Basic Medical Plan information
ExxonMobil International Medical and Dental Plan (the Plan)
Plan sponsor and participating affiliates
The ExxonMobil International Medical and Dental Plan is sponsored by:
Exxon Mobil Corporation
5959 Las Colinas Blvd.
Irving, Texas 75039-2298
The ExxonMobil International Medical and Dental Plan is identified with government agencies under two numbers:
The Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 636.
Plan administrator and discretionary authority
The Plan Administrator of the ExxonMobil International Medical and Dental Plan is the Administrator-Benefits who is the Manager-Global Benefits Design, Exxon Mobil Corporation. The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits.
The claims administrator, Cigna, provides information about claims payments, providers participating in the Plan, benefit pre-determinations, and appeals of denied claims.
Claims fiduciary and appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Cigna for all medical and dental benefits appeals.
Cigna has full and final discretionary authority to construe and interpret the terms of the Plan in its application to any participant or beneficiary and to decide any and all claim appeals.
For appeals of eligibility or enrollment issues:
P.O. Box 18025
Norfolk, VA 23501-1867
For service of legal process:
Corporation Service Company
211 East 7th Street, Suite 620
Austin, TX 78701-3218
Cigna - for appeals on benefits issues:
Cigna may be contacted for appeals of benefits issues at an address provided by calling Cigna Customer Service or as reflected on your Explanation of Benefits.
NOTE: No appeals of eligibility will be available regarding decisions that a dependent child no longer meets the clinical definition of totally and continuously disabled. All decisions by Cigna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.
Type of plan
The ExxonMobil International Medical and Dental Plan is a welfare plan under ERISA.
The Plan's fiscal year ends on December 31.
Benefits under the Plan are funded through premiums paid by participants and the Company.
No implied promises
Nothing in this summary plan description says or implies that participation in the ExxonMobil International Medical and Dental Plan is a guarantee of continued employment with the company.
If the ExxonMobil International Medical and Dental Plan is amended or terminated
The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the ExxonMobil International Medical and Dental Plan and any of their provisions. If any reductions in benefits are made in the future, you will be notified within sixty (60) days of the signing of the amendment. In the event the Plan is terminated, you may have the right to elect continuation coverage, as described in the COBRA section of this summary plan description, in any other health plan option maintained by Exxon Mobil Corporation or its controlled group.
Your rights under ERISA
As a participant in the International Medical and Dental Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants 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 Medical Plan, including contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical 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 Medical 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 Medical 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 plan fiduciaries
In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other 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 the Plan documents or the latest Summary Annual Report from the 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 Federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. All lawsuits must be brought within three years of the date of the original claim.
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 the Plan, you should contact the Cigna Global Service Center or the ExxonMobil Benefits Service Center. If you have any questions 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.
Notice of federal requirements
Women's Health and Cancer Rights Act
If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage copayment and deductibles which apply to other plan benefits:
- Reconstruction of the breast on which the mastectomy was performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance,
- Prostheses, and
- Services for physical complications in all stages of mastectomy, including lymphedema.
The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.
If you have any questions about your benefits, please contact Cigna Customer Service.
Coverage for maternity hospital stay
Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.