If You Have Other Coverage (applicable to the Health Benefits Plan)

If you and your spouse work for different employers, you may each be covered by health insurance where you work. If you or an eligible family member has coverage under the MPTN health care plan and coverage under another health care plan, benefits from the MPTN Plan are coordinated with those of the other plan.

The coordination of benefits rules are designed to make sure that your health care expenses are fully covered under your health care plans but you do not collect more than the plan limit. The rules determine how much each plan pays when you or your family members are covered under more than one health care plan. The rules involve two steps:

Determining which plan pays first (called the “primary coverage”), and
Determining how much the MPTN Plan will pay.

Excess Insurance

If at the time of injury, sickness, disease or disability there is available, or potentially available any coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this plan shall apply only as an excess over such other sources of coverage. The plan’s benefits will be excess to, whenever possible:

any primary payer besides the plan;
any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage;
any policy of insurance from any insurance company or guarantor of a third party;
worker’s compensation or other liability insurance company; or
any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

Vehicle Limitation

When medical payments are available under any vehicle insurance, the plan shall pay excess benefits only, without reimbursement for vehicle plan and/or policy deductibles. This plan shall always be considered secondary to such plans and/or policies. This applies to all forms of medical payments under vehicle plans and/or policies regardless of its name, title or classification.

Which Plan Pays First

To determine the plan that provides primary coverage, use the following rules:

For you — The MPTN Plan generally is primary. Submit your health care expenses to the MPTN Plan first, then to any other plan.
- If you are covered under Medicare — If you are still working for MPTN and you have Medicare coverage, the medical coverage you have through MPTN is primary, so you should submit your medical bills to MPTN’s Plan first. Then submit any medical expenses not covered by the MPTN Plan to Medicare for payment.
- If you are receiving Workers’ Compensation benefits — If you are receiving benefits from Workers’ Compensation, contact Risk Management, which will coordinate all Workers’ Compensation claims. If you are receiving payment from Workers’ Compensation, you must notify Pequot Plus Health Benefit Services at 1-888-779-6872.
For your spouse — Your spouse’s employer-sponsored plan is generally primary, if he or she is enrolled in it. Submit your spouse’s expenses to the other plan first, then to the MPTN Plan, if your spouse is also enrolled in the MPTN Plan.
For your dependent children — When the child is covered under both parents’ plans, the plan of the parent whose birthday falls earlier in the calendar year pays benefits first. If you and your spouse have the same birthday, the plan covering the child the longest pays first. If the other plan has not adopted this “birthday rule,” that plan’s rules determine which plan is primary.

If you are divorced, legally separated, or remarried, or if the parents were never married, the plans generally pay benefits in this order:

The plan of the parent with custody,
The plan of the spouse of the parent with custody,
The plan of the parent without custody, then
The plan of the spouse of the parent without custody.

Sometimes a court assigns responsibility to one parent for paying a child’s health care expenses — for example, if there is a divorce. Court decrees take precedence over all other rules. Whenever a court decree specifies the parent who is financially responsible for the child’s health care expenses, the coverage of that parent is primary.

MPTN requests other insurance updates yearly or for other reasons throughout the year. You will receive an insurance update questionnaire which needs to be filled out and returned to Pequot Plus Health Benefit Services. Please provide Pequot Plus with the information requested to complete the processing of the claim(s) for the patient. In accordance with the terms of your health plan, Pequot Plus must have this information within forty five (45) days of the date on the letter.

Be advised that payment of your claims will not be released until the requested information is received. Further, failure to provide this information in a timely manner will result in the denial of your claims rendering you responsible for payment of these charges. You have one (1) year from the date of the last letter to respond to this information for your claims to be considered. After one (1) year, your claims will not be reprocessed and will be considered closed for timely filing.

If None of These Rules Apply

In any other situation, the plan that has covered the person the longest is primary. You should submit expenses to that plan first.

How Much the Plan Pays

If the MPTN Plan is primary — MPTN benefits are paid according to the regular plan provisions, and the other plan pays benefits according to its own coordination of benefits provisions.

