that would be considered reasonably
necessary for the care and treatment of the diagnosed injury;

(6) Pro-Admission Testing: Routine diagnostic, x?ray and
laboratory examinations performed within three days of a scheduled
Approved Facility con?nement (these tests must be performed at the same
Approved Facility where such con?nement is to occur):

(7) Utilization Review: A review made'by designated health care
personnel to consider. in accordance with establisheds medical criteria,
requests from Approved Physicians for medical procedures. tests or other
services prior to the provision of such requested services to determine
whether they are Medically Necessary. the specific benefit of the services for
the Participant. and any alternative means to provide such services;

(8) Nurse Case Managers: The Claims Administrator may assign
a- nurse case manager or other health care professional to monitor services
provided or requested on behalf of a Participant. and to'othe'rvvise assist the
Claims Administrator or the Participant with his or her return to work; and

(9) Referral to Specialty Providers: The Claims Administrator
may direct any Participant to an Approved Physician or other health care
provider who is recognized to be a specialist with the type of condition for
which the Participant may need assistance. 

(9) Second Medical Opinions. The Plan reserves the right to require a
second medical opinion from an Approved Physician selected by the Claims
Administrator for purposes of obtaining an independent Medical Evaluation or
for any other reason relating to the payment of Medical-Benefits. Wage
Replacement Benefits. or any other bene?ts under this Plan. lf a-Participant refuses

PartnerScum 23
Rev. i21'22!?

to be examined by an Approved Physician selected by the Claims Administrator for
the second opinion, all benefits under the Plan shall be-suspended.

(1) The Claims Administrator will wel
Approved Physician and the Approved Phy
opinion and make a benefit determination und
Participant is in disagreement with the diagnos
by the Approved Physician whose opinion
Administrator ("Physician then the Partici
medical opinion; The Partial 
advance of receiving any second medical opinionin order for this opinion to
be considered by the Plan. if the Participant provides advance notice to the
Claims Administrator, then the Participant shall have the right to a one-time
examination at his or her own expense by another physician ("Physician 
This examination by Physician shall be solely for the purpose of evaluating
the Participant?s condition and making a treatment recommendation.



gh the ?ndings of the treating
sician providing the second
or the Plan. However, if the
is or treatment recommended
is accepted by the Claims
pant may request a second

if the diagnosis and treatment recommended by Physician is
contrary to that of Physician A, then the Claims Administrator shall designate
a peer review physician who will evaluate the medical records and advise the
Claims Administrator, and who may designate another Approved Physician
for a further medical examination. if the Participant refuses to be so
examined, all benefits under the Plan may be Suspended. The diagnosis
and/or recommended treatment of the peer review physician or this last
Approved Physician will be controlling. The fees and related expenses of the
peer review physician and this last Approved Physician will be paid by the
Plan (although the Participant shall have the option of paying up to one-half
of such fees and expenses). -

4.3 Suspension Or Termination of Bene?ts. Thed'Ciaims Administrator may
deny a claim for, or suspend or terminate the payment of, Plan .benefits otherwise due a
Participant if:

9 and/or alcohol testing in
or refuses to provide the
es to).drug and/or alcohol-

the Participant refuses to submit to dru
ubstance abuse policy,
sentatlves with.(or acce



not receive prior approval for all medical care


accordance with the Employer's 
Company and its designated repre
testing information related to an in]

the Participant doe
other than Emergency Care;

the Participant utilizes a non?approved physician or facility other then

for Emergency Care;

?Ccm-rght2
1222?!?

the Participant refuses to submit to examination by anApproved


or (other than the treating Approved

Physician selected by the Claims Administrat
Physician) as required by the Claims Administrator with respect to any surgical
procedure or other diagnosis or treatment opinion rendered by the treating.
Approved Physician for which the Claims Administrator considers a second medical
opinion advisable; -



.29

 

 the Participant reaches Maximum Rehabilitative Capacity;

the Participant is persistently to treatment. including. but
not limited to. due to the need for Participant behavioral
modification recommended by the treating Approved Physician;

the Participant fails to provide accurate information to. or fails to follow
the directions of. a treating Approved-Physician. Following the directions of a
treating Approved Physician includes, but is not limited to. any recommended
treatment, therapy, course of action, abstinence. or rehabilitation program;

the Participant fails or refuses to allow an authorized representative of
the Plan to accompany the Participant to an appointment with a health care
provider;

the Participant fails to keep. or is late for. a scheduled appointment
with a health care provider. Except in extraordinary circumstances as determined
by the Claims Administrator.-a first missed appointment shall result in a warning
and/or suspension of bene?ts and a second missed appointment shall result in a .
termination of benefits;

the Participant engages in conduct following an Injury which is
determined by the treating Approved Physician to be an Injurious practice that is
hindering the Participant's recovery from the injury;

the Participant does not actively participate in activities that increase
the likelihood of the Participant's return to work or preulnjury status. including. but
not limited to. reporting Participant?s work status or expected recovery time after
each appointment or as directed?during the course of the claim:

I - the Participant fails to inform the Participant?s supervisor that he or she .
has been released by an Approved Physician to return to full or Temporary Alternate
Duty. or fails to timely report to work in accordance with such work release within 24

hours of such release;

the Participant receives benefits with respect to the injury from any
workers' compensation law (whether or not any coverage. for benefits is actually in
farce under such law); 

the Participant has been untruthful or demonstrates bad faith in
connection with administration of the Plan. including, but not limited to, any aspect
of the required information supplied as part of the injury reporting or employment
process;

(0) the Participant fails to fully cooperate with the Claims Administrator
(including. but not limited to. failure to comply with the provisions of Section 
in connection with the administration of the Plan. including. but not limited to.
'subrogation or coordination of bene?ts procedures; or 

PartnerScuce 
1

(P) the Participant fails or refuses to comply with any of the provisim?u?f .

the Plan or the rules and procedures adopted by the Claims Administrator for the
administration of the Plan.

4.4 Final Compromise And Settlement. At the Claims Administrator's option,
the Claims Administrator may notify the Participant of the Plan?s intention to be released
from any further known and unknown benefit and all other injury-related claims by such
Participant and pay a ?nal claim settlement to, or with respect to, such Participant in
exchange for the Participant?s agreement to a release of liability in favor of the Plan,

Employers, Claims Administrator, Appeals Committee, and other interested parties with

respect to such claims. in that event, the Claims Administrator may appoint an actuary.
appraiser, and/or Approved Physician to investigate, determine, and capitalize such claims,
or use such other valuation method asthe Claims Administrator may specify. The
payment by the Plan and/or Employer of the value of ?such claims (as finally determined by
the Claims Administrator) shall be made in such manner as the Claims Administrator may
determine. No additional claims will be subsequently accepted with respect to such injury.
Any actuary .or appraiser shall apply such rules. standards. and assumptions (present
value discount, inflation, and mortality rates, etc.) as the Claims Administrator may
determine. The Participant must cooperate and provide all information, sign such forms
and agreements, and submit to all medical examinations as may be requested by the
Claims Administrator to arrive at a valuation and settlement of the Participant?s claims. No
further benefits will be payable to, or with respect to, a Participant who fails or refuses to
accept the Claims Administrator's claim valuation, sign the release agreement presented
by the Claims Administrator, or otherwise comply with the requirements of this Section or
other provisions of the Plan. Prior or subsequent to the Claims Administrator's evaluation
and determination of the value of a Participant's claims, the Claims Administrator may
determine to not capitalize and satisfy any such claim as desortbed above and to instead
continue eligibility for benefit payments and defer the above valuation and settlement.

:9

ARTICLE 
ADMINISTRATION
5.1 Plan Administrator.

 . Administrator: The Companyshaii-ube the?Pian- Administrator and
named fiduciary of the Plan. The Plan shalt be administered on behalf of the
Company and all other Employers by the Claims Administrator and Appeals
Committee. The Claims Administrator or Appeals Committee so appointed shall
serve in such of?ce until his or her death, resignation, or removal by the Company.
The Company may change the Claims Administrator or Appeals Committee with or
without cause at any time. and may modify the membership of the Claims
Administrator. or Appeals Committee positions at any time and from time to time.
The Claims Administrator and Appeals Committee shall keep such records of their
proceedings and acts as they deem to be necessary or appropriate for the purposes
of the Plan. The Claims Administrator and Appeals Committee shall cause such
information, documents or reports to be prepared, provided and/or ?led as may be
necessary tocompiy with?the provisions of ERISA, or any other applicable law. The
Plan shall operate and keep its records on the basis of the Plan Year. 

201? PaMHSoxvcs 
[2122!?

 

 Administrative Authority: Subject to the Plan claims procedures, the
Claims Administrator and Appeals Committee shall have discretionary and final

authority to interpret and Implement the provisions of the Plan. including. but not?

limited to. making all factual and legal determinations, correcting any defect.
reconciling any Inconsistencyand supplying any omission, and making any and all
determinations that may Impact a claim for benefits hereunder. The Claims
Administrator and Appeals Committee shall perform all ?of the duties and may
exercise all of the powers and discretion that the Claims Administrator and Appeals
Committee deem necessary or appropriate for the proper administration of the Plan.
and shall do so in a uniform. nondiscriminatory manner. Any failure by the Claims
Administrator or Appeals Committee to apply any provisions of this Plan to any
particular situation shall not represent a waiver of the Claims Administrator?s or
Appeals Committee's authority to apply such provisions thereafter. Every
interpretation. choice. determination or other exercise by the Claims Administrator or
Appeals Committee of any power or discretion given either expressly or by
implication to it shall be conclusive and binding upon all parties having or claiming to
have an interest under the Plan or otherwise directly or indirectly affected by such
action. without restriction. however, on the right of the Claims Administrator or
Appeals Committee to reconsider and redetermlne such action.- There shall be no
de novo review by any arbitrator or court of any decision rendered by the Appeals
Committee and any review of such decision shall be limited to determining whether
the decision was so arbitrary and capricious as to be an abuse of discretion. The
Claims Administrator and/or Appeals Committee may adopt such rules and
procedures for the administration of the Plan as are consistent with the terms
hereof. 

