Reso 2010-1529 - Laserfiche WebLink

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) 11.45.02 Engagement in an illegal occupation; 11.45.03 Your participation in, or cOlnrnission of, any act punishable by law as a felony whether or not you are charged or convicted. 11.46 Ventilator dependent care, except as provided in Part X (Schcdule of Basic Benefits) for 100 days lifetime maximum benefit. 11.47 Workers' Compensation benefits. Any sickness or injury for which the covered person is paid benefits, or may be paid benefits if claimed, if the covered person is covered or required to be covered by Workers' Compensation. In addition, if the covered person enters into a settlement giving up rights to recover past or future medical benefits under a Workers' Compensation law, AvMed shall not cover past or future Medical Services that are the subject of or related to that settlement. Furthermore, if thc covered person is covered by a Worker's Compensation program that limits benefits if other than specified health care providers arc used and the covered person receives care or services from a health care provider not specified by the program, AvMed shall not cover the balance of any costs remaining after the program has paid. ') ..") XII. COORDINATION OF BENEFITS 12.01 The services and benefits provided under this Contract are not intended to and do not duplicate any benefit to which Members are entitled under any other Group Hcalth Insurance, HMO, personal injury protection and medical payments under the automobile insurance laws of this or any other jurisdiction, governmental organization, agency, or any other entity providing health or accident benefits to a Member, including but not limited to: Medicare, Worker's Compensation, Pnblic Health Servicc, Champus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law. - AvMcd coverage will be primary to Medicaid and Children's Health Insurance Program (CHIP) benefits. ) 12.02 If any covered person is eligible for services or benefits under two or more plans as set forth in Section 12.0 I, the coverage under those plans will be coordinated so that up to but not more than 100% of any eligiblc expense will be paid for or provided by all such plans combined. The Member shall execnte and deliver such instruments and papers as may be required and do whatever else is necessary to secure such rights to AvMed. Failure to do so will result in nonpaymcnt of Claims. Requested information should be provided to AvMed within 30 days of request or Member will be responsible for payment of the Claim. Information received after one year from date of service will not be considered. 12.03 The standards governing the coordination of benefits are the following, pursuant to the provisions of Section 627.4235, Florida Statutes: 12.03.01 The benefits of a policy or plan that covers the person as an employee, member, or subscriber, other than as a dependent, are determined before those of the policy or plan which covers the person as a dependent. 12.03.02 Except as stated in Subsection 12.03.03, when two or more policies or plans cover the same child as a dependent of different parents: a) The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls earlier in a year are detennined before the benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls later in the year; but 37 A V-CIIOICE-2009 MP-5320 (10/09)