Benefits from Other Sources
Please review this section carefully. It provides information on benefits from other sources.
Third-Party Liability
There may be situations in which you have a legal right to recover the cost of medical care from a third party who may be responsible for the illness or injury. For example, if you are injured in a store, the owner may be responsible for expenses related to the injury.
If you have such a claim against a third party, the following rules apply (as used in this section, "you" means you or your covered dependent):
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If the plan has paid any benefits to you (or on your behalf ), the plan is entitled to recover the amount paid from the proceeds of any settlement or recovery you receive from the third party or by one or more insurers whose insurance policies have become applicable. Insurance includes, but is not limited to, automobile liability, automobile no-fault, uninsured or underinsured motorist, business or commercial liability or umbrella liability regardless of whether such insurance is maintained by the third party, you or any other person or entity. If you continue to receive medical treatment for the illness or injury after obtaining the settlement or recovery, benefits will not be paid for the continuing treatment unless you can prove that the total cost of treatment (including the cost of obtaining the settlement or recovery) is more than the amount you have recovered or expect to recover.
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If you recover any amount from the third party, the plan is entitled to full reimbursement for all related benefits paid to you (or on your behalf ) immediately upon the recovery (whether by action of law, settlement or otherwise), regardless of whether you have been made whole. The plan will reduce its reimbursement amount only by a proportionate share of your actual attorneys' fees and costs up to a maximum reduction of one-third. You must hold the proceeds of the recovery in trust for the plan, which will have a security interest in, and lien on, any recovery you make, to the extent of the benefits the plan has paid and the expenses it has incurred in obtaining the recovery.
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The Trust may require you to sign and deliver any legal documents necessary to secure the plan's rights of subrogation. If the Trust asks you to sign an agreement to hold the proceeds of any recovery in trust, you must do so before any benefits will be paid.
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If you do not take legal action against a third party, the plan may initiate such action, and you must authorize the plan to sue, compromise or settle any third party claim in your name. You must cooperate fully with the plan in any proceeding against a third party to reimburse the plan for benefits that were paid to you (or on your behalf) and related to the third party claim.
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This provision applies to any illness or injury subject to the Trust's third party liability where the benefits the Trust seeks to recover begin on or after 12 months. Any dispute regarding the interpretation, application or administration of the Trust's third party reimbursement provision shall be resolved through arbitration. Arbitration shall be conducted in accordance with the Oregon Uniform Arbitration Act, ORS 36.600, et. seq. The parties shall split the cost of arbitration unless the Arbitrator orders otherwise. Each party shall bear its own attorneys' fees. In reviewing any issue, the Arbitrator's scope of review shall be whether the Board of Trustees was in error on an issue of law, acted arbitrarily or capriciously in the exercise of its direction, or its findings of fact were unsupported by substantial evidence.
Motor Vehicle Accidents
A motor vehicle accident in which you may have a legal right to recovery is a form of third party liability. Therefore, the above rules on claims against the third party apply. Before benefits will be paid, you must provide the Trust with the name and address of the other vehicle's driver and his or her insurance company.
Additionally, if you are injured in or by a motor vehicle operated by you or a dependent, the plan will not pay expenses which would be covered as primary by personal injury protection benefits where such coverage is required by law. This exclusion shall apply even if you failed to obtain such mandatory coverage. Amounts recovered under any auto insurance policy including automobile liability, automobile no-fault, uninsured and underinsured motorist, business or commercial liability or umbrella liability regardless of whether such insurance is maintained by a third party, you or any other person or entity are subject to the Trust's third party reimbursement provisions. Coverage under this plan will be secondary where allowed by law.
Before the plan pays benefits:
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You must have the minimum legally required motor vehicle insurance
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You must provide the Trust with information about any motor vehicle insurance payments made available to you or your covered dependent
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If the Trust requests, you must sign an agreement to hold the proceeds of any recovery in trust for the plan.
Workers' Compensation
The plan does not pay benefits for illness or injury covered under workers' compensation law. For example, if you become ill or are injured as a result of, or in the course of, your employment, your employer or a workers' compensation insurer may be responsible for health care expenses related to the illness or injury. If you filed a claim for workers' compensation that was denied and are in the process of appealing the denial, benefits will be paid to you subject to the following conditions.
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Prior to paying benefits, the plan must receive notice of the denial from your workers' compensation insurer.
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You must provide the Trust Office with a signed agreement to reimburse the plan in the event your workers' compensation claim is paid or settled.
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You must reimburse the plan for all benefits paid to you for the illness or injury for which you are entitled to compensation by the settlement or disposition of your workers' compensation claim.
Recovery of Benefits Paid in Error
If the Trust mistakenly pays benefits to which you are not entitled or pays a person who is not eligible for payment, the plan has the right to recover that payment from the person paid or from anyone who has benefited from the payment. The plan may recover the improperly paid benefits from any individual who has provided misinformation to the Trust or from you if you have failed to notify the Trust of your dependent's loss of eligibility and these actions have resulted in the payment of improper benefits. The plan may recover improperly paid benefits by deducting future benefits payable to the employee through whom the recipient of the improper benefits has eligibility or any dependents of the employee. The Trust's right to deduct future benefits shall apply to any failure to reimburse the plan from any settlement or recovery when benefits have been advanced pursuant to the plan's third-party liability provisions.
Alternative Coverage
The Trust's self-funded medical, prescription drug, dental and vision plans offer no conversion option or alternative self-pay coverage.
If you or a covered dependent are receiving treatment for a totally disabling condition at the time your coverage ends, the plan will continue to provide Major Medical benefits for the treatment of that specific condition only. These benefits will be provided for the lesser of: the number of months you (or your dependent) were covered under the plan before your coverage ended; or 12 months for you (as the covered employee); or, six months for any covered dependent. Extended coverage will stop before these time limits if you or your dependent cease to be totally disabled, the Plan terminates within 31 days of your coverage ending or you reach the maximum lifetime benefit of $1 million. To receive this extension, you must provide the Trust Office written documentation of your disability within 90 days of your coverage ending.
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Trust Prescription Drug Plan (for members enrolled in the Trust Preferred Provider Plan (Regence), Trust Indemnity Medical Plan (Regence) and Providence Personal Option EPO)
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Providence Open Option POS
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Kaiser Permanente HMO.
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