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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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| Coordination of Benefits ("COB") |
There are special rules for paying claims if you are covered under
more than one plan. For example, these
rules will apply if your spouse has group medical coverage from his or her employer.) These
rules determine the
order in which bills are submitted and paid by the various plans.
They also limit the amount of reimbursement
to 100 percent of the covered expenses.
Please read this section carefully so that you may identify the plan to
which you should submit your claims first. Primary and Secondary Plans A primary plan is a plan whose benefits are determined without taking the existence of any other plan into consideration. A secondary plan is a plan which is not a primary plan. A plan that does not have order of benefit determination rules is always the primary plan. You must first submit your claims and receive payment from the primary plan before any benefits will be paid under the secondary plan. Once you submit your expenses to the primary plan, you may then submit any outstanding balances, along with the Explanation of Benefits or the Statement of Denial from the other plan, to the secondary plan for payment. When you incur a claim, the primary plan pays benefits up to the allowed amount of charges for the covered person without regard to any other secondary plans. If the charges exceed the maximum allowed by the primary plan, you should submit the additional charges to the secondary plan. The secondary plan then adjusts its benefits so that the total benefit paid is not more than the allowable expenses, or more than 100 percent of the actual charges. No plan pays more than the maximum payable under that plan without the coordination of benefits. There are different rules for determining primary and secondary plans for each different benefit. Please read the following sections carefully to determine how to file claims for each benefit. There are special coordination of benefits rules if you are covered under more than one Fund policy. Please contact the Fund office for details.) Accidental Death & Dismemberment Benefits are paid without regard to other coverage, except for coverage provided under this Fund. Dental Because you, the participant, are the patient, this is the primary plan and any other plan is the secondary plan. The Fund uses the American Dental Association Guidelines on Coordinating Dental Benefits to determine how payments are to be made. Disability This Plan is the primary plan, except in cases where company-paid sick days, Workers' Compensation, motor vehicle insurance, or any other insurance (other than individually purchased disability policies) is available. In those cases, this plan will supplement the other plan and is therefore the secondary plan. However, our supplemental payment will not exceed our primary payment. For example, if you cannot work because you were in a motor vehicle accident and your motor vehicle insurance pays 80% of your weekly salary, this plan would not make any payment because you are already receiving more than 66-2/3% of your weekly salary as allowed under this Plan. Life Insurance Benefits are paid without regard to other coverage. Medical Coverage (Personal Choice) Because you, the participant, are the patient, this plan is the primary plan and any other plan is the secondary plan. Mental, Nervous, Drug & Alcohol Because you, the participant, are the patient, this plan is the primary plan and other plan is the secondary plan. Prescription Drug Because you, the participant, are the patient, this is the primary plan and any other plan is the secondary plan. Prescription Incentive Program This plan is always supplemental to all other sources of coverage. If you are eligible for prescription coverage under any other plan, that other plan is the primary plan and this plan is the secondary plan. Vision Benefit payments are not coordinated with any other plan. Therefore, this plan is the primary plan. Coordinating With Third Parties (Subrogation or Reimbursement) The Fund has the right of subrogation or full reimbursement for all costs and benefits paid or incurred, or which will be incurred in the future, when any claim for benefits is filed on your behalf or on behalf of your dependent or beneficiary (hereinafter collectively "you") where the event(s) that caused the claim are or may be the fault of, or the claim may be payable by, any other party, including but not limited to Workers' Compensation, an insurance policy, another benefit plan, or any party that may be responsible for the event(s) related to the claim. In these cases, you must notify the Fund of the existence of any such party and/or the occurrence of any such event(s). You are also obligated to notify the Fund if you receive payment from any party. If you are involved in a lawsuit, insurance claim, other claim or settlement as a result of such events, you must notify the Fund of the name and address of any counsel you retain, insurance adjuster handling the claim, the progress of the case or claim, any settlement offers, trial dates, payments, etc. The Fund is entitled to 100% reimbursement of all costs and benefits, except as may be specifically agreed to by the Fund in writing, when you receive any payment from another party, if the Fund has paid or incurred, or will incur in the future, any such costs and/or benefits. The Fund's rights of subrogation and reimbursement shall apply and be honored regardless of whether the participant or beneficiary has been, or will be, made whole. So if you submit a claim and receive payment from another party for the same claim or as a result of the injury or illness, you must reimburse the Fund. You must provide the Fund with all documents and information, including but not limited to the name and address of any counsel you retain, insurance adjuster, or other persons, that may be related to the claim and the Fund's reimbursement right, as requested by the Fund. You may not attempt to prejudice the Fund's subrogation or reimbursement rights. If you do not honor the Fund's subrogation or reimbursement rights, the Fund may bring an action against you to recover the costs and benefits paid, and/or you may be denied future benefits to the extent necessary to recover the costs and benefits paid by the Fund. If the Fund denies your future benefits in order to recover the costs and benefits paid by the Fund, your benefits will remain denied until such time as you have provided the Fund with information and documents on denied claims sufficient to fully satisfy your reimbursement obligations to the Fund. If legal action against you is necessary to protect the Fund's rights, you will also be liable for all costs of collection, including reasonable attorneys' fees. All disputes concerning reimbursement rights and obligations will be resolved in accordance with the claims review and appeal procedures. In addition, the Fund reserves the right to intervene in any action or to bring an action to protect its reimbursement rights. |