Delegation of Responsibilities: The Claims Administrator?s and
Appeais'Committee's authority shall include. but not be limited to. the power to

to allocate or delegate fiduciary and non-fiduciary responsibilities or duties to
Associates 'or third persons, including any insurer or contract administrator, and,

except as is otherwise provided by applicable law, these persons to whom such

responsibilities and duties have not been allocated ordelegated shall not be liable
for any act or omission of those persons to whom such responsibilities and duties
have been allocated or delegated. Except as otherwise provided under ERISA,
neither an Employer, the directors, officers, partners, managers, or supervisors of
an Plan Administrator. the Claims Administrator or. the Appeals
Committee norany person designated to carry out fiduciary responsibilitiespursuant
to this Plan shall be liable for any act. or failure to act. which Is made in good faith
pursuant to the provisions of the Plan.

5.2 Funding Policy and Method. All bene?ts payable to or with respect to a
Participant under this Plan shall be paid or provided for by the Employer who was the
employer of such Participant at the time of his or her Injury. Unless provided by a trust
established pursuant to the Plan, said benefits she'll be paid by such Employer at the
direction of the Claims Administrator or Appeals Committee or its designated
representative solely .out of the general assets of such Employer. The'Employers shall
have no obligation to establish any fund or trust for the payment of benefits under this Plan.
An Employer" shall have no obligation, but shall have the right. to obtain insurance
contracts with one or more Insurers to provide funds to the Employer that can be used. if

PartnerSource . 
ROV t2r22ftt .

the Employer so desires in its sole discretionI to pay all or any portion of a benefit payable
under this Plan but no benefits under the Plan are guaranteed under any contract or policy
of insurance and the Employer of the Participant shall be solely responsible for the
payment of claimshereunder. Any such funds shall not be considered ?plan assets" for
purposes of ERISA and shall constitute a part of the general assets of the Employer. Any
such insurance contract shall be owned by, and (unless contrary to legal requirements
adhered to by the insurer) all amounts shall be payable thereunder to, the Employer that
applied for the contract, and no Participant shall have any interest in, or right to, any
amounts payable under the contract. - -

ARTICLE VI
CLAIMS PROCEDURES

6.1 Filing a Claim for Bene?ts. A claim for Medical Bene?ts. Wage
Replacement Benefits. or Dismemberment Bene?ts under the Plan shall be initiated by a
Participant (or his or her Representative) by complying with the notice requirements of
Section 4.1, and (it) submitting to medical treatment in accordance with Section 4.2. A
claim for Medical Benefits can also be directly submitted on the behalf of a Participant to
the Claims Administrator by a health care professional. A claim for Death Benefits under
the Plan shall be initiated by a Bene?ciary providing notice of entitlement thereto to the
Claims Administrator within 90 days after the date of the Participant's death. 

What is a Claim?Each medical service or supply 'for which
payment is requested. (it) Wage Replacement Bene?t for a particular payroll period,
or claim for Death Bene?ts or Dismemberment Bene?ts. shall be deemed a
separate "claim" forbenefits that is subject to a Determination under the Plan. The
Plan's payment of a particular claim (for example; payment for an initial medical
evaluation, even on a claim that may have been reported late) does not waive or

. otherwise prejudice theyClaims Administrator's or Appeals Committee's right to deny
another particular claim or all future claims for benefits under the Plan. As stated
above, any failure by the Claims Administrator or Appeals Committee to apply any
provisions of this Plan to any particular situation shall not represent a waiver of the
Claims Administrator's or Appeals Committee?s authority to apply such provisions
thereafter.

Who is a Claimant?4A Claimant or a Claimant's Representative may
?le a claim for bene?ts under the Plan. as well as an appeal of an Adverse Bene?t
Determination. References in this to "claimant" shallinclude a Participant.
a medical provider seeking payment for a service or supply, a Bene?ciary, or a
claimant's Representative, as applicable. The Plan shall have the right to establish
reasonable procedures for whether and to what extent an individual has
been authorized to act on behalf of a claimant. However, with respect to an Urgent
Care Claim, a physician or other health care provider licensed, accredited and
certified to perform specified health services consistent with state law and with
knowledge of a claimant?s medical condition shall be permitted to act as the
authorized Representative of the claimant.

Part1qu . . 3 3
Boy. 12:12!? -

 

 information to Submit?Claims must include the information required
by Section 4.1(b) and such other reasonable information requested by the Claims
Administrator, such as medical records or a written statement from an independent
service provider evidencing the date. type of services rendered, and the total cost of
such services. in addition, the Claims Administrator may require the claimant to
provide a written and signed statement which provides that the Covered Charge has
not been reimbursed, or is not reimbursable under any other plan or program.
Further. the Claims Administrator may also request that the claimant ?le all
appropriate claims and requests for payment from any other plan or program
maintained by the claimant prior to making any payments under this Plan. See
ARTICLE Vii on "Coordination of Benefits and Subrogation". The Claims .
Administrator may rely upon all such information furnished by the claimant, including
the claimant's current mailing address. and shall have no obligation or duty to locate

a claimant.

Submission of Medical Bills for Payment?Approved Physicians
and Approved Facilities will be requested to invoice all health care-related charges
directly to the Claims Administrator (or an Employer, which shall immediately
transmit such invoice to the Claims Administrator). However, in the event that a
Participant receives such an invoice or pays such a charge, all requests for payment
or reimbursement of Covered Charges must be ?led with the Claims Administrator
within 30 days from the date such expenses are incurred or, if later, the date such
Participant receives an invoice from an Approved Physician. Approved Facility, or
other health care provider (in the case of Emergency Care) for such expenses.

incomplete Claim Submissions?um the event that a claim. as
originally submitted, is not complete. the Claims Administrator shall notify the
claimant in the manner described below, and the claimant shall have the
responsibility for providing the missing information. Notwithstanding the foregoing.
the period of time within which a benefit Determination must be made shall begin at
the time that a claim is filed in accordance with this Plan, without regard to whether
all the information necessary to matte a benefit Determination accompanies the
claimant's filing. Subject to the applicable provisions of this Article Vi, .in the event
that the period of time for a particular claim is extended due to a claimant?s failure to
submit information necessary to decide a claim, the period for making the benefit
determination shailbe suspended from the date on which the. notification of the
extension is sent to the claimant until the date on which the Claims Administrator
receives the claimant's response to the request for additional information.

6.2 Claims Review.

Notice of initial Bene?t Determination The Claims Administrator
shalt provide notice to the claimant of its initial bene?t Determination as foiiows:

(1) Urgent Care, Pro-Service Medical Claims in the case of a
Pro-Service Claim for Medical Benefits that is an Urgent Care Claim, the
Claims Administrator shall notify the claimant of the Plan's initial benefit
Determination (whether adverse or not) as soon as possible, taking into
account the medical exigencies of the particular claim, but not later than 72
hours after receipt of the claim. A Determination that such claim will be

@Topy?ght 2012 Partnqu 34
it". 12122!?

covered can be communicated to the claimant verbally, in writing, or by
electronic notice; but an Adverse Benefit Determination must be provided in
writing or by electronic notice as described further below. if the claimant 
fails to follow the Plan's procedures for ?ling an Urgent Care Claim, or (Ii)
otherwise fails to provide suf?cient information to determine whether, or to
what extent. benefits are covered or payable under the Plan on an Urgent
Care Claim. then: .

(A) The Claims Administrator shall notify the claimant as

soon as possible, but not later than 24 hours after its receipt of the
claim, of the procedure to follow or the speci?c information necessary
to complete the claim. Notification may be oral. unless the claimant
requests a written notice. This notice requirement shall only apply to
the extent that such failure is a communication by a claimant that is
received by the Claims Administrator. and the communication names 'a
specific claimant, a speci?c medical condition or and a

speci?c treatment, service or product for which approval is requested.

(B) The claimant shall then be given a reasonable amount of
time, taking into account the circumstances, but not less than 48
boots, to correct such failure.

(C) The Claims Administrator shall then notify the claimant of
the Plan's initial bene?t Determination as soon as possible, but not
later than 48 hours after the earlier of the Claims Administrator's
receipt of the specified information necessary to complete the claim, or
(ii) the end of the time period given the claimant to provide such
information.

(2) Concurrent Medical Care Decisions - if the Claims'

Administrator has approved an ongoing course of medical treatment to be
provided over a period of time or number of treatments:

(A) The Claims Administrator shall notify the claimant of any
reduction or termination by the Plan of course of treatment. Such
reduction or termination shall be consideration Adverse Benefit
Determination and the Claims-Administrator shall notify the claimant
suf?ciently in advance of the reduction or termination?to allow the
claimant to appeal and obtain a benefit Determination on review
before the course of treatment is actually reduced or terminated.

(B) Any request by a claimant to extend the course of
treatment beyond the prescribed period of time or number of
treatments previously approved by the Plan that is an Urgent Care

Claim shall be decided as soon as possible, taking into account the .

medical exigencies of the claim. The Claims Administrator shall make
an initial bene?t Determination, whether adverse or not, within 24
hours after its receipt of the claim: provided that any such claim is

made to the Plan at least 24 hours prior to the expiration of the .

prescribed period of time or number of treatments. if such claim is not

@Copyrr'ght 2012 Paman 35

Rev 

 

made to the Plan within such 24-hour period, the request shall be
treated as an Urgent Care Claim and be decided within the normal
Urgent Care Claim timeframes as soon as possible. taking into
account the medical exigencies of the claim, but not later than 72
hours after receipt).

