Here it is, from 2001. Note that you can modify it within limits to be most advantageous to your situation:
Medical Reimbursement Plan, Responsive Software
Section 1 Purpose of Plan
1.01 The purpose of this Medical Reimbursement Plan (hereinafter the "Plan") is to provide for the payment for, or provision of, uninsured medical and dental expenses for participating Employees, spouses of participating Employees, and Dependents of participating Employees.
1.02 It is intended that this Plan qualify as an accident and health insurance plan as defined by Code Sec. 105 of the Internal Revenue Code of 1986, as amended ("Code"), and that benefits paid to Employees hereunder be excludable from their gross incomes by reason of Code Sec. 105(b).
Section 2 Definitions
Unless a different meaning is clearly indicated by the context, whenever used in this document, these words shall have the following meaning:
2.01 Benefits. Any amounts paid to a Participant in the Plan as reimbursement for Eligible Medical and Dental Expenses (as defined in Section 2.06) incurred by the Participant during the Plan Year or by the Participant's spouse or the Participant's Dependents (as defined in Code Sec. 152).
2.02 Code. The Internal Revenue Code of 1986, as amended.
2.03 Coverage Period. The Plan Year during which Benefits under this Plan are available.
2.04 Dependent. Any individual who is a Dependent (as defined in Code Sec. 152) of a Participant.
2.05 Effective Date. The First day of January, 2001.
2.06 Eligible Medical and Dental Expenses. Expenses incurred by the Employee, the Employee's Spouse, or the Employee's Dependents, after the Effective Date of the Employee's participation in this Plan and during the Plan Year otherwise allowable as deductions under Code Sec. 213 (without regard to the limitations in Code Sec. 213(a)). For purposes of this Plan, an expense is incurred when the Employee, Spouse or Dependent receives the medical care or services giving rise to the claimed expense.
2.07 Employee. Any person who is an Employee of the Employer for federal withholding tax purposes.
2.08 Employer. The company creating this Plan, or an affiliate or successor thereof that adopts this Plan.
2.09 Participant. Any Employee who has met the eligibility requirements set forth in Section 3.
2.10 Plan Administrator. The person appointed by Employer who has authority and responsibility to manage the Plan.
2.11 Plan Year. The Plan's annual accounting period, which begins on January 1 and ends on December 31 for the first Plan Year and thereafter as long as the Plan remains in effect.
2.12 Spouse. An individual who is legally married to a Participant other than an individual separated from a Participant under a legal separation agreement or decree.
Section 3 Conditions for Eligibility
3.01 Any full-time Employee is eligible to participate in the Plan as of the Effective Date provided that the Employee is not a member of a collective bargaining unit of Employees covered by a collective bargaining agreement with Employer as part of which accident and health benefits have been the subject of good-faith negotiations.
3.02 For this purpose, a full-time Employee is an individual who normally works at least one hour per week.
Section 4 Amount of Benefits
4.01 The maximum amount per Plan Year that a Participant may receive as reimbursement under this Plan is $10,000.
4.02 For purposes of this Section 4, reimbursements of expenses for a Participant's Spouse or Dependent are treated as having been received by the Participant.
4.03 Employer shall pay all costs of providing the Benefits due under this Plan. Employer reserves the right to enter into any arrangement, contractual or otherwise, that Employer deems helpful to the proper and efficient operation of the Plan including, but not by way of limitation, the right to enter contracts with insurance companies and third-party administrators.
Section 5 Payment of Benefits; Claims; and Claims Review Procedure
5.01 Subject to the provisions of this Section, each Participant shall be entitled to the Benefits set out in this Plan for Eligible Medical and Dental Expenses incurred after the Effective Date of his or her participation in the Plan.
5.02 All claims for Benefits under the Plan must be made on forms maintained by Employer. Claims may be submitted at any time after the expense is incurred but in no event later than 120 days after the close of the Plan Year in which the medical treatment or service giving rise to the claim was received.
5.03 Once payment of a claim has been approved by the Plan Administrator, Employer shall pay the Participant's Benefit due under the Plan as soon as is reasonably feasible, but in no event later than 120 days after the date payment of the claim was approved.
5.04 If any claim for Benefits under this Plan is denied, in whole or in part, then Employer shall promptly provide the Participant written notice stating the reason(s) for the denial, citing the Plan provisions upon which the denial is based, describing what information Participant needs to supply in order to perfect the claim (if applicable), and notifying Participant of the review procedure herein.
