Page 85 - Aegion Value Plan SPDs
P. 85
Right Of Recovery
If the amount of the payments made by This Plan is more than should have paid under this COB provision,
the Plan may recover the excess from one or more of the persons:
1. The Plan has paid or for whom the Plan have paid; or
2. Any other person or organization that may be responsible for the benefits or services provided for the
Member.
The "amount of the payments made" includes the reasonable cash value of any benefits provided in the
form of services.
Medicare
Any benefits covered under both this Plan and Medicare will be paid pursuant to Medicare Secondary Payer
legislation, regulations, and Health Care Financing Administration guidelines, subject to federal court
decisions. Federal law controls whenever there is a conflict among state law, Plan provisions, and federal
law.
Except when federal law requires the Plan to be the primary payer, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Parts B and/or D. Where Medicare is the responsible
payer, all sums payable by Medicare for services provided to Members shall be reimbursed by or on behalf
of the Members to the Plan, to the extent the Plan has made payment for such services. If the Member
has not enrolled in Medicare Part B and Medicare Part B is primary, we will calculate benefits as if they had
enrolled.
Workers’ Compensation
The benefits under the Plan are not designed to duplicate any benefit for which Members are eligible under
the Workers’ Compensation Law. All sums paid or payable by Workers’ Compensation for services
provided to a Member shall be reimbursed by, or on behalf of, the Member to the Plan to the extent the
Plan has made or makes payment for such services. It is understood that coverage hereunder is not in lieu
of, and shall not affect, any requirements for coverage under Workers’ Compensation.
Other Government Programs
Except insofar as applicable law would require the Plan to be the primary payer, the benefits under the Plan
shall not duplicate any benefits to which Members are entitled, or for which they are eligible under any other
governmental program. To the extent the Plan has duplicated such benefits, all sums payable under such
programs for services to Members shall be paid by or on behalf of the Member to the Plan.
Subrogation and Right of Reimbursement
These provisions apply when the Plan pays benefits as a result of injuries or illnesses You sustained and
You have a right to a Recovery or have received a Recovery from any source.
Recovery
A “Recovery” includes, but is not limited to, monies received from any person or party, any person’s or
party’s liability insurance, uninsured/underinsured motorist proceeds, workers’ compensation insurance or
fund, “no-fault” insurance and/or automobile medical payments coverage, whether by lawsuit, settlement
or otherwise. Regardless of how You or Your representative or any agreements characterize the money
You receive as a Recovery, it shall be subject to these provisions.
85
If the amount of the payments made by This Plan is more than should have paid under this COB provision,
the Plan may recover the excess from one or more of the persons:
1. The Plan has paid or for whom the Plan have paid; or
2. Any other person or organization that may be responsible for the benefits or services provided for the
Member.
The "amount of the payments made" includes the reasonable cash value of any benefits provided in the
form of services.
Medicare
Any benefits covered under both this Plan and Medicare will be paid pursuant to Medicare Secondary Payer
legislation, regulations, and Health Care Financing Administration guidelines, subject to federal court
decisions. Federal law controls whenever there is a conflict among state law, Plan provisions, and federal
law.
Except when federal law requires the Plan to be the primary payer, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Parts B and/or D. Where Medicare is the responsible
payer, all sums payable by Medicare for services provided to Members shall be reimbursed by or on behalf
of the Members to the Plan, to the extent the Plan has made payment for such services. If the Member
has not enrolled in Medicare Part B and Medicare Part B is primary, we will calculate benefits as if they had
enrolled.
Workers’ Compensation
The benefits under the Plan are not designed to duplicate any benefit for which Members are eligible under
the Workers’ Compensation Law. All sums paid or payable by Workers’ Compensation for services
provided to a Member shall be reimbursed by, or on behalf of, the Member to the Plan to the extent the
Plan has made or makes payment for such services. It is understood that coverage hereunder is not in lieu
of, and shall not affect, any requirements for coverage under Workers’ Compensation.
Other Government Programs
Except insofar as applicable law would require the Plan to be the primary payer, the benefits under the Plan
shall not duplicate any benefits to which Members are entitled, or for which they are eligible under any other
governmental program. To the extent the Plan has duplicated such benefits, all sums payable under such
programs for services to Members shall be paid by or on behalf of the Member to the Plan.
Subrogation and Right of Reimbursement
These provisions apply when the Plan pays benefits as a result of injuries or illnesses You sustained and
You have a right to a Recovery or have received a Recovery from any source.
Recovery
A “Recovery” includes, but is not limited to, monies received from any person or party, any person’s or
party’s liability insurance, uninsured/underinsured motorist proceeds, workers’ compensation insurance or
fund, “no-fault” insurance and/or automobile medical payments coverage, whether by lawsuit, settlement
or otherwise. Regardless of how You or Your representative or any agreements characterize the money
You receive as a Recovery, it shall be subject to these provisions.
85
