Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.13 Subrogation and Reimbursement

1. Participant Must Agree to Subrogation and Reimbursement.As a condition to the receipt of benefits under this article, a Covered Individual agrees:
   1. to reimburse the Plan to the extent any benefit payments are recovered from the proceeds of any judgment or settlement, payment or otherwise, on account of any illness, injury, or condition for which an employer or other third party (or their respective insurers), or your own personal, home, or automobile insurer may be liable, regardless of whether such recovery is less than the actual loss suffered by the person, and irrespective of whether responsibility is accepted or denied by an employer or third party;
      
      
   2. to waive any argument or contention that any action by the Plan in state court is pre-empted by federal law; and
      
      
   3. to assign to the Plan the Covered Individual's right of action against the employer or other third party (or their respective insurers) to the extent benefits have been paid or may be paid in the future.
      
      In addition, any Covered Individual must, as a condition to eligibility and the receipt of Plan benefits;
      
      
   4. notify the Plan Office within thirty (30) days of making a claim against an employer or other third party (or their respective insurers), or your own personal, home, or automobile insurer relating to an incident leading to damages, benefits or other compensation, of the fact and nature of such claim;
      
      
   5. furnish any information or assistance and execute any documents that the Plan may require; and
      
      
   6. take no action that may prejudice or interfere with such rights.
2. Subrogation & Reimbursement. Whether or not the preceding requirements are satisfied, the Board;
   1. is automatically assigned a Covered Individual's right of action against an employer or other third party (or their respective insurers), or your own personal, home, or automobile insurer to recover benefits that have been paid or may be paid in the future;
      
      
   2. has the right to intervene at any time in any action brought against an employer or other third party (or their respective insurers), or your own personal, home, or automobile insurer to recover all benefits that have been paid or may be paid in the future;
      
      
   3. shall be reimbursed fully from the proceeds of any judgment, settlement, or other resolution of any action or proceeding to recover benefits that have been paid or may be paid in the future, regardless of whether the total amount of such recovery is less than the actual loss suffered by the person;
      
      
   4. shall be reimbursed 100% of the charges it paid in a lump sum at the time payment is received by a Covered Individual, his or her dependents, or his or her representative; and
      
      
   5. has an automatic first lien upon any recovery to the extent of benefits that have been paid or in the future may be paid.
   In all instances set forth above in this subsection, the Board shall have such rights regardless of whether the total amount of the recovery is less than the actual loss suffered by the Covered Individual. The Board shall also be fully reimbursed for any charges paid in error, whether the error was that of the Plan, Participant, or Dependent.
   
   
3. Recovery by the Plan. Should any Covered Individual fail to comply with any of the foregoing requirements, the Board may suspend that Covered Individual's ongoing eligibility for benefits and deny pending or future claims until such time that he or she is in compliance with such requirements. Should any Covered Individual enter into any settlement of any claim pursuant to state workers' compensation law or personal injury law (whether or not a lawsuit is filed) that does not include complete and final resolution of the Plan's lien, claim for reimbursement and/or subrogation claim immediately upon effectuation of such settlement, the Plan may suspend the Covered Individual's ongoing eligibility for benefits and deny pending or future claims until the Plan has recouped an amount equal to the value of such claim. Such recoupment may be accomplished via processing of medical benefit claims without payment of the amounts normally payable under the Plan. The Plan expressly rejects the application of legal theories such as the "collateral source," "make-whole" and "common fund" doctrines to the extent that they may prevent or limit the Plan's recovery from any payment that a Covered Individual receives from a third party (or its insurer). The Plan's reimbursement will not be reduced to pay any portion of the attorneys' fees and costs associated with the Covered Individual's legal recovery. This section applies to any nofault insurance recoveries and all proceedings and actions, including but not limited to proceedings under any state workers' compensation acts, and any actions for negligence, medical malpractice, products liability, and other torts or wrongful acts.
   
   
4. Subrogation and Reimbursement for HMO Benefits. Rules similar to those set forth above in this section shall apply to individuals covered under one of the HMOs to the extent provided in the applicable HMO contract.