(C) Any request by a claimant to extend the course of
treatment beyond the prescribed period of time or number of
treatments previously approved by the Plan that is not an Urgent Care
Claim shalt be treated as a new bene?t claim and decided within the
tlmeframe appropriate to the type of claim as a Pro-Service Claim
or a Post?Service Claim).

Noti?cation of any Adverse Bene?t Determination concerning a request to
extend the course of treatment, whether involving an Urgent Care Claim or
not, shall be made In accordance with the provisions of this Section.

(3) Non-Urgent Care, PreuService Medical Claims - in the case
of a Pre~8ervice Claim for Medical Benefits that is not an Urgent Care Claim.
the Claims Administrator shall notify the claimant of the Plan?s initial benefit
Determination (whether adverse or not) within a reasonable period of time
appropriate to the medical circumstances, but not later than 15 days after its
receipt of theclaim. A Determination that such claim will be covered can be
communicated to the claimant verbally, In writing, or by electronic notice; but
an Adverse Benefit Determination must be provided in writing or by electronic
notice as described further below.

(A) If the claimant fails to follow the Plan?s procedures for
filing a non-urgent care, Pre-Service Claim, then the Claims
Administrator shall notify the claimant as soo?? as possible. but not
later than 5 days after its receipt of the claim, of the procedures to
follow. Notification may be oral, unless the claimant requests a written
notice. This notice-requirement shall only apply to the extent that such
failure is a communication by a claimant that is received by the Claims 
Administrator. and the communication names a speci?c claimant, a
specific medical condition or and a specific treatment,
service or product for: which approval is'requested I

(B) The Claims Administrator may extend the 15-day benefit
Determination period up to an additional 15 days if it determines that,
due to matters beyond the control of the Plan, an initial benefit
Determination cannot be made within the first t5~day period, and
noti?es the claimant of the special circumstances requiring the
extension and the date by which the Plan expects to render a decision.
If the extension is necessary due to a failure of the claimant to submit
the information necessary to decide the claim. the extension notice
shall speci?cally describe the required information and the claimant
shall then be given at least 45 days to provide the speci?ed
information. However, the Claims Administrator?s tlmeframe for

Partrzechucn 

Rev 

making a benefit Determination shall be suspended until the date upon
which the claimant responds to the request for additional information. 

(4) Post-Service Medical Bene?t, Wage Replacement Bene?t,
Death Bene?t. and Dismemberment Bene?t Claims - in the case of a
Post-Service Claim for. Medical Bene?ts or a claim for Wage Replacement
Bene?ts. Death Bene?ts or Dismemberment Bene?ts. the Claims
Administrator shall notify the claimant of an Adverse Benefit Determination
within 30 days after its receipt of the claim. The Claims Administrator'may
extend this period up to an additional 15 days If the Claims Administrator
determines that an extension is necessary due to matters beyond the control
of the'Pian. Notice of such extension must be provided to the claimant prior
to the expiration of the initial 30-day period and state the special
circumstances requiring the extension, and (it) the date by which the Plan

expects to render a decision. if the extension relates to a claim for Wage -

Replacement Bene?ts, such notice shall also state the standards on which
entitlement to bene?ts is based, and (ii) unresolved issues that prevent a
benefit determination on the claim and what additional information is needed
to resolve those issues. If additional information is requested with the
extension notice, the claimant shall have 45 days from the date of the notice
of extension in order to provide the specified information. However, the
Claims Administrator's timeframe for making a bene?t Determination shall be
suspended until the date upon which the claimant responds to the request for
additional information.

Manner and Content of Adverse Bene?t Determinations - If the

initial benefit Determination is an Adverse Bene?t Determination. the Claims
Administrator shall provide a written or electronic notice to the claimant that satisfies
the following requirements: .

(1) Any electronic notice shall satisfy regulations that
specify the standards for electronic disclosure of benefit plan information:

(2) The notice shall be written In a manner calculated to be
understood by the claimant; 

The notice? shall set forth the speci?c reason or reasons for the
Adverse Benefit Determination, making reference to the speci?c Plan
provisions on which the Adverse Bene?t Determination is based;

(4) if an internal rule, guideline, protocol or other similar criterion
was relied upon in making an Adverse Bene?t Determination on a claim for
Medical Benefits or Wage Replacement _Benefitsl the notice shall state that
such rule, guideline. protocol or other similar criterion was relied upon in
making the Adverse Bene?t Determination and that a copy thereof shall be
provided free of charge to the claimant upon request;

(5) if the Advorse Bene?t Determination of a Medical or Wage
Replacement Bene?ts claim is based _upon medical necessity, an
experimental treatment or similar exclusion or limit. the notice shall provide

2012 ParetorScuoo 

Rev. 1

 

either an explanation of the scientific or clinical judgment for the Adverse
Bene?t Determination, applying the terms of the Plan to the claimant's
medical circumstances. or a statement that such explanation will be provided
free of charge upon request;

I (6) The notice shaliinclude a statement that in the case of an
Adverse Benefit Determination on review by the Appeals Committee, the
Plan offers no further voluntary levels of appeal and that the claimant can
pursue his or her right to bring a legal action under ERISA section 502(a);

(7) if the initial Adverse Bene?t Determination involves an Urgent
Care Claimy the notice shall provide a description of the expedited review
process applicable to such claims. Noti?cation of an Adverse Benefit
Determination that involves an Urgent Care Claim may be provided to the
claimant orally 'within the time frames specified above, provided that the oral
notification satis?es the requirements of this subsection and that a written or
electronic notice satisfying the requirements of this subsection is furnished to
the claimant not later than 3 days after the oral notification;

(8) The notice shall describe any additional materials or information
necessary for the claimant to perfect the claim and explain why such material
or information is necessary; and 

(9) The notice shall provide a description of the Plan's review
procedures (including the time limits applicable to these review procedures).

(0) Appeal of Adverse Benefit Determinationszhe claimant may
appeal in writing an lnItlalAdverse Benefit Determination to the Appeals Committee
within the following number of days following his or her receipt of the Adverse
Benefit Determination from the Claims Administrator:

(1) 180 days for a Medical Benefits or Wage Replacement Benefits
claim; or 

(2) 60 days for a Death Benefit or Dismemberment Benefit claim.

If the Adverse Benefit Determination involves an Urgent Care. Claim for Medical
Bene?ts, the claimant'may request orally or in writing an expedited review of the
Adverse Benefit Determination and all necessary information, including the Plan's
benefit Determination on'review. shall be transmitted between the Plan and the
claimant by telephone, facsimile or other available expeditious method.

Appeals Committee Consideration?When reviewing the appeal of
an Adverse Benefit Determination, the Appeals Committee shall comply with the
following requirements:

(1) The claimant may submit written comments, documents,
records. and other information relating to the claim-for benefits! and the
Appeals Committee shall take all of such information into account when

2012f?aftner8ouoo 
Rev Wail!?

reviewing such claim. without regard to whether such information was
submitted or considered in the initial benefit Determination;

(2) The claimant may receive. upon request and free of charge.
reasonable access to. and copies of. all documents. records. and other
information that is Relevant to the claimant's claim for bene?ts (as
determined by the Appeals Committee);

(3) The Appeals Committee review of an Adverse Bene?t
Determination on a claim for Medical Benefits or Wage Replacement Benefits
shall not give any deference to the initial Adverse Bene?t Determination.

(4) lithe appeal request on a Medical Bene?ts or Wage-
Replacement Benefits claim is based in whole or in part on a medical
judgment. including Determinations with'regard to whether a particular
treatment. drug or other item is experimental. investigationai or not medically
necessary or appropriate. the Appeals Committee shall consult with an

- Approved Physician who has appropriate training and experience in the field

of medicine Involved in the medical judgment. This Approved Physician shall
not be an individual who was consulted in connection with the initial Adverse
Benefit Determination or a subordinate of such individual.

(5) Upon request of a claimant. the Appeals Committee shall
identify the individual names of any medical or vocational experts whose
advice was obtained in connection with an initial Adverse Benefit
Determination. without regard to whether the advice of such experts was
relied upon in making the bene?t Determination.

Timing of Notice of Bene?t Determination on Review The

Appeals Committee shall provide notice to the claimant, as described in subsection
below. of the Plan?s benefit Determination on review in accordance with the

following timelrames:

(1) Urgent Care, Pro-Service Medical Claims - in the case of a
Pro-Service Claim for Medical Benefits that is an Urgent Care Claim. the
Appeals Committee shall notify the claimant of the Plan?s benefit
Determination on' reviewers" soon as possibieg taking into accouni'th?e? medical
exigencies of the claim. but not later than 72 hours after its receipt of the
claimant's appeal request. No extension of- time is available for Appeals
Committee Determinations on the'review of claims for Medical Benefits.

(2) Non-Urgent Care, Pro-Service Medical Claims - in the case
of a Bra-Service Claim for. Medical Benefits that is not an Urgent Care Claim.
the Appeals Committee shall notify the claimant of the Plan's benefit
Determination on review within a reasonable period of time appropriate to the
medical circumstances. but not later than 30 days after its receipt of the
appeal request. No extension of time is available for Appeals Committee
Determinations on the review of claims for Medical Benefits.

