2020/12/16 Council Agenda Packet

Section 7 General Provisions 7.1 Policyholder Duties. Prior to the first day of each month, the Policyholder shall furnish the Company with the information reasonably required to administer benefits using the Company's approved forms or electronic formats. The Company will rely on such information to provide benefits to Enrollees. The Policyholder shall collect enrollment forms and verify Enrollees satisfy all applicable eligibility requirements Upon reasonable advance request, the Company retains the right to audit payroll and other records to verify eligibility, participation, group size, contribution, and other terms of agreement 7.2 Subrogation. Covered Services for the diagnosis or treatment of an injury or disease, which is possibly caused by a third party, are provided solely to assist the Enrollee. By providing Covered Services, the Company and the Participating Provider are not acting as volunteers and are not waiving any right to reimbursement or subrogation. 7.2.1 If the Company and Participating Provider provide Covered Services for the treatment of an injury or disease which is possibly caused by a third party, it will: a. Be subrogated to the rights of the Enrollee to recover the Reasonable Cash Value of the Covered Services provided; and b. Have security interests in any damage recoveries to the extent of all payments made or the Reasonable Cash Value of the Covered Services provided subject to the limitations specified below. 7.2.2 As a condition of receiving Covered Services, the Enrollee shall: a. Provide the Company and Participating Provider with the name and address of the parties liable, all facts known concerning the injury, and other information as reasonably requested; b. Hold in trust any damage recoveries until the final determination or settlement is made and to execute a trust agreement guaranteeing the Company's and Participating Provider's subrogation rights; and c. Take all necessary action to seek and obtain recovery to reimburse the Company and Participating Provider for the Reasonable Cash Value of the Covered Services. 7.2.3 The Enrollee is entitled to be fully compensated for the loss. After the Enrollee has been fully compensated for the loss, the Company and Participating Provider are entitled to the remaining proceeds of any settlement or judgment that results in a recovery from the third party or third party's insurer(s) up to the Reasonable Cash Value of the Covered Services provided. 7.2.4 Services payable under any motor vehicle medical, motor vehicle no-fault, underinsured or uninsured motorist, personal injury protection, homeowner's, commercial premises coverage workers' compensation, or other similar contract or insurance are not covered. 001 L-WA811(5/20) 19