Index

About Dental

Eligibility and Enrollment

Dental PPO

Covered Expenses

Exclusions

Payments

Claims

Continuation Coverage

Key Terms

Benefit Summary

Administrative and ERISA Information

Q. What other information do I need to know about the Plan?

A. This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.

The formal name of the Plan is the ExxonMobil Dental Plan.

Plan Sponsor and Participating Affiliates

The ExxonMobil Dental Plan is sponsored by:

Exxon Mobil Corporation
5959 Las Colinas Blvd
Irving, Texas 75039-2298

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Dental Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request. 

Certain employees covered by collective bargaining agreements as well as employees of Station Operators Inc., dba ExxonMobil CORS do not participate in the plan.

Basic Plan Information

Plan Administrator
The Plan Administrator for the ExxonMobil Dental Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits as follows:

Claims Administrator
The claims administrator, Aetna, provides information about claims payment, providers participating in the Dental PPO, and benefit pre-determinations.

Claims Fiduciary and Appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for dental mandatory appeals and the Administrator-Benefits for voluntary appeals. You may contact the claims fiduciary as follows:

Type of Plan
The ExxonMobil Dental Plan is a welfare plan under ERISA providing dental benefits.

Plan Numbers
The ExxonMobil Dental Plan is identified with government agencies under two numbers: the Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 555.

Plan Year
The plan year is the calendar year.

Plan Funding
Benefits are funded through employee and employer contributions.

Benefit Claims Procedures

Filing a Claim
You or your provider must file a claim in writing to Aetna Member Services. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you.

Claims for benefits where the Plan provisions do not require approval before dental care is obtained are the most common claims filed under the ExxonMobil Dental Plan. These claims are made after care is received. Aetna will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If Aetna needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period. An additional 15 days is all that is allowed. If an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.

If you have a question or a problem with a plan benefit, contact Aetna Member Services.

Denied Claims
If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe:

• The specific reason(s) for the denial.
• The process for requesting an appeal.

Filing a Mandatory Appeal
If your claim is denied, you, your beneficiary, or your designated representative may file an appeal to Aetna. The written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc). The written appeal may also include a request for reasonable access to, and copies of, all documents, records, and other information relevant to your claim. You must submit your written appeal within 180 days from the date of the denial notice.

The review will take into account all comments, documents, records, and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Aetna will respond to the appeal within 60 days.

If Aetna needs additional time to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time must be allowed.

If the appeal is denied, you will receive written notice of the decision. The notice will set forth:

• The specific reason(s) for the denial and the plan provisions upon which the denial is based.
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim.
• A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure.
• A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).

Statute of Limitations
After you have received the response to the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided.

Filing a Voluntary Appeal
If your appeal is denied, you may submit a voluntary appeal to the Administrator-Benefits. New information pertinent to the claim is required for the voluntary appeal to be considered. You must submit your voluntary appeal within 30 days of the denial of your mandatory appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending.

You will be notified within 15 days after your request was received whether or not the information was considered new information. If it is determined that there is new relevant information, a decision will be made within 60 days after the Administrator-Benefits receives your request for a voluntary appeal. If it is determined that there is no new information pertinent to your claim, your voluntary appeal will not be considered.

No Implied Promises

Nothing in this SPD says or implies that participation in the ExxonMobil Dental Plan is a guarantee of continued employment.

Future of the Plan

ExxonMobil expects to continue the Plan. However, ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the Plan or any of its provisions at any time and for any reason. A change may also be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.

Expenses incurred before the effective date of a plan change or termination won't be affected. Expenses incurred after a plan is terminated won't be covered. If the Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference. If all claims and expenses are paid and there's still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of employees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the Plans.

Your Rights Under ERISA

As a participant in the ExxonMobil Dental Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a plan participant, you shall be entitled to:

Receive Information About Your Plan and Benefits

• Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Dental Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Dental Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
• Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Dental Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies.
• Receive a summary of the Dental Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Dental Plan Fiduciaries
In addition to creating rights for Dental Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Dental Plan, called "fiduciaries" of the Dental Plan, have a duty to do so prudently and in the interest of you and other Dental Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

Enforce Your Rights

• If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision, without charge, and to appeal any denial, all within certain time schedules.
• Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Dental Plan documents or the latest summary annual report from the Dental Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
• If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Dental Plan's decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in Federal court. If it should happen that Dental Plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. Any such lawsuit must be brought within 1 year of when you first had the right to sue. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions
If you have any questions about your Dental Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call Benefits Administration. 

If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.