Reso 2010-1529 - Laserfiche WebLink

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) b) Second, the coverage purchased nnder the plan covering the person as a fanner employee, or as the former employee's dependent provided according to the provisions of COBRA. ) 12.04 For the purpose of determining the applicability and implementing the terms of the Coordination of Benefits provision of this Contract, AvMed may, without the consent of or notice to any person, release to or obtain fronl any other insurance company, organizations or person, any infonnation, with respect to any Subscriber or applicant for subscription, which AvMed deems to be necessary for such purposes. 12.05 Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other plans, AvMed shall have the right, exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts AvMed shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be deemed to be benefits paid nnder this Plan. 12.06 All treatments must be Medically Necessary and comply with all terms, conditions, Limitations, and Exclusions of this Plan even if AvMed is secondary to other coverage and the treatment is covered under the other coverage. 12.07 If the amount of the payments made by AvMed is more than it should have paid under the provisions of this Part XII, it may recover the excess from one or more of the persons it has paid or for whom it has paid; or 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 fonn of services. 12.08 In the event the Subscribing Group offers Health Reimbursement Arrangements (HRA) in connection with this Plan, the HRA is intended to pay solely for otherwise un-reimbursed medical expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and its benefits shall not be taken into account when detennining benefits payable under any other plan. -) ) XIII. SUBROGATION AND RIGHT OF RECOVERY If AvMed provides health care benefits under this Contract to a Member for injuries or illness for which another party is or may be responsible, then AvMed retains the right to repayment of the full cost of all benefits provided by AvMed on behalf of the Member that are associated with the injury or illness for which another party is or may be responsible. AvMed's rights of recovery apply to any recoveries made by or on behalf of the Member from the following third-party sources, as allowed by law, including but not limited to: payments made by a third-party tortfeasor or any insurance company on behalf of the third-party tort feasor; any payments or awards under an uninsured or underinsured motorist coverage policy; any worker's compensation or disability award or settlement; medical payments coverage under any automobile policy, premises or homeowners medical payments coverage or premises or homeowners insurance coverage; any other payments from a source intended to compensate a Member for injuries resulting from an accident or alleged negligence. For purposes of this Contract, a tortfeasor is any party who has committed injury, or wrongful act done willingly, negligently or in circumstances involving strict liability, but not including breach of contract for which a civil suit can be brought. Member specifically acknowledges AvMed's right of subrogation. When AvMed provides health care benefits for injuries or illnesses for which a third party is or may be responsible, AvMed shall be subrogated to the Member's rights of recovery against any party to the extent of the full cost of all benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against any party with or without the Member's consent. ) 39 A V-CHOICE-2009 MP-5320 (10/09)