Reso 2010-1529 - Laserfiche WebLink

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() ) 12.42 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to applicable State and Federal laws or as specified in the Elective Termination of Pregnancy amendment to the Subscribing Group Contract. 12.43 Travel expenses including expenses for ambulance services to and from a physician or Hospital except in accordance with Section 10.01. 12.44 Treatment for armed forces service-connected medieal eare (for both sickness and injury). 12.45 Treatment ofa condition resulting from: o Participation in a riot or rebellion; Engagement in an illegal occupation; Your participation in, or commission of, any act punishable by law as a felony whether or not you are charged or convicted. 12.46 Ventilator dependent eare, except as provided in Part X (Schedule of Basic Benefits) for ]00 days lifetirne maximurn benefit. 12.45.01 12.45.02 12.45.03 12.4 7 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 the covered person is covered by a Worker's Compensation program that limits benefits if other than specified health care providers are used and the covered person receives care or services from a health care provider not specified by the prograrn, AvMed shall not cover the balance of any costs remaining ) after the program has paid. XIlI. COORDINATION OF BENEFITS I I l 13.0 I 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 Health 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 hut not limited to: Medicare, Worker's Compensation, Public Health Service, Champus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law. AvMed coverage will be primary to Medicaid and Children's Health Insurance Program (CHIP) benefits. 13.02 If any covered person is eligible for services or benefits under 2 or more plans as set forth in Section 13.01, the coverage under those plans will be coordinated so that up to but not more than 100% of any eligible expense will be paid for or provided by all such plans cornbined. The Member shall execute and deliver such instruments and papers as rnay be required and do whatever else is necessary to secure such rights to AvMed. Failure to do so will result in nonpayment 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. 13.03 The standards governing the coordination of benefits are the following, pursuant to the provisions of Chapter 627.4235, Florida Statutes: 34 A V -Gl 00-2009 MP-5319 (10/09)