If the other plan is primary (usually it will be secondary, unless you have coverage from more than two plans) —

Then the primary plan pays benefits first. After the primary plan pays benefits, MPTN determines the benefits that would be payable if the MPTN Plan were primary (that is, as if there were no other coverage). All of MPTN’s rules will apply in determining the benefit that is payable — including the MPTN Plan’s deductible and maximum benefit provisions and any applicable reasonable and customary limits determining what portion of the total cost is covered. Once the amount payable if MPTN were primary is determined, MPTN will pay the lesser of:
- the amount MPTN would pay if it were primary, or
- the amount of the charge covered under the MPTN Plan remaining after the primary plan has paid benefits.

Third Party Recovery, Subrogation and Reimbursement (applicable to the Health Benefits Plan)

Payment Condition

The plan, in its sole discretion, may elect to conditionally advance payment of benefits in those situations where an injury, sickness, disease or disability is caused in whole or in part by, or results from the acts or omissions of participants, and/or their dependents, beneficiaries, estate, heirs, guardian, personal representative, or assigns (collectively referred to hereinafter in this section as “participant(s)”) or a third party, where any party besides the plan may be responsible for expenses arising from an incident, and/or other funds are available, including but not limited to no-fault, uninsured motorist, underinsured motorist, medical payment provisions, third party assets, third party insurance, and/or guarantor(s) of a third party (collectively “coverage”).

Participant(s), his or her attorney, and/or legal guardian of a minor or incapacitated individual agrees that acceptance of the plan’s conditional payment of medical benefits is constructive notice of these provisions in their entirety and agrees to maintain 100% of the plan’s conditional payment of benefits or the full extent of payment from any one or combination of first and third party sources in trust, without disruption except for reimbursement to the plan or the plan’s assignee. The plan shall have an equitable lien on any funds received by the participant(s) and/or their attorney from any source and said funds shall be held in trust until such time as the obligations under this provision are fully satisfied. The participant(s) agrees to include the plan’s name as a co-payee on any and all settlement drafts. Further, by accepting benefits the participant(s) understands that any recovery obtained pursuant to this section is an asset of the plan to the extent of the amount of benefits paid by the plan and that the participant shall be a trustee over those plan assets.

In the event a participant(s) settles, recovers, or is reimbursed by any coverage, the participant(s) agrees to reimburse the plan for all benefits paid or that will be paid by the plan on behalf of the participant(s). If the participant(s) fails to reimburse the plan out of any judgment or settlement received, the participant(s) will be responsible for any and all expenses (fees and costs) associated with the plan’s attempt to recover such money.

If there is more than one party responsible for charges paid by the plan, or may be responsible for charges paid by the plan, the plan will not be required to select a particular party from whom reimbursement is due. Furthermore, unallocated settlement funds meant to compensate multiple injured parties of which the participant(s) is/are only one or a few, that unallocated settlement fund is considered designated as an “identifiable” fund from which the plan may seek reimbursement.

Subrogation

As a condition to participating in and receiving benefits under this plan, the participant(s) agrees to assign to the plan the right to subrogate and pursue any and all claims, causes of action or rights that may arise against any person, corporation and/or entity and to any coverage to which the participant(s) is entitled, regardless of how classified or characterized, at the plan’s discretion, if the participant(s) fails to so pursue said rights and/or action.

If a participant(s) receives or becomes entitled to receive benefits, an automatic equitable lien attaches in favor of the plan to any claim, which any participant(s) may have against any coverage and/or party causing the sickness or injury to the extent of such conditional payment by the plan plus reasonable costs of collection. The participant is obligated to notify the plan or its authorized representative of any settlement prior to finalization of the settlement, execution of a release, or receipt of applicable funds. The participant is also obligated to hold any and all funds so received in trust on the plan’s behalf and function as a trustee as it applies to those funds until the plan’s rights described herein are honored and the plan is reimbursed.

The plan may, at its discretion, in its own name or in the name of the participant(s) commence a proceeding or pursue a claim against any party or coverage for the recovery of all damages to the full extent of the value of any such benefits or conditional payments advanced by the plan.