5.05 A Participant whose claim for reimbursement has been denied may request a review of the denial. The request for review must be in writing and must be received by Employer no later than 120 days from date the claim was denied.
Employer shall permit any Participant who timely files a request for review of a claim denial hereunder to inspect all pertinent documents relating to the Plan in general and to the denial in particular (other than those documents the disclosure of which is prohibited by law). After conducting the review (which may, at the reviewer's discretion, include interviews with Participant and such other individuals as Employer or Participant may suggest), the reviewer shall issue a written decision that includes the reasons therefore and the Plan provisions upon which the decision is based.
5.06 Coverage under this Plan shall cease as of the first day of the month after the month in which a Participant is no longer employed by Employer. Such Participant shall, however, have the right to submit a reimbursement claim for any Eligible Medical and Dental Expense arising during the Coverage Period at any time before the expiration of 120 days after the close of the Plan Year in which the expense arose, and to receive the Benefits provided under the Plan.
Section 6 Plan Administration
6.01 Employer shall have the exclusive authority and responsibility to direct administration of the Plan. Subject to Section 6.02, the Chief Accounting Officer shall be the Plan Administrator
6.02 Notwithstanding Section 6.01, Employer reserves the right, at its option, to delegate all or any part of the authority and responsibility for plan administration to any party or parties, regardless of whether said party or parties are employed by Employer.
6.03 The Plan Administrator shall have the authority to:
- make such regulations and to prescribe the use of such forms as may be necessary for the efficient operation of the Plan;
- require any person to provide such information as may, in the Plan Administrator's discretion, be necessary for the Plan's proper administration and to condition the payment of Benefits hereunder upon receipt of said information;
- to decide questions regarding eligibility and the payment or nonpayment of Benefits; and
- exercise such other powers as may be reasonably necessary to administer the Plan properly and efficientl y.
6.04 Except to the extent permitted by law, the Plan Administrator shall not be personally liable for any act or failure to act in the performance of his or her duties as such, except for his or her own willful misconduct or willful breach of the terms of this Plan.
6.05 Unless the Board of Directors otherwise directs, the Plan Administrator shall serve without compensation. Employer shall pay for all reasonable expenses incurred by the Plan Administrator in the performance of his or her duties.
Section 7 Amendment or Termination of Plan
7.01 Although Employer intends this Plan to continue indefinitely, Employer reserves the right to amend or terminate the Plan at any time. This right includes the right to make such retroactive amendments as may be necessary to comply with Code Sec. 105 or any successor or similar provision or to comply with the rules and regulations of any other governing authority.
Section 8 No Employment Rights
8.01 Neither the existence of this Plan, nor any action with respect to it, shall confer upon any person the right to continued employment with Employer.
8.02 The existence of this Plan, and all actions taken with respect to it, confer no additional rights to any type of financial benefit from Employer other than that described in Section 4.01.
Section 9 Governing Law
9.01 Unless otherwise governed or pre-empted by the provisions of the Employee Retirement Income Security Act of 1974 (ERISA), this Plan shall be governed by the laws ofthe situs of Employer's principal business office.
Section 10 Headings and Terms
10.01 All headings in this Plan are for reference only and shall not be construed as defining or limited the matter contained thereunder.
10.02 All terms contained in this Plan shall be deemed to include the masculine and feminine genders and all references to the singular shall be interpreted to include the plural and vice versa, as proper construction may require.
Section 11 Tax Effects
11.01 Neither the Employer nor the Plan Administrator makes any representation or warranty as to whether payments received under this Plan shall be includible in income for federal or state income tax purposes.
11.02 As between Employer and Employee, an Employee receiving reimbursement hereunder shall bear full responsibility for payment of federal and state income tax (if any) that Employee's receipt of such reimbursement may generate.
Section 12 Severability and Integration
12.01 If the event that any part of this Plan shall be declared invalid by a court of competent jurisdiction, the remaining provisions hereof shall be give full force and effect to the fullest extent possible.
12.02 This document contains the entire Plan. In the event that the provisions hereof shall be in conflict with any other document of Employer describing the parties rights and duties arising hereunder, this Plan shall control.
On behalf of Employer, the following Corporate Officers have set forth their signatures below.
President _____________________________________
Date _________________________________________
Chief Accounting Officer __________________________________
Date ______________________________________
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