2012 PartrterScuou 39

Rev 

(3) Post-Service Medical Bene?t, Wage Replacenient Benefit.
Death Bene?t, and Dismemberment Bene?t Claims In the case of a
Post-Service Claim for Medical Benefits or a claim for Wage Replacement
Benefits, Death Bene?ts or Dismemberment Benefits, the Appeals Committee
shall notify the claimant of the Plan's bene?t Determination on review within
45 days after its receipt of the appeal request. The Appeals Committee may
extend this period up to an additional 45 days on a claim for Wage
Replacement Benefits, Death Benefits. or Dismemberment Benefits if the
Appeals Committee determines thatan extension is necessary due to
matters beyond the control of the Plan. Written or electronic notification of an
extension must be provided to the claimant prior to the expiration of the initial
45-day period and indicate the special circumstances requiring the extension
and the date by which the Plan expects to render a decision.

Manner and Content of Bene?t Determination on Review - The
Appeals Committee shall provide a claimant with written or electronic notification of
the Plan?s benefit Determination on review. If the decision on review is an Adverse
Benefit Determination. the notice must satisfy all the requirements set forth in
subsection through (6) above, and also state that the claimant is entitled to
receive. upon request and free of charge, reasonable access?to. and copies of. all
documents, records, and other information Relevant to the claimant's claim for Plan

benefits.

(9) Extension of Time Frames Allowed by Law or Agreement In the
event that ERISA rules and regulations permit additional time for decisions or
actions by the Claims Administrator or Appeals Committee. the'Ciaims Administrator
or Appeals Committee may exercise their discretion to. utilize (but not exceed) those
extended time frames: provided. however. that this discretion shall only be
exercised when necessary to provide a full and fair review of a claimant's right to
benefitslin accordance with the terms of this Plan additional time needed to
obtain an appointment and results of a medical examination). Upon request by the
Plan. a claimant may also voluntarily agree to an extension or further extension 'of
any time period within which the Plan must decide ,a claim. .

Exhaustion of Administrative Remedies: No legal action can be
orwith respect to a Participant to-recover benefits under the Plan before
the foregoing claim procedures have been exhausted; Every right of action
by any Participant, former Participant. a Participant's Representative, Beneficiary, or
the Participant's estate against the Plan. or any Plan fiduciary, must be brought no
later than one (1) year from the date that the foregoing claim procedures have been
exhausted (due to claimant inaction. claimant receipt of a ?nal Adverse Benefit
Determination on appeal, or otherwise). Unless contrary to applicable law, any
ERISA right of action or other legal action challenging a Plan decision-shall be
brought in the United States District Court for the Northern District of Texas. Dallas

Division. . 

?Ccp-ynghi?20i2  

Rev. 

 
COORDINATION 0F. nub 

7.1 Reduction in Bene?t Payments. Benefit payments under this Plan shall be
reduced by:

the amount of any applicable federal or state income, employment. or
other taxes that are required by law to be withheld; 

I the Participant's earnings from any employer after disability begins.
amounts legally garnished, and Participant contributions (through salary reduction or
otherwise) to a cafeteria plan or other pro-tax salary deferral employee benefit plan
if such plan permits contributions from the Participant's wage replacement bene?t
payments under this Plan; and

- (0) except as otherwise specified under Section any amount paid
or available with respect to the Participant's injury under the following: Social
Security Act, the Railroad Retirement Act, workers? compensation law,
unemployment compensation law, occupational disease law or any other
government program or similar law. The Plan shall deduct from Plan benefits the
estimated benefit amounts for which the Participant is likely to be eligible under such
other deductible sources of income, regardless of whether the Participant actually

applies for such other deductible source of income.

7.2 Coordination 0f Bene?ts. if a Participant is covered under this Plan and
one or more other benefit plane, then (unless otherwise subject to Section 7.3) any Medical
Bene?ts and Wage Replacement Benefits payable under this Plan will be either regular
bene?ts or reduced bene?ts that, when added to the benefits of the other plan(s), Will not
exceed 100% of the amount described herein. The purpose of this provision is to prevent
duplicate payments under plans that would exceed 100% of the benefits described in this
Plan. in the coordination of benefits, one of the plans will be designated as the primary
plan and the other plans will be designated as secondary. The primary plan will pay its full
benefits ?rst, then the secondary plan(s) will pay, but payments will be coordinated so that
the total from all plans will not be more than the benefits described in this Plan.

- For purposes of this Section 7.2; "other benefit plans" shall mean? any
health or disability?type benefits provided under (1) any individual. group, blanket or
franchise plan, (2) other prepaid coverage under service plan contracts, ?or under
group or individual plans, policies or a practice, (3) uninsured arrangements of
group or group?type coverage. (4) labor-management trusteed plans, labor
organization plans, employer organization plans, or employee bene?t organization
plans, (5) bene?ts coverage in a group, grOUp-type and individual policy or policies
of automobile coverage (including, but not limited to medical payment coverage,
personal injury protection coverage, uninsured motorists coverage and underlnsured
motorists coverage, and (6) any other group~type contracts that is, these contracts
which are not available to the general public and can be obtained and maintained
only because of membership in or connection with a'particular organization or

group.

 
RSV. 

 Except as specified under Section 72(0). if a person is covered by
more than one plan to which this coordination of benefits provision applies, then the
following rules will determine which plan will be, primary:

(1) With respect to health benefits only. when only one of the plane
has a coordination of benefits provision. then the plan without such a

provision will be the primary plan;

(2) The plan under which the person is covered other than as a
dependent (for example. active associate, former associate, inactive
associate, COBRA participant or retiree) will be the primary plan over a plan
Which covers the person as a dependent;

(3) The plan under which the person is covered as an active
associate will be the primary plan over a plan which covers the person as
former associate, inactive associate. COBRA participant or retiree;

(4) if none of these rules establish an order of benefit
determination. then the plan that has covered the person for the longer period
of time will be the primary plan, 

Any provision herein to the contrary notwithstanding. Medical Benefits
payable under this Plan to or with respect to any Participant who is in ?current
employment status" as defined for purposes of Medicare. and who is eligible for
benefits under Medicare. shall be primary and shall not be reduced by the amount of
benefits payable to or with respect to such Participant under Medicare. which will be
considered the secondary plan. The fact that a Participant is eligible for or provided
medical assistance under a state plan will not be taken into account In making
payments under the Plan.

The Participant must notify the Claims Administrator of such other
benefit plans and cooperate with the Claims Administrator in (1) furnishing copies of
other policies. coverages or plans which may be applicable to the injury. and in (2)
completing and returning to such Claims Administrator any questionnaire or forms
inquiring about. or assigning rights to recover under. other policies. coverages or
plane which may cover or be applicable to such Participant.

. 7.3 Subrogation and Reimbursement Rights. For purposes of Section 7.3.
7.4. and 7.5 of this Plan. the term ?Payee? means a Participant or Beneficiary or their family
members. heirs. estate. or other Representative (in their individual or representative
capacity). singularly orcoiiectively as the context may require to give the Plan the broadest

possible rights of recovery.

Right of Subrogatlon: if a Payee becomes entitled to or directly or
indirectly receives Plan bene?ts for any injury caused by the negligence or other act
or omission of any person or organization (including. but not limited to. an
Employer). andis (or later becomes) entitled to or otherwise collects any damages
or other compensation in connection with such injury (including. but not limited to,
damages for negligence. survival. wrongful death or other legal or equitable action).
whether by insurance. litigation. settlement or other proceeding. the Payee shall

Partner'Scurm 42
Rev. 12:22:11

automatically be required to subrogate his, her or its right to and reimburse the
Plan out of said damages or other compensation to the extent of the Plan benefits
. paid to. or with respect to, the Payee and (it) subrogate his. her or its right to and
reimburse the Plan out of said damages or other compensation for all medical
management, investigation. attorneys' fees. costs of recovery; and other expenses
related to the claim for benefits (including any subrogatlon proceeding). The
subrogation rights of this Plan even apply with respect to a Payee'who is (or later
becomes) entitled to or otherwise collects any damages or other compensation in
connection with such injury but has not and will not receive any Plan benefits if such
person?s claim for damages or other compensation is dependent on whether the
Participant had or has a valid claim against a third party. in the sole and exclusive
discretion of the Claims Administrator and in consideration of all relevant facts and
circumstances, the Claims Administrator may waive its right of subrogation.

Written Confirmation: Upon request of the Plan, the Payee shall
provide the Plan written confirmation of this subrogatlon right, including execution of
any assignment. lien form or other document requested by the Claims Administrator
to enable the Plan to recover such Plan benefits and related expenses. Any failure
of a Payee to give written confirmation of the Plan's subrogation rights does not
adversely affect its rights of subrogation because the Plan's right of subrogation

arises automatically once payment under this Plan is made to or on behalf of the .

. Payee.

Right to Reimbursement: if a Payee fails, refuses-or neglects-to
reimburse the Plan or otherwise comply with the provisions of this Section. or (it)
payments are made under the Plan based on fraudulent information or otherwise in
excess of the amount necessary to satisfy the provisions of thelPian, then the Plan
shall still have all remedies and rights of recovery specified herein. The Plan shall
also have the right to terminate or suspend bene?t payments and/or recovergthe
reimbursement of all amounts above due to the Plan by withholding. offsetting and
recovering such amounts out of any future Plan benefits or amounts othenrvise due
from the Plan to or with respect to such Payee.

Right of Recovery: The Plan shall have the first lien recovery against
any benefits paid or to be paid by the Plan. The Plan shall also have the right to
bringa lawsuit and assert a constructive trust or other interest against any and all
persons that?have assets to which the Pian'can claim rights. The Plan has? the right
of ?rst recovery from any Judgment, settlement or other payment. regardless of
whether the Payee has been "made whole.?