If the participant(s) fails to file a claim or pursue damages against:

The responsible party, its insurer, or any other source on behalf of that party.
Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage.
Any policy of insurance from any insurance company or guarantor of a third party.
Workers’ compensation or other liability insurance company.
Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

The participant(s) authorizes the plan to pursue, sue, compromise and/or settle any such claims in the participant’s/participants’ and/or the plan’s name and agrees to fully cooperate with the plan in the prosecution of any such claims. The participant(s) assigns all rights to the plan or its assignee to pursue a claim and the recovery of all expenses from any and all sources listed above.

Right of Reimbursement

The plan shall be entitled to recover 100% of the benefits paid, without deduction for attorneys’ fees and costs or application of the common fund doctrine, made whole doctrine, or any other similar legal or equitable theory, without regard to whether the participant(s) is fully compensated by his or her recovery from all sources. The plan shall have an equitable lien which supersedes all common law or statutory rules, doctrines, and laws of any State prohibiting assignment of rights which interferes with or compromises in any way the plan’s equitable lien and right to reimbursement. The obligation to reimburse the plan in full exists regardless of how the judgment or settlement is classified and whether or not the judgment or settlement specifically designates the recovery or a portion of it as including medical, disability, or other expenses. If the participant’s/participants’ recovery is less than the benefits paid, then the plan is entitled to be paid all of the recovery achieved. Any funds received by the participant are deemed held in constructive trust and should not be dissipated or disbursed until such time as the participant’s obligation to reimburse the plan has been satisfied in accordance with these provisions. The participant is also obligated to hold any and all funds so received in trust on the plan’s behalf and function as a trustee as it applies to those funds until the plan’s rights described herein are honored and the plan is reimbursed.

No court costs, experts’ fees, attorneys’ fees, filing fees, or other costs or expenses of litigation may be deducted from the plan’s recovery without the prior, express written consent of the plan.

The plan’s right of subrogation and reimbursement will not be reduced or affected as a result of any fault or claim on the part of the participant(s), whether under the doctrines of causation, comparative fault or contributory negligence, or other similar doctrine in law. Accordingly, any lien reduction statutes, which attempt to apply such laws and reduce a subrogating plan’s recovery will not be applicable to the plan and will not reduce the plan’s reimbursement rights.

These rights of subrogation and reimbursement shall apply without regard to whether any separate written acknowledgment of these rights is required by the plan and signed by the participant(s).

This provision shall not limit any other remedies of the plan provided by law. These rights of subrogation and reimbursement shall apply without regard to the location of the event that led to or caused the applicable sickness, injury, disease or disability.

Participant is a Trustee Over Plan Assets

Any participant who receives benefits and is therefore subject to the terms of this section is hereby deemed a recipient and holder of plan assets and is therefore deemed a trustee of the plan solely as it relates to possession of any funds which may be owed to the plan as a result of any settlement, judgment or recovery through any other means arising from any injury or accident. By virtue of this status, the participant understands that he or she is required to:

Notify the plan or its authorized representative of any settlement prior to finalization of the settlement, execution of a release, or receipt of applicable funds.
Instruct his or her attorney to ensure that the plan and/or its authorized representative is included as a payee on all settlement drafts.
In circumstances where the participant is not represented by an attorney, instruct the insurance company or any third party from whom the participant obtains a settlement, judgment or other source of coverage to include the plan or its authorized representative as a payee on the settlement draft.
Hold any and all funds so received in trust, on the plan’s behalf, and function as a trustee as it applies to those funds, until the plan’s rights described herein are honored and the plan is reimbursed.

To the extent the participant disputes this obligation to the plan under this section, the participant or any of its agents or representatives is also required to hold any/all settlement funds, including the entire settlement if the settlement is less than the plan’s interests, and without reduction in consideration of attorneys fees, for which he or she exercises control, in an account segregated from their general accounts or general assets until such time as the dispute is resolved.

No participant, beneficiary, or the agents or representatives thereof, exercising control over plan assets and incurring trustee responsibility in accordance with this section will have any authority to accept any reduction of the plan’s interest on the plan’s behalf.

