Reso 2010-1529 - Laserfiche WebLink

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') ') n ) ) a) First, benefits of a plan covering a person as an employee, member, or subscriber. h) Second, benefits of a plan of an active worker covering a person as a dependent. c) Third, Medicare benefits. 13.03.07 If an individual is covered under a COBRA continuation plan as a result of the purchase of coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987 (Pub.L. No. 99-272), and also under another Group Health Insurance plan, the following order of benefits applies: a) First, the plan covering the person as an employee or as the employee's dependent. h) Second, the coverage purchased under the plan covering the person as a former employee, or as the former employee's dependent provided according to the provisions of COBRA. 13.04 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 from any other insurance company, organizations or person, any information, with respect to any Subscriber or applicant for subscription, which AvMed deems to be necessary for such purposes. 13.05 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 deerned to be benefits paid under this Plan. 13.06 All treatments must be Medically Necessary and cornply 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. 13.07 Ifthe amount of the payments made by AvMed is more than it should have paid under the provisions of this Part XIII, 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 form of services. 13.08 In the event the Subscribing Group offers Health Reimbursernent Arrangernents (HRA) in connection with this Plan, the HRA is intended to pay solely for otherwise un-reirnhursed 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. XIV. 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 Mernber from the following third-party sources, as allowed by law, including but not limited to: payrnents made by a third-party tortfeasor or any insurance cornpany on behalf of the third-party tortfeasor; 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 36 A V-GlOO-2009 MP-5319 (10/09)