CC RES 03-011 A RESOLUTION APPROVING AND ADOPTING CHANGE TO THE CITY OF ST. ANTHONY FLEXIBLE BENEFIT PLAN

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Any revocation, request for reinstatement and post-leave coverage choice must be made • using Employer forms. In the case of a revocation, the form must be submitted no later than 30 days after the commencement of the family and medical leave. In the case of a request for reinstatement, the form must be submitted no later than 30 days after return from the family or medical leave. If you take a military leave of absence you may have a right to have your coverage under the medical expense reimbursement portion of this Plan continued. Upon your return from a military leave of absence you may have a right to reinstate your coverage without any waiting periods. Please contact the Assistant City Manager at 612-789-8881 as soon as you know you will be taking a family or medical leave or a military leave of absence. ■ Updated Claims Appeal Process: CLAIMS FOR BENEFITS Claims under the health insurance, dental insurance or life insurance are described in the Certificates of Coverage for those benefits. Unless otherwise proved in this document,the Certificates of Coverage or other documents governing a particular benefit plan,the following procedure will apply to claims for benefits under the Plan. You or your beneficiary may file a written claim with the Employer requesting a benefit • under the Plan or objecting to the determination of your benefit. You must file a claim on the form or forms available for that purpose in order for a claim to be valid. Forms are available from the sources referenced in this booklet,or you may obtain the form you need from the Plan Administrator. The Plan Administrator will notify you in writing within 30 days after your written application for benefits of your eligibility or non-eligibility for benefits under the Plan. If the Plan Administrator needs additional time to evaluate your claim, it will notify you within the first 30 days how much additional time is needed,but not more than another 15 days. If the Plan Administrator requests additional information, you will have 45 days to provide that information. The review period will be suspended until the specified information is received. If the Plan Administrator determines that you are not eligible for benefits or full benefits,the notice will tell you: (1) the specific reasons for the denial, (2) the specific provision of the Plan on which denial is based, (3) a description of any additional information or material necessary for you to perfect your claim(and an explanation of why such information or material is necessary),and (4) an explanation of the Plan's claim review procedure, including the time limits applicable to the review procedure.