Page 98 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

 You have enrolled in Medicare but choose to obtain services from a doctor that opts-out of
the Medicare program.

When calculating this Coverage Plan's Benefits in these situations for administrative convenience,
the Claims Administrator may, as the Claims Administrator determines, treat the provider’s billed
charges, rather than the Medicare approved amount or Medicare limiting charge, as the Allowable
Expense for both this Coverage Plan and Medicare.

Right to Receive and Release Needed Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable under This Plan and other Plans. The Claims Administrator may get the facts
the Claims Administrator needs from, or give them to, other organizations or persons for the purpose of
applying these rules and determining benefits payable under This Plan and other Plans covering the
person claiming benefits.

This Plan need not tell, or get the consent of, any person to do this. Each person claiming benefits under
This Plan must give the Claims Administrator any facts the Claims Administrator needs to apply those
rules and determine benefits payable. If you do not provide the Claims Administrator the information the
Claims Administrator needs to apply these rules and determine the Benefits payable, your claim for
Benefits will be denied.

Payments Made

A payment made under another Plan may include an amount that should have been paid under This
Plan. If it does, the Claims Administrator may process This Plans’ payment for that amount to the
organization that made the payment. That amount will then be treated as though it were a benefit paid
under This Plan. This Plan will not have to pay that amount again. The term "payment made" includes
providing benefits in the form of services, in which case "payment made" means reasonable cash value of
the benefits provided in the form of services.

Does This Plan Have the Right of Recovery?

If the amount of the payments This Plan made is more than This Plan should have paid under this COB
provision, This Plan may recover the excess from one or more of the persons This Plan have paid or for
whom This Plan have paid; or any other person or organization that may be responsible for the benefits
or services provided for you. The "amount of the payments made" includes the reasonable cash value of
any benefits provided in the form of services.

Overpayment and Underpayment of Benefits

If you are covered under more than one medical plan, there is a possibility that the other plan will pay a
benefit that the Plan should have paid. If this occurs, the Plan may pay the other plan the amount owed.

If the Plan pays you more than it owes under this COB provision, you should pay the excess back
promptly. Otherwise, the Plan Sponsor may recover the amount in the form of salary, wages, or benefits
payable under any Plan Sponsor-funded benefit plans, including this Plan. The Plan Sponsor also
reserves the right to recover any overpayment by legal action or offset payments on future allowable
expenses.
If the Plan overpays a health care provider, the Claims Administrator reserves the right to recover the
excess amount from the provider pursuant to Refund of Overpayments, below.

95 Section 7: Coordination of Benefits