Attorney?s Fees and Expenses: The Plan's subrogation rights and
first lien will not be reduced by attorneys? fees or expenses incurred by any party in
pursuing recovery against a third party and the "common fund" doctrine shall not
apply. Any 'attorn?eys' fees and/or expenses incurred by or at the request of the
Payee or his, her or its attorneys in a third party or other action shall be the sole
responsibility of such party.

7.4 Notice Of Legal Proceedings. A Payee (whether or not such person has
received or may in the future directly or indirectly receive Plan bene?ts) shall provide the
Claims Administrator with prior written notice of the involvement of such party in any

Partnme 43
Rev 19021?

 

lawsuit, settlement discussion or other proceeding (for negligence. wrongful death, survival
or other cause of action), one of the principal purposes of which is recovering, from any,
person or organization, damages or other compensation in any way related to any injury
for which Plan benefits have been or may in the future be paid. - The Plan shall have the
right to intervene for itself and on behalf of a Payee in any such lawsuit, settlement
discussionor other proceeding. if a Payee neglects, fails or refuses to seek a recovery
from any person or organization for 'any injury caused by the negligence or other act or
. omission of such person or organization, the Plan shall have the right to institute a lawsuit
or other proceeding or do any other act that in the opinion of the Claims Administrator may
be necessary or desirable to recover the Plan bene?ts paid (and to be paid in the future),
plus all medical management, investigation, attorneys? fees, costs of recovery, and other
expenses incurred by the Plan.

7.5 Assignment Of Rights. By participating in_ this Plan, a Participant, obligates
himself or herself, as well as all other Payees (in both their individual and representative
capacities), to the provisions of this Plan, including, without limitation, Sections 7.3, 7.4,
and 7.5 hereof. Upon the request of the Claims Administrator, at Payee shall assign to the
Plan the right to intervene in or institute any lawsuit, settlement discussion, or other
proceeding described in Sections 7.3 and/or 7.4, and to use the name of such party for
such purpose. The Plan shall have the right to select legal counsel of its own choice and
such counsel shall have complete control over-the conduct of any such lawsuit, settlement
discussion, or other proceeding without the consent or participation of any such Payee.
Whenever the Plan shall intervene in or institute any lawsuit or other proceeding as
permitted by the provisions of this Section, the Plan may pursue same to a final
determination and the Plan expressly reserves the right to appeal from any adverse
judgment or decision. The Payee shall give the Plan all reasonable aid in any such
lawsuit, settlement discussion, or other proceeding in effecting settlement, in securing
evidence, in obtaining witnesses, or as may otherwise be requested by the Claims
Administrator. The Payee shall release the Plan, the Employers, the Plan Administrator,
the Claims Administrator, the Appeals Committee, and their respective directors, officers,
agents, consultants, attorneys, and associates from all claims, causes of action, damages
and liabilities of whatever kind or character that may directly or indirectly arise out of the
pursuit or handling by the Plan of any such lawsuit, settlement discussion or other

proceeding. -
ARTICLE Vill-
TERMINATION AND AMENDMENT

The Company shall have the right and power at any time and from time to time to amend
this Plan, in whole or in part. on behalf of all Employers, and at any time to terminate this
Plan or any Employerfs participation hereunder; provided, however, that no such
amendment or termination shall reduce the amount of any benefit payable to, or with
respect to, a Participant under the Plan in connection with an injury occurring prior to the
date of such amendment or termination. Any such amendment or termination shall be
pursuant to formal written action of a representative authorized to act on behalf of the

Company.

2M2  
Rev 12/22)?

ARTICLE lX
GENERAL PROVISIONS

9.1 inability to Make Payment. in the event an individual becomes entitled to a
payment under this Plan and such payment cannot be made because the address
provided by the individual is incorrect. (it) because the individual fails to respond to a notice
sent to the address provided by the individual. because of con?icting claims to such
payment. or (iv) because of any other reason. the amount of stioh payment. if and when
made, shall be the amount determined under the provisions of ARTICLE iil without interest

9.2 Claims Administrator and Appeals Committee indemnity. The Employers
shall indemnify and hold harmless any Associate designated as the Claims Administrator
or the? Appeals Committee. and any other associate of an Employer to whom the Claims
Administrator or Appeals Committee has delegated administrative authority respect to
the Plan. against any claim. cost. expense (including reasonable attorneys fees), judgment
or liability (including any sum paid in settlement of a claim with the approval of the
Company) arising out of any act or omission to act of the Claims Administrator or Appeals
Committee under this Plan. except in the case of willful misconduct. -The Employers shall
be jointly and severally liable for any amounts owed pursuant to this Section.

9.3 Provision. Except as expressly provided for in this Plan. no
right or interest of any Participant or Beneficiary under this Plan may be assigned,
transferred or alienated. in whole or'in part, either directly or by operation of law. and no
such right or interest shall be liable for or subject to any debt. obligation or liability of such
Participant or Beneficiary. .

9.4 Employment Noncontractuai. The establishment of this Plan shall not
enlarge or otherwise affect an Associate's "at by an Employer. and an
Employer may terminate the employment of any Associate at any time and/or modify the
Associate's working relationship as desired. for any or no reason (with or without

cam)- 33 freely and Wii?. "1.9 semester? as if maiden had.th been established. 

such payment to be made to the guardian of the person. managing conservator or
guardian of the estate of the Participant, (ii) to a relative or friend of the Participant. to be
expended for the Participant's bene?t. to a custodian for the Participant under any
Uniform Gifts to Minors Act. or (iv) to a trust established for the Participant. The Claims
Administrator shall not be obligated to see to the proper application or expenditure of any
payment so made. Any payment made pursuant to the power herein conferred upon the
Claims Administrator or Appeals Committee shall operate as a complete discharge of all
obligations of the Plan and the Claims Administrator and Appeals Committee, to the extent
of the payments so made.

Part1an 45
it?. 12mm 9

9.6 Participation By Affiliates. With _the consent of the Company, any
incorporated or unincorporated trade or business which is a member of a control group
(within the meaning of Section 3(40) of ERISA) with reapect to which the Company is also
a member may adopt and become a participating Employer under this Plan. A list of those
participating Employers is attached hereto as Appendix B. 

9.7_ Plan Documents Control. This written Plan document constitutes the entire
Plan. and no oral' or written representation or promise concerning the Plan whichiis
inconsistent with the provisions of this Plan document shall have any effect. The
provisions of this Plan document shall be the sole source of all legally enforceable rights
with respect to the benefits herein provided.

9.8 Construction. The titles to the Articles and the headings of the Sections in
this Plan are placed herein for convenience of reference only and in case of any conflict
the text of this instrument, rather than such titles or headings, shall control. Whenever a
noun or pronoun is used in this Plan in plural form and there be only one person or entity
_withln the scope of the word so used, or in singular form and there be more than one
person or entity within'the scope of the word so used, such word or pronoun shall have a
plural or singular meaning as appropriate under the circumstance.

9.9 Separability. if for any reason any provision of this Plan Is determined to be
invalid or contrary to applicable law, such invalidity shall not impair the operation of or
otherwise affect the remaining provisions of this Plan.

9.10 Applicable Law. This Plan shall be governed and construed in accordance
with the provisions of ERISA and. except where superseded by federal law, the laws of the

State of Texas.

9.11 Application of Health Insurance Portability and Accountability Act.? This
Plan is exempt from the gro?p health plan requirements of Part 7 of ERISA by operation of
one or alcombination of'the excepted benefits listed in ERISA Section 733(c)(1) and is
therefore exempt from the standards. rules, regulations and. other requirements of the
Health Insurance Portability and Accountability Act. 

9.12 Application of Patient Protection and Affordable Care Act. This Plan is
exempt from the group health plan requirements of the Public Health Service Act by
operation of one or a combination of the excepted benefits listedvinv Title 42- of the United
States Code Section and is therefore exempt from the standards. rules,
regulations and other requirements of the Patient Protection and Affordable Care Act.

9.13 Application of Other Group Health Plan Requirements. This Plan is
exempt from the group health plan requirements of any other standardsI rules. regulations
or other requirements that utilize or reference the excepted bene?ts de?nition listed in

Section 733(c)(1);

(cocopyngisrzoia swam:m 48
nav. imam

IN WITNESS WHEREOF, this Plan has been executed by the Company} this
day of . 2012. to be effeclive March 1, 2012.

WALMART STORES, INC.

-
(Slgnature and Title)

2012 Pam-?Scuba 4 7
Rev 12mm

APPENDIX A
ARBITRATION OF CERTAIN INJURY-RELATED DISPUTES

ARBITRATION POLICY OVERVIEW

The Employer hereby adopts a mandatory company policy requiring that certain claims or disputes
must be submitted to final and binding arbitration under this arbitration requirement ("Policy/0. This
binding arbitration will be the sole and exclusive remedy for resolving any such claim or

dispute.

For purposes of this Policy or ?Company? shall mean Walmart Stores,
Inc., and Its successors or assigns and any other entity affiliated, owned or related to
Walmart Stores, inc. for which an associate has or may have standing to sue.

Covered Claims:

(1)

(2)

any legal or equitable claim or dispute relating to enforcement or interpretation of
the arbitration provisions In a Receipt, Safety Pledge and Arbitration
Acknowledgement form, an associate training program, or this Policy; and

any legal or equitable claim by or with respect to an associate for any form of
physical or damage, harm or death which relates to an accident.
occupational disease, or cumulative trauma (Including, but not limited to, claims of
negligence or gross negligence or discrimination; claims for intentional acts,
assault, battery, negligent hiring! training! supervisionf retention, emotional
distress, retaliatory discharge, or violation of any other noncrimlnai federal, state
or other governmental common law, statute, regulation or ordinance in connection
with a lob~reiated injury.- regardless of whether the common law doctrine was
recognized or whether th'e statute, regulation or ordinance was enacted before or
after the effective date of this Policy).