Excess Insurance

If at the time of injury, sickness, disease or disability there is available, or potentially available any coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this plan shall apply only as an excess over such other sources of coverage, except as otherwise provided for under the plan’s Coordination of Benefits section.

The plan’s benefits shall be excess to any of the following:

The responsible party, its insurer, or any other source on behalf of that party.
Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage.
Any policy of insurance from any insurance company or guarantor of a third party.
Workers’ compensation or other liability insurance company.
Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

Separation of Funds

Benefits paid by the plan, funds recovered by the participant(s), and funds held in trust over which the plan has an equitable lien exist separately from the property and estate of the participant(s), such that the death of the participant(s), or filing of bankruptcy by the participant(s), will not affect the plan’s equitable lien, the funds over which the plan has a lien, or the plan’s right to subrogation and reimbursement.

Wrongful Death

In the event that the participant(s) dies as a result of his or her injuries and a wrongful death or survivor claim is asserted against a third party or any coverage, the plan’s subrogation and reimbursement rights shall still apply, and the entity pursuing said claim shall honor and enforce these plan rights and terms by which benefits are paid on behalf of the participant(s) and all others that benefit from such payment.

Obligations

It is the participant’s/participants’ obligation at all times, both prior to and after payment of medical benefits by the plan:

To cooperate with the plan, or any representatives of the plan, in protecting its rights, including discovery, attending depositions, and/or cooperating in trial to preserve the plan’s rights.
To provide the plan with pertinent information regarding the sickness, disease, disability, or injury, including accident reports, settlement information and any other requested additional information.
To take such action and execute such documents as the plan may require to facilitate enforcement of its subrogation and reimbursement rights.
To do nothing to prejudice the plan’s rights of subrogation and reimbursement.
To promptly reimburse the plan when a recovery through settlement, judgment, award or other payment is received.
To notify the plan or its authorized representative of any settlement prior to finalization of the settlement.
To not settle or release, without the prior consent of the plan, any claim to the extent that the participant may have against any responsible party or coverage.
To instruct his or her attorney to ensure that the plan and/or its authorized representative is included as a payee on any settlement draft.
In circumstances where the participant is not represented by an attorney, instruct the insurance company or any third party from whom the participant obtains a settlement to include the plan or its authorized representative as a payee on the settlement draft.
To make good faith efforts to prevent disbursement of settlement funds until such time as any dispute between the plan and participant over settlement funds is resolved.

If the participant(s) and/or his or her attorney fails to reimburse the plan for all benefits paid or to be paid, as a result of said injury or condition, out of any proceeds, judgment or settlement received, the participant(s) will be responsible for any and all expenses (whether fees or costs) associated with the plan’s attempt to recover such money from the participant(s).

The plan’s rights to reimbursement and/or subrogation are in no way dependent upon the participant’s/participants’ cooperation or adherence to these terms.

Offset

If timely repayment is not made, or the participant and/or his or her attorney fails to comply with any of the requirements of the plan, the plan has the right, in addition to any other lawful means of recovery, to deduct the value of the participant’s amount owed to the plan. To do this, the plan may refuse payment of any future medical benefits and any funds or payments due under this plan on behalf of the participant(s) in an amount equivalent to any outstanding amounts owed by the participant to the plan. This provision applies even if the participant has disbursed settlement funds.

Minor Status

In the event the participant(s) is a minor as that term is defined by applicable law, the minor’s parents or court-appointed guardian shall cooperate in any and all actions by the plan to seek and obtain requisite court approval to bind the minor and his or her estate insofar as these subrogation and reimbursement provisions are concerned.

If the minor’s parents or court-appointed guardian fail to take such action, the plan shall have no obligation to advance payment of medical benefits on behalf of the minor. Any court costs or legal fees associated with obtaining such approval shall be paid by the minor’s parents or court-appointed guardian.

Language Interpretation

The plan administrator retains sole, full and final discretionary authority to construe and interpret the language of this provision, to determine all questions of fact and law arising under this provision, and to administer the plan’s subrogation and reimbursement rights. The plan administrator may amend the plan at any time without notice.

Severability

In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sections of this provision and plan. The section shall be fully severable. The plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the plan.