Page 108 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

All other terms, provisions and conditions shown in your Health Benefits Plan Booklet will continue to
apply.

Does the Plan Require Examination of Covered Persons?

In the event of a question or dispute regarding your right to Benefits, the Plan Sponsor may require that a
Network Physician of its choice examine you at the Plan's expense.

Is Workers' Compensation Affected?
Benefits provided under the Plan do not substitute for and do not affect any requirements for coverage by
workers' compensation insurance.

How Are Benefits Paid When You Are Medicare Eligible?

Benefits under the Plan are not intended to supplement any coverage provided by Medicare.
Nevertheless, in some circumstances Covered Persons who are eligible for or enrolled in Medicare may
also be enrolled under the Plan.

If you are eligible for or enrolled in Medicare, please read the following information carefully.
If you are eligible for Medicare on a primary basis (Medicare pays before Benefits under the Plan), you
should enroll in and maintain coverage under both Medicare Part A and Part B. If you don't enroll and
maintain that coverage, and if the Plan Sponsor's Plan is the secondary payer as described in Section 7:
Coordination of Benefits, the Claims Administrator will process the Plan Sponsors payment of Benefits
under the Plan as if you were covered under both Medicare Part A and Part B. As a result, you will be
responsible for the costs that Medicare would have paid and you will incur a larger out-of-pocket cost.

If you are enrolled in a Medicare Advantage (Medicare Part C) plan on a primary basis (Medicare pays
before Benefits under the Plan), you should follow all rules of that plan that require you to seek services
from that plan's participating providers. When the Plan Sponsor's Plan is the secondary payer, the Claims
Administrator will process the Plan Sponsor's payment of any Benefits available to you under the Plan as
if you had followed all rules of the Medicare Advantage plan. You will be responsible for any additional
costs or reduced Benefits that result from your failure to follow these rules, and you will incur a larger out-
of-pocket cost.

Subrogation and Reimbursement
The Plan has the right to subrogation and reimbursement. References to "you" or "your" in this
Subrogation and Reimbursement section shall include you, your estate and your heirs and beneficiaries
unless otherwise stated.

Subrogation applies when the Plan has paid Benefits on your behalf for a Sickness or Injury for which any
third party is allegedly responsible. The right to subrogation means that the Plan is substituted to and
shall succeed to any and all legal claims that you may be entitled to pursue against any third party for the
Benefits that the Plan has paid that are related to the Sickness or Injury for which any third party is
considered responsible.
Subrogation Example:
Suppose you are injured in a car accident that is not your fault, and you receive Benefits under the Plan
to treat your injuries. Under subrogation, the Plan has the right to take legal action in your name against
the driver who caused the accident and that driver's insurance carrier to recover the cost of those
Benefits.

105 Section 8: General Legal Provisions