The Fund requires a written promise that you repay the entire amount advanced by the Fund regardless of why, where or from whom you receive money. The Fund has no obligation to share in the legal costs and fees of obtaining a third-party recovery in a common Fund. Also, the Fund’s right of recovery matures without regard to whether you are made whole economically for injuries you sustain.
This Plan does NOT provide benefits if the medical expenses are covered by workers’ compensation or occupational disease law.
Purpose of Third-Party Liability Provisions
In some instances, you may be injured on the job or in a car accident or some other type of accident for which a third party is responsible. In those situations, an employer’s workers’ compensation carrier, your own or someone else’s auto insurance company, or another third party, may be responsible for paying your medical bills as well as your weekly accident and sickness expenses. Under those circumstances, the Fund is not responsible for paying, and does not cover, your medical bills and accident and sickness expenses relating to the accident.
Waiting for someone else to pay for your injuries can be difficult, particularly in situations where your doctor or hospital requires pre-determination of payment. Recovery can sometimes take a long time. Therefore, while the Fund is not responsible for paying your bills in these circumstances, the Board of Trustees recognizes the difficulty of waiting for payment from a third party and has developed a program to temporarily advance benefits to you while you wait for payment from the responsible third party .
How Third Party Liability Recovery Works
The Third Party Liability provisions of the Plan entitle the Fund to collect, directly from any responsible third party or insurance carrier, or from you, any money it advances to pay benefits relating to injuries you sustained and for which a third party is legally obligated to pay. In exchange for your written promise to pay back the Fund in full, from any recovery you receive, the Fund will advance you benefits for medically appropriate treatment which the Fund would cover in the event that no third party was involved. Your acceptance of these advanced benefits constitutes your agreement to repay the Plan in the event you receive a recovery in any form from any other person or party relating to the accident.
The Fund’s rights of reimbursement and subrogation apply regardless of the terms of the claim, demand, right of recovery, cause of action, judgment, award, settlement, compromise, insurance or order, regardless of whether the third party is found responsible or liable for the injury or illness, and regardless of whether you and/or your dependent actually receive the full amount of such judgment, award, settlement, compromise, insurance or order. The Fund’s rights of reimbursement and subrogation provide the Fund with first priority to any and all recovery in connection with the injury or illness, whether such recovery is full or partial and no matter how such recovery is characterized, why or by whom it is paid, or the type of expense for which it is specified.
This recovery includes amounts payable under your or your dependent’s own uninsured motorist insurance, under-insured motorist insurance, or any medical pay or no-fault benefits payable. Neither the “make-whole” doctrine nor the “common fund” doctrine apply to the Fund’s rights of reimbursement and subrogation. The Fund’s rights of reimbursement and subrogation are for the full amount of all related benefits payments; this amount is not offset by legal costs, attorney’s fees or other expenses incurred by you or your dependent in obtaining recovery.
The Fund has a constructive trust, lien and/or an equitable lien by agreement in favor of the Fund on any amount received by you, your dependent or a representative of you or your dependent (including an attorney) that is due to the Fund under this Section, and any such amount is deemed to be held in trust by you or your dependent for the benefit of the Fund until paid to the Fund. You and your dependent hereby consent and agree that a constructive trust, lien, and/or equitable lien by agreement in favor of the Fund exists with regard to any payment, amount and/or recovery from a third party. In accordance with that constructive trust, lien, and/or equitable lien by agreement, you and your dependent agree to cooperate with the Fund in reimbursing it for Fund costs and expenses.
Also, if you or your dependent receive any benefit payments from the Fund for any injury or illness, the Fund is subrogated to all rights of recovery available to you or your dependent arising out of any claim, demand, cause of action or right of recovery that has accrued, may accrue or which is asserted in connection with such injury or illness, to the extent of any and all related benefit payments made or to be made by the Fund on your or your dependent’s behalf. This means that the Fund has an independent right to bring an action in connection with such injury or illness in your or your dependent’s name and also has a right to intervene in any action brought by you or your dependent, including any action against an insurance carrier including under any uninsured or underinsured motor vehicle policy.
Any charges for any medical or other treatment, service or supply to the extent that the cost of the professional care or hospitalization may be recovered by, or on behalf of, you or your dependent in any action at law, any judgment compromise or settlement of any claims against any party, or any other payment you, your dependent or your attorney may receive as a result of the accident or injury, no matter how these amounts are characterized or who pays these amounts, are excluded from Plan coverage, as provided in this Section.
What You Need To Do
Under the Plan’s Third Party Liability provision, a participant must fulfill the following obligations in order to have his/her claims processed through the Fund:
- You and/or your dependent are required to notify the Fund within ten days of any accident or injury for which someone else may be liable. Further, the Fund must be notified within ten days of the initiation of any lawsuit or settlement negotiations relating to the accident and of the conclusion of any settlement, judgment or payment relating to the accident to protect the Fund’s claims.
- You and your dependent, if applicable, must sign the Subrogation Agreement provided by the Fund. This Subrogation Agreement also must be executed by your or your dependent’s attorney, if applicable. However, even if you or your dependent or a representative of you or your dependent or a representative of you or your dependent (including your or your dependent’s attorney) do not execute the required Subrogation Agreement and the Fund nevertheless pays benefits to or on behalf of you or your dependent, you or your dependent’s acceptance of such benefits shall constitute your or your dependent’s agreement to the Fund’s right to subrogation or reimbursement from any recovery by you or your dependent from a third party that is based on the circumstance from which the expense or benefit paid by the Fund arose, and your or your dependent’s agreement to a constructive trust, lien, and/or equitable lien by agreement in favor of the Fund on any payment amount or recovery that you or your dependent recovers from a third party.
- You must file claims with the Fund Office on time;
- You must cooperate with Plan representatives as may be necessary or appropriate to enable the Plan to recover payments from any third party;
- You must immediately reimburse the Plan for any expenses paid by the Plan with any money recovered from a third party, no matter how characterized;
- You must not do anything to impair, prejudice or discharge the Plan’s right of subrogation to recover from any third party; and
- You must assign to the Plan the right to bring an action against any third party responsible for the injuries sustained if you decline or fail to bring such action.
- Under this provision, you and/or your dependent are obligated to take all necessary action and cooperate fully with the Fund in its exercise of its rights of reimbursement and subrogation, including notifying the Fund of the status of any claim or legal action asserted against any party or insurance carrier and of your or your dependent’s receipt of any recovery. If you are asked to do so, you must contact the Fund Office immediately. You or your dependent also must do nothing to impair or prejudice the Fund’s rights. For example, if you or your dependent chooses not to pursue the liability of a third party, you or your dependent may not waive any rights covering any conditions under which any recovery could be received. Where you or your eligible dependent chooses not to pursue the liability of a third party, the acceptance of benefits from the Fund authorizes the Fund to litigate or settle your claims against the third party. If the Fund takes legal action to recover what it has paid, the acceptance of benefits obligates you and your dependent (and your attorney if you have one) to cooperate with the Fund in seeking its recovery, and in providing relevant information with respect to the accident.
- You or your dependent must also notify the Fund before accepting