Subrogation and Reimbursement
Subrogation is the substitution of one person or entity in place of another with reference to a lawful claim, demand or right. The Plan will be subrogated to and shall succeed to all rights of recovery that you may have against a Third Party under any legal theory of any type for 100% of the benefits that the Plan provides to you or will provide to you. In addition to any subrogation rights and in consideration of the coverage provided by the Plan, the Plan also has an independent right to be reimbursed by you for 100% of the benefits the Plan provides to you or will provide to you.
The Plan has the right to recover 100% of the payments made or to be made on your behalf when you, your heirs, assigns, representatives or estate recover money or have the right to recover money from any of the following sources. These sources are called "Third Parties":
  • Any person or entity alleged to have caused you to suffer sickness, injuries or damages, or who caused or is responsible for the sickness, injuries or damages.
  • Any insurer or other indemnifier of any person or entity alleged to have caused or who caused the sickness, injuries or damages.
  • Your employer.
  • Any person or entity who is or may be obligated to provide health care benefits or payments to you, including health care benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance, medical payment coverage (auto, homeowners or otherwise), Workers' Compensation coverage, medical malpractice coverage, or coverage by other insurance carriers or third-party administrators.
  • Any person or entity that is liable for payment to you on any equitable or legal theory.
The Plan may obtain recovery through subrogation, reimbursement, refunds of overpayments or through any other available legal theory. The right of recovery applies regardless of whether you have been fully compensated for your injuries or condition.
You agree as follows:
  • That you will cooperate with the Plan and its Claims Administrators in a timely manner in protecting the Plan's legal and equitable rights to subrogation and reimbursement, including, but not limited to:
    • notifying the Plan's Claims Administrators in writing as soon as you learn that a Third Party may be liable for causing your need for health care benefits,
    • providing any relevant information requested by the Plan or its Claims Administrators,
    • signing and/or delivering such documents as the Plan or its Claims Administrators reasonably request to secure the subrogation and reimbursement claims,
    • responding to requests for information about any sickness, accident or injuries,
    • appearing at legal proceedings such as depositions and in court, and
    • obtaining the consent of the Plan or its Claims Administrators before releasing any party from liability of payment of health care expenses.
  • That failure to cooperate in this matter will be deemed a breach of contract, and as such the Plan has the right to terminate health care benefits and/or institute of legal action against you. If the Plan incurs attorney's fees and costs in order to enforce its rights of subrogation and reimbursement, it has the right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been paid to the Plan,
  • That the Plan has the sole authority and discretion to resolve all disputes regarding the interpretation of the language of this Summary Plan Description.
  • That no court costs or attorneys' fees may be deducted from our recovery without express written consent from the Plan or Claims Administrators; any so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's Fund Doctrine" will not defeat this right, and the Plan is not required to participate in or pay court costs or attorneys' fees to the attorney hired by you to pursue your damage/personal injury claim.
  • That regardless of whether you have been fully compensated or made whole, the Plan may collect from you the proceeds of any full or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either before or after any determination of liability) or judgment no matter how those proceeds are captioned or characterized. The proceeds available for collection will include, but are not limited to, any and all amounts earmarked as economic, non-economic and punitive damages, whether in the form of settlements or judgments. No "collateral source" rule, any "Made-Whole Doctrine" or "Make-Whole Doctrine" claim of unjust enrichment, nor any other equitable limitation shall limit the Plan's subrogation and reimbursement rights.
  • That the health care benefits paid by the Plan or its Claim Administrators may also be considered to be health care benefits advanced.
  • That you agree that if you receive any payment from any Third Party or an insurer as a result of an injury or illness, whether by settlement (either before or after any determination of liability), or judgment, you will serve as a constructive trustee over the funds, and failure to hold such funds in trust will be deemed as a breach of your duties hereunder.
  • That you or an authorized agent, such as your attorney, must hold any funds received from any Third Party that are due and owed to the Plan, as stated herein, separately and alone (e.g.in a separate bank account or in your attorney's trust account), and failure to hold funds as such will be deemed as a breach of contract, and may result in the termination of health care benefits or the institution of legal action against you.
  • That you will transfer title to the constructive trust to the Plan for all health care benefits that have been paid or will be paid as a result of your sickness, injury or illness.
  • That the Plan will be entitled to recover reasonable attorney fees from you that are incurred in collecting from you any funds held by you that you recovered from any Third Party.
  • That the Plan may offset from any future health care benefits otherwise allowed the value of health care benefits paid or advanced under this section to the extent not covered by the Plan.
  • That you will neither accept any settlement that does not fully compensate or reimburse the Plan without the written approval of the Plan or its Claims Administrators, nor will you do anything to prejudice the Plan's rights under the provision.
  • That you will assign to the Plans all rights of recovery against Third Parties, to the extent of the reasonable value of services and health care benefits the Plan provided, plus reasonable costs of collection.
  • That the Plan's rights will be considered as the first priority claim against Third Parties, including tortfeasors for whom you are seeking recovery, to be paid before any other of your claims are paid. Further, the first priority right to payment is superior to any and all claims, debts or liens asserted by any medical providers, including but not limited to hospitals or emergency treatment centers, that assert a right to payment from funds payable from or recovered from an allegedly responsible or responsible third party and/or insurance carrier,
  • The Plan's subrogation and reimbursement rights apply to full and partial settlements or judgments or other recoveries paid or payable to you or your representative on your behalf no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic and punitive damages, whether in the form of settlements or judgments. The Plan is not required to help you to pursue your claim for damages or personal injuries and no court costs or attorneys' fees may be deducted from our recovery without express written consent from the Plan or Claims Administrators; any so-called "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's Fund Doctrine" will not defeat this right,
  • That the Plan's rights will not be reduced due to your own negligence.
  • That the Plan may, at its option, take necessary and appropriate action to preserve its rights under these subrogation and reimbursement provisions, including but not limited to providing or exchanging medical payment information with an insurer, the insurer's legal representative or other third party, and/or filing suit in your name, which does not obligate the Plans in any way to pay you part of any recovery the Plans might obtain.
  • That the Plan shall not be obligated in any way to pursue this right independently or on your behalf.
  • That if the injury or condition giving rise to subrogation or reimbursement involves a minor child, this section also applies to the parents or guardian of the minor child.
  • That in the case of a wrongful death, this section also applies to your estate, personal representative of your estate, and your heirs, legatees or beneficiaries.
  • That if the injury or condition giving rise to subrogation or reimbursement involves the wrongful death of a Plan Participant, also called "member," this section will apply to any personal representative of the Plan Participant.
  • If a third part causes or is alleged to have caused you to suffer a sickness, injury or damages while you are covered under the Plan, the provisions of this section will continue to apply, even after you are no longer covered,
  • The Plan and the Plan Administrator (or the Claims Administrators acting on their behalf) have the authority and discretion to resolve all disputes regarding the interpretation of the language contained in these provisions, and shall have the such powers and duties as are necessary to discharge their duties and functions, including the discretionary authority to (1) construe and enforce the terms of these subrogation and reimbursement provisions and rights, and (2) make determinations with respect to the subrogation amounts and reimbursements owed to the Plan.