The'determination of whether a claim is covered by this Policy.

This arbitration requirement includes all claims listed above that an associate has
now or in the future against an Employer or the Company, its officers, directors,

owners, associates, representatives, agents, subsidiaries, af?liates, successors,-

or assigns (even if such claim relates to matters occurring before the effective
date of this Policy, if the associate has not ?led a legal action in any court or with
any governmental agency prior to such data).

Excluded Claims: This arbitration requirement does not, however, Include the
following claims:

(1)

?Copyr?ht 2012 PartrerSourca
Rev 110311

any legal or equitable claim under ERISA for bene?ts, ?duciary breach, or
other problem or relief solely relating to bene?ts payable under this Plan. if
an associate wishes'to appeal a denial of benefits under the Plan, such associate
must follow the process described in ARTICLE VI of the Plan. After ekhausting
the appeal process outlined in ARTICLE Vi or the Plan, any action challenging a
Plan decision, or any other ERISA right of action, must be brought in the United
States District Court for the Northern District of Texas, Dallas Division.

i9)

(2) Any claim filed with an administrative agency in accordance with applicable law.

(3) Any criminal act or complaint, including but not limited to, restitution by an
associate for a criminal act for which he or she has been found guilty or no
contest. or if the criminal proceedings have been resolved by deferred

adjudication. 

without regard to whether they have completed and signed a Receipt, Safety Pledge
and Arbitration Acknowledgement form or similar written or electronic receipt. These
provisions also apply to any claims that may be brought by an associate?s spouse,
children, parents, beneficiaries, representatives, executors, administrators. guardians.
heirs or assigns (including. but not limited to. any survival or wrongful-death claims).

ARBITRATION PROCESS

is) Required Notice of All Claims: When a party seeks arbitration. such party must give

written notice of any claim to the Judicial Workplace Arbitrations, and the
other party within the applicable statute of limitations for such claim'. The day the act
complained of occurred will be counted for purposes of determining the applicable

shall be void and deemed waived. The ?ling of a lawsuit will not tell the running of
the applicable statute of limitations to request arbitration of a claim, nor will the
doctrine of equitable tolling apply to extend the limitations period for the party to
request arbitration.

to the Employer. in care of Jennifer D. Hurless, c/o CMI, 1025 Trinity Mills Rd.
#120 Carrollton, TX 75006 (or such other person or address as the Employer may
specify). if the Employer wishes to invoke arbitration. the Employer must also
give written notice to the associate at the last address recorded in the associate's
personnel file.

(2) The party requesting arbitration must tile a petition with JWA speci?cally identify

- and describe?in the- written notice all claims asserted'and the?facts' on which the
claims are based. is written notice shall be sent to JWA and the other party by
certi?ed or registered, mail, return receipt requested. The responding party shall

special exceptions with the arbitrator on the basis that the petition does not satisfy
the requirements of this arbitration requirement. The form and timing of these
pleadings shall follow the deadlines in the Texas Rules of Civil Procedure.

(3) if after expiration of the applicable statute of limitation a court has ordered the
parties to arbitrate, and (ii) such court or arbitrator for whatever reason has
determined that the claim is not void and deemed waived, then the party that is
compelled to arbitrate must give notice of such claim to JWA and serve the other

?Copyr?tt20t2Partne?Scuca
Rev [202?! 

party with 30 days of such order or the party?s claim shall be void and deemed
waived. Such notice must be given In the manner described above.

Arbitration Filing Fees: The associate shall pay a nonrefundable arbitration ?ling fee

to)

equal to the standard associate ?ling fee speci?ed under then?current JWA Arbitration
Procedures. The associates ?ling fee must be paid when he or she submits a request for
arbitration (or, if this process is challenged by an associate. when arbitration is compelled

by court order). The Employer shall pay a nonrefundable arbitration ?ling fee equal to the 

standard employer ?ling fee-speci?ed under then?current JWA Arbitraticin Procedures.
The Employer will also pay the arbitrator?s entire fee and any other JWA administrative
expenses; provided, however, that an associate may elect to also pay up to one?half of
these fees and expenses. The arbitrator shall state his or her hourly rate in writing
prior to the time that the arbitrator is selected. The arbitrator?s rate shall not change
during the pendency of a case. if the arbitrator must travel. the time spent in travel and
reasonable travel expenses shalt be paid as specified above.

(1) if the arbitrator finds completely in favor of the associate on all claims. the
Employer will reimburse the associate for his or her share of the filing fee.

if the Employer initiates the arbitration (by means other than a motion in court to

compel arbitration), the associate will pay no portion of the JWA or arbitrator filing
fees.

Choosing an Arbitrator:
contrary, JWA arbitraticns shall be conducted by a single arbitrator. The parties to the
dispute shall be presented a panel with a minimum of three different prospective JWA
arbitrators from whom they shall choose. The parties may agree to the selection of one
particular arbitrator from the panel. if agreement is not reached, the piatntift(s) and
defendant(s) shall have an equal number of strikes. Plaintiff(s) and defendant(s) shall
each strike one arbitrator from the panel. The parties shall continue to strike arbitrators
from the panel until one arbitrator remains. That person shall then arbitrate the claim. if
for any reason, this method does not result in the selection of one arbitrator. .JWA shall
select the arbitrator.

(1) Unless otherwise agreed to in writing by the parties. the arbitrator selected by the
parties in accordance with those. rules (1) shall be a former Judge (and/or attorney
licensed to practice in the State of Texas) with experience in personal injury
litigation, and (2) shall be selected from a panel of arbitrators located in Dallas
_County, Texas.

(2) The prospective arbitrator shall disclose any financial interest or relationship with
any of the parties of which the prospective arbitrator is aware. Any party may
challenge the quali?cations or neutrality of an arbitrator by presenting a written
objection within ten (10) days after receiving an arbitrator?s disclosure. The non-
chalienging party may either agree or ?le a response to the objection within ten (10)
days of receiving the objection. .JWA will review any objection and determine
whether a particular objection is valid. decision is conclusive on this matter.

2012 PartnerSouoe

Rev 120.311

Absent express agreement between the parties to the

id)

(al

(0

(9)

(ii)

(3) After the selection process is completed, if the arbitrator so selected becomes
unable to serve for any reason. the parties shall again go through the same
selection process described above. -

Scheduling Order: Within a reasonable time after the arbitration has commenced, the
arbitrator shall issue a scheduling order setting 'forth deadlines. including without
limitation, such items as deadlines for discovery to be completed,? parties to be joined.
pleadings to be ?led or amended?and setting forth a hearing date.

Discovery and Motion-Practice: Parties to the arbitration may use all discovery devices
(interrogatories, requests for production, admissions, depositions. etc.) that are allowed
under the Texas Rules of Civil Procedure. Any party may also make motions, including
dispositive motions. that can be ?led in Texas state court (or Federal court, if applicable).

Pro-Arbitration Remedies: The arbitrator may award relief to a party. including
injunctive relief. prior to the ?nal hearing for arbitration. The arbitrator may postpone any
hearing with the mutual agreement of the parties or by any party's request with good
cause shown. The arbitrator may also direct the parties to mediation prior to the
arbitration hearing. if the parties cannot agree to a mediator, the arbitrator shall appoint
one. Mediation is a nonbinding process. The parties meet and with the help of a
mediator attempt to reach a settlement of a dispute. The settlement must be acceptable
to both parties and the mediator cannot impose a settlement upon a party.

Arbitrator Authority: The arbitrator, and not any federal, state, or local court or
agency, shall have exclusive authority to resolve any dispute relating to the
interpretation, applicabilityl enforceability or formation of this agreement including, but
not limited to. any claim that all or any part of this agreement is void or voidabie.

(1) At any time, the arbitrator will have the authority to consider and grant
motions consistent with the Texas Rules of Civil Procedure (or Federal
Rules of Civil Procedure,
motions for summaryiudgment.

(2) The arbitrator is authorized only to rule on the claims set forth in the original

(3) The arbitrator shall also not commingle the standards for state law
determinations and remedies (for example negligence claims and special
damage awards) with the standards for federal law determinations and
remedies that may or may not be subject to this Policy (for example, 
benefit eligibility and ERISA damage awards are not subject to arbitration). .

Arbitration Procedures: Any arbitration under this Policy will be administered by the
Judicial Workplace Arbitrations, inc. under its then-current JWA Arbitration
Procedures. 

(1) Preliminary Hearing: After arbitrator selection, a preliminary hearing may be
scheduled upon request by the parties, the JWA or the selected arbitrator. At this

Permusouce

Rev 

if applicable), including, but not limited to, 

(3)

(4)

(5)

(6)

hearing, the arbitrator will work with the parties to narrow the issues. establish a
discovery schedule, arrange for an acceptable procedure for the filing of any
motions and arrange for the earliest and most efficient arbitration hearing possible

for the issues in dispute.

Discovery: The arbitrator will have discretion to order pro-hearing exchange of
information. including but not limited to, document production, information
requests. depositions, subpoenas, and summaries of expected testimony. The
arbitrator can issue protective orders as he or she deems necessary or
appropriate to protect the; privacy or other legal rights of the parties and/or
witnesses. 

Reccrding the Hearing: Either party may arrange for, and pay the cost of, a
court reporter to provide a stenographic record of the proceedings. Otherwise,
the arbitration hearing will not be recorded. - .

Attorney Fees: Each party shall be responsible for their own attorney's fees. if
any. However, if any party prevails on a statutory claim which allows the
prevailing party to be awarded attorney's fees. or if there is a written agreement
providing for such fees, the arbitrator may award reasonable attorney's fees to the

prevailing party.

Other Arbitration Expenses: Each party shall also be response for any costs for
witnesses called, any costs to produce evidence requested by the other party,
deposition costs, and transcripts. The Employer will pay fees and expenses
charged by the arbitrator or the JWA for the arbitration; however, the associate
may elect to pay up to one-half of these fees and expenses if requested.

Failure to Attend: if you or the Employer fail to attend a scheduled arbitration
hearing without good cause (as determined by the arbitrator), any claim brought
by the party failing to attend will be dismissed and cannot be pursued further.

Arbitration Decision: Unless the parties agree otherwise, the arbitrator will make
a final and binding decision within 30 days after the hearing is closed. The final
decision and the arbitration award, if any, shall be made consistent with the remedies
available underthe state or federal statute, common law, code or regulation that is the
subject of the claim. Judgment on any award by the arbitrator may be entered into any
court having jurisdiction over the claim and shall have the same legally binding effect
as if the judgment had been rendered in such court.

(1)

(2)

(3)

20t2 PartrerSou-rce
Rev 12212!?

The arbitrator's decision shall be rendered in writing and include a brief
summary of all ?ndings of fact and conclusions of law'neoessary to support
the arbitrator's decision.

The arbitrator shall assess the, JWA filing fee, arbitrator fees and expenses, and
attorney's fees against a party upon a showing by the other party that the first
party?s claim is frivolous. or unreasonable, or factually or legally groundless.

All decisions rendered by an arbitrator under this Policy will be kept con?dential
by all parties, and shall not serve as binding. legal precedent with respect to
subsequent claims or disputes under this Policy.

5

(3) An arbitrator's decision can be challenged in a state or federal court of law
only on such basis as are available under the Federal Arbitration Act.

ADDITIONAL INFORMATION



(0)

Binding Effect: This Policy for resolving claims by arbitration is equally binding upon,
and applies to any such claims that may be brought by, an Employer and each
associate and his/her spouse, children. parents, beneficiaries, representatives,
executors, administrators, guardians. heirs or assigns (including. but not limited to, any
survival or wrongful-death claim). This binding arbitration will be the sole and exclusive
remedy for resolving any such claim or dispute.

(1) This Policy applies to each associate and the Employer without regard to whether
they have completed and signed a Receipt, Safety Pledge and Arbitration
Acknowledgement form or similar written receipt. Adequate consideration for this
Policy is represented by, among other things, eligibility for (and not necessarily
any receipt of) benefits under this Plan and the fact that it is mutually binding on
both the Employer and associates. Any actual payment of benefits under this
Plan to or with respect to? an associate shall serve as further consideration for and
represent the further agreement of such associate to the provisions of this Policy.

I This Policy shall remain in effect with respect to the Employer and all associates,
without regard to any associate refusal of benefits under this Plan. return of
benefit payments under this Plan to an Employer, ineligibility for or cessation of
benefits under this Plan in accordance with its terms; or any voluntary or
involuntary termination of an associate's employment with an Employer.

(2) This Policy is not subject to ERISA requirements or otherwise dependent upon
the benefit provisions of this Plan in any way. and is'lncluded herein strictly as a
matter of convenience in documentation. This Plan and?Policy also in no way
changes the "at will? employment status of any associate not covered by a
collective bargaining agreement. .

(3) if either party initiates a claim covered by this Policy by any means other
than arbitration, the responding party shall be entitled to dismissal of such
action, and the recovery of all costs and attorney's fees and expenses
related to such action. 

Amendment or Termination of Arbitration Policy: The Company shall have the 

right and power at any time and from time to time to amend this Policy, in whole or in

ewes-cues

Rev 121221?

Shall alter the arbitration requirements of this Policy with respect to an Injury occurring
prior to the date of such amendment or termination. In addition. any such amendment
or termination of this arbitration Policy shall not be effective until at least 14 days after
written notice has been provided to associates. Any such amendment or termination
shall be pursuant to formal written action of a representative authorized to act on

behalf of-the Company.

PadrerSouoc
RSV 12127.? I

APPENDIX I
PARTICIPATING EMPLOYERS

Walmart Stores, Inc. (Plan Sponsor)
FEIN: 71-0415188

Walman Storee Texas. LLC
FEIN: 74-3019386

Walmart Associates. Inc.
FEIN: 71 -0794409

Sam's East, Inc.
FEIN: 71-?0794412

Walmart Realty Company
FEIN: 71-0505854

Clalms Management, Inc.
FEIN: ?fl?0738006

Walmarl.com, Inc.
FEIN: 7143834007

Walmart Transportation, LLC
FEIN: 71?0862103 

A list of any additional employers is available upon request from the Plan Admlnistrator.

201 2 para.an
Rev 11mm

APPENDIX I
COBRA CONTINUATION COVERAGE NOTICE

The federal law requirements of COBRA continuation coverage (as amended from time to
time) apply to grOUp health benefits provided under the Plan. This Notice is intended to inform
you in summary fashion of your rights and obligations.

Please note that group health bene?ts provided under the Plan are limited to treatment
of injuries which are sustained during the course and scope of your employment with
the Company. Therefore, continuation of group health coverage would not be practical
if you experienced a termination of employment with the Company for whatever reason.

in addition, if you have a covered injury during your employment with the Company,
the Plan would continue to provide you with health bene?ts for that injury following
your termination of employment (subject to the terms and limits in the Plan) unless
your employment is terminated based upon gross misconduct; Therefore, termination
of employment in this situation is not a qualifying event under COBRA because it does
not result in a loss of coverage under the Plan.

Finally, the Plan does not provide coverage for dependents. Therefore, any
continuation coverage provided under COBRA with respect to dependents would not

be'applicabie to this Plan.

 

Under a federal law known as covered associates and their covered spouses and covered dependent children
("qualified bene?ciaries?) have the right to elect temporary health care continuation coverage at group rates when such
coverage ends clue to certain "qualifying events.? With respect to the Plan, COBRA applies to the Plan?s medical and dental
bene?ts. This Notice informs associates, and'thcir covered spouses and covered dependents, in a summary fashion of
their options and obligations under COBRA.

QUALIFYING EVENTS

For covered Associates: lt?you are an Associate covered by the Plan's medical and/or dental benefits, you may be entitled to
continue the bene?ts you have if you lose coverage (or if your required premiums increase) because your employment
terminates or because there is a reduction in your hours worked. -

For covered Spouses: if you are the spouse of a covered Associate and are covered by the Plan?s medical and/or dental
benefits, you may be entitled to continue the bene?ts you have if you lose coverage (or if your required premiums increase)
for any of the following reasons: -
. - Your spousc?s employment terminates
A reduction in your spouse?s work hours
The death ofyour spouse
- You become divorced or legally separated from your spouse

For covered dependent children:
if you arc the dependent child of a covered Associate and are covered by the Plan?s medical andfor dental benefits, you may
be entitled to continue the bene?ts you have ifyou lose coverage for any ofthc following reasons:

A termination ofthe Associate's employment 

A reduction in Associate's work hours

The death ofthe Associate

You cease to be an eligible dependent child under the Plan

if a child is born to or placed for adoption with a covered Associate or tumor Associate during any'period the Associate or
former Associate has continued coverage under COBRA, the child may also elect COBRA coverage as a qualifier!

@Copy?gtn 2012 Parke-Sousa
Rev 12122111

bene?ciary. The child?s COBRA cchragc period will be determined according to the date ofthe qualifying event that gave
risclto the covered Associate?s or former covered Associate?s COBRA coverage. 

NOTIFICATION REQUIREMENTS TO PROTECT YOUR COBRA RIGHTS

The Plan will offer you COBRA coverage only alter the Risk Management Department has been notified that a qualifying

event has occurred.

Under COBRA, the covered Associate, spouse or dependent child must inform the Risk Management Department within 60
days ofa divorce or legal separation or a child?s losing dependent status under the Plan. Notice of divorce or legal separation
or loss of a child?s eligible dependent status must be given by writing to the Risk Management Department at the following

address:

Wahnart Texas injury Care Benefit Plan
c/o Risk Management

Attn: COBRA

922 W. Walnut

Rogers, Arkansas 72756-3540

A late noti?cation, or notice in any other manner, will cause your rights to continuation coverage under COBRA to be
forfeited. This means that if you fail to give proper notice, your coverage will terminate and you will not have the right to
continue coverage under COBRA. Upon receiving notice, the Risk Management Department will notify the COBRA
Administrator of the qualifying event and the COBRA Administrator will provide qualified bene?ciaries additional
information regarding COBRA coverage, including how to elect COBRA coverage.

Your employer has the responsibility of notifying the Risk Management Department of qualifying events that are an
Associate's termination of employment, reduction in hours or death which results in a loss of Plan coverage. The Risk
Management Department will then notify the COBRA Administrator of these qualifying events. The notice to the COBRA

ELECTION PERIOD . -
Once the COBRA Administrator is notified that a qualifying event has occurred, it will notify qualified bene?ciaries of their
right to elect COBRA coverage. Generally, the right to COBRA coverage only applies to the Plan's medical and/or dental
benefits covering the qualified beneficiary the day before the qualifying event. Each quali?ed bene?ciary has a separate
election right. A quali?ed beneficiary has 60 days to elect COBRA coverage from the later of the date coverage is lost under

the Plan due to the qualifying event or the date notification is provided by the COBRA Administrator to the quali?ed
henc?ciary._

This 60-day period is the maximum election period. if an election is not_properly made within this period, all rights to

elect COBRA coverage will and. An Associate who is a quali?ed bene?ciary or a qualified bene?ciary who_is_the Spouse of.

.the.Associata(or was the spouse on the day before the qualifying event) may elect COBRA coverage on behalf of all of the other qualified

beneficiaries with respect to the qualifying event. Also, a child?s parents or legal guardian may elect COBRA coverage on
behalf ofa minor child, and a legal representative or the estate ofa quali?ed bene?ciary may make an election on behalf of
an incapacitated or deceased qualified beneficiary. If COBRA coverage is elected and the individual pays the applicable
premium, the Plan is required to provide coverage that is identical to the coverage provided to similarly situated active
Associates, including those made available during a subsequent open enrollment period. If coverage is changed or-modit?ied
for similarly situated active Associates, COBRA coverage may be similarly changed and/or modified for quali?ed

beneficiaries.

LENGTH OF COBRA COVERAGE

18-month period. Each quali?ed beneficiary has the right to 18 months of COBRA coverage from the date of the qualifying event if .

coverage is lost due to the Associato?s termination of employment (other than for reasons of gross misconduct) or a reduction
in work hours. The 18-month period can be extended in 2 circumstances:

?Cepyr-ght 2012 PermerScwae
HEW 

 Disability: The period may be extended to up to 29 months ifthe Social Security Administration determines that
a quali?ed bene?ciary is disabled. The disability must have started some time before the quali?ed beneficiary?s 60th day
of COBRA coverage and last at least until the end of the 18-month period. All qualified bene?ciaries with respect to the
same qualifying event as the?disabled quali?ed bene?ciary are entitled to the extension of coverage. To be emitted to the
extension, the quali?ed beneficiary must notify the COBRA Administrator of tire disability determination. obtain tire (iisabtiity
determination ?oor the Social Security Administration and provide a copy oftite determination to the COBibi Administrator. Notice of
tire disability determination must be provided to tire COBRA Administrator within 60 days of the inter of the date of the origami
qrtaiitjting event or the date of tire disabtitty determination and before the original i8 months coverage ends. if notice oftizc
disability determination is provided within the 60-day period. a copy of tire disability determination may be provided to tire COBRA
Administrator any time before the end of tire origiaai its-month period. If there is a ?nal determination that the quali?ed
beneficiary is no longer disabled, the quali?ed beneficiary must notify the COBRA Administrator within 30 days of the
Social Security Administration determination. in that event, COBRA coverage extended beyond the 18-month period will
be terminated for all quali?ed bene?ciaries.

Seoundury events: An extension ofthe 18-month period can occur if, during the [8 months Coverage, a second
qualifying event occurs (divorce, legal separation, death, or loss of status as a dependent child) which would entitle the
Associate's spouse or children to 18 additional months of COBRA coverage. In these circumstances, the [3 months of
COBRA coverage may be extended to 36 months from the date of the original qualifying event. The extension is not
available to the Associate or former Associate. ifa second event occurs, it is the qualified bene?ciary's obligation to notify
the COBRA Administrator within 60 days ofthe event by telephone or in writing. at the address and telephone number
listed For the COBRA Administrator at the end of this notice. Notice in any other manner or outside this time period forfeits
your right to the additional extension. In no event will COBRA coverage last beyond 36 months from the date of the
original qualifying event. -

if an Associate becomes entitled to Medicare and later, but within 18 months of that date, loses coverage because of a
termination in employment or reduction in hours worked, the COBRA coverage period for the Associatc's spouse or
dependent children may be extended to 36 months from the date the Associate became entitled to Medicare while employed.

3o~month period. lfthe original qualifying event causing the loss of coverage was the Associate?s death, divorce, legal separation,
or loss of status as an eligible dependent child under the Plan, then each quali?ed bene?ciary losing coverage as a result of the
event has the right to elect 36 months of COBRA coverage from the date of the qualifying event.

ELIGIBILITY AND PREMIUMS 

You do not have to show that you are insurable to elect COBRA coverage. However, you must be covered under the Plan on the
day before the qualifying event in order to be eligible to elect COBRA coverage. A limited exception to this rule applies to
individuals who fail to return from an FMLA-approved leave of absence, children born to or placed for adoption with a covei??d
Associate during the COBRA coverage period, and spouses whose coverage is terminated by an Associate in anticipation of
divorce. The Risk Management Department or COBRA Administrator reserves the right to verify eligibility and terminate
COBRA coverage retroactively ifyou are determined to be ineligible, fail to inform it ofa change in your eligibility, or if there has
been a material misrepresentation of the facts. his can occur where you fail to inform the Risk Management Department of your
divorce, legal separation or ceasing to attend college, for example, so that the Plan provided coverage in circumstances in which
coverage should have been terminated.

A quali?ed beneficiary must pay all of the applicable premium plus a 2% administration charge for COBRA coverage. These
premiums may be adjusted in the future if the applicable premium amount changes. if the COBRA coverage period is extended
beyond 13 months due to a Social Security Administration determination of disability, the Plan may charge up to 150% of the
applicable premium during the extended period for the disabled qualified beneficiary and any nondisablcd qualified bene?ciaries
in the disabled quali?ed beneficiary's coverage group. There is a grace period of30 days for the regularly scheduled 
premrums. -

This is the maximum grace period under the Plan; the Plan does not provide for an extension beyond what ls required by
law. 

TERMINATION 0F COBRA COVERAGE
COBRA coverage will be terminated prior to tire marinara: COBRA coverage period (tire applicabie 18?, 29- or 3641mm}: period)
for any of the following reasons: I - -

Wei-Mart and its af?liated entities cease to provide group health coverage to any of its Associates.

?Com??1t2012 Formulae-urea
Rev i202? 

 Any required premium is not paid in a timely Fashion (taking into account the applicable grace period).
A qualified bene?ciary becomes covered, after the date on which COBRA coverage was elected, under a group health plan,

- A quali?ed bene?ciary becomes entitled to Medicare Part A or Part bene?ts on a date after the date of the COBRA

- The qualified beneficiary submits a fraudulent claim or other incorrect information.
A quali?ed bene?ciary?rtoli?es the COBRA Administrator that he or she wishes to cancel COBRA coverage.

Once your COBRA coverage terminates, it cannot be reinstated for any reason.

ADDRESS CHANGES .- 

in order to ensure that you receive information properly and efficiently, please contact the Risk Management Department at the
address listed below to notify it of any address changes as soon as possible. Failure on your part to do so may result in delayed
notification and loss of COBRA coverage options. You should also keep a copy, for your records, of any notices you send to the
Risk Management Department or COBRA Administrator.

PLAN ADMINISTRATWE I
if you do not understand any part of this notice, or if you have questions regarding COBRA coverage or the Plan. please contact
the Risk Management Department at the address listed below. in addition, all notices required for the Plan's medical and dental
benefits must be given in writing to the Risk Management Department at the following address:

Wahnart Texas injury Care Bene?t Plan
cfo Risk Management Department

Attn: COBRA -

922 W: Walnut Street

Rogers, Arkansas 727564540

The COBRA Administrator is Conexls. The address and telephone number for the COBRA Administrator are:

Conexis

Box 226101
Dallas, TX 75222
(800) 5704863

Department at the address listed above. For more information about your rights under the Employee Retirement income Security
Act including COBRA, and other laws affecting this plan, contact the nearest Regional or District Office of'the US.
Department of Labor?s Employee Bene?ts Security Administration in your area or visit the EBSA website at

(Addresses and telephone numbers of Regional and District EBSA Of?ces are available through EBSA's
website.) 

(Remnant 2012 PartnerScuca
Rev 

 

The following is to be used by guardians of minor associates and associates unable
to complete and acknowledge this program through the computer based learnan module.

APPENDIX 
RECEIPT, SAFETY PLEDGE AND ARBITRATION ACKNOWLEDGEMENT

RECEIPT OF MATERIALS. By my signature below. I acknowledge that I have received and read (or had the
opportunity to read) the Summary Plan Description (the for the Walmart Stores. Inc. Texas Injury Benefit

Plan. effective March 1. 2012.

INJURY NOTICE AND MEDICAL PROVIDERS. I understand and agree that ill am injured on the job. I most
notify my supervisor within 24 hours of the time of the Injury and receive any medical care from a Plan?approved
physician within 14 days of my Injury In order to receive bene?ts under the Plan.

SAFETY PLEDGE. I agree to familiarize myself with the safety program for the Employer and to perform my
job according to the general and departmental safety rules of the Employer. i will also use any personal
protective equipment that is provided to me. I also agree to immediately report to my supervisor any accident 
that involves another associate. a customer. a vendor. or me. I will also immediately report any unsafe act.
condition or equipment. i will also cooperate with any accident Investigations. and actively participate in any

Employer safety training programs.

 

ARBITRATION. I also acknowledge that this SPD includes a mandatory company policy requiring that claims
or disputes relating to the cause of an on-Ihe-job Injury (that cannot otherwise be resolved between the
Employer and me) must be submitted to an arbitrator. rather than a judge and jury in court. i understand that
by receiving this SPD and becoming employed (or continuing my employment) with the Employer at any time on
or after March 1. 2012. I am accepting and agreeing to comply with these arbitration requirements. i understand
that the Employer is also accepting and agreeing to comply with these arbitration requirements. All covered
claims brought by my spouse, children. parents. bene?ciaries. Representatives. executors. administrators.
guardians. heirs or assigns are also subject to the Employer's arbitration policy. and any decision of an arbitrator
will be final and binding on such persons and the Employer. I understand that the arbitrator. and not a judge
or jury. has the exclusive authority to resolve any dispute about the enforceability 29! this arbitration

process.

 

 

 

 

 

 

 



Associate's Signature Date

Print Associate's Name Associate?s Identification Number
Parent or Legal Guardian Signature Date

(if Associate under age 18)

 

 

 

Print Parent or Legal Guardian Name Associate?s Work Location or Department

 

PWuScmoe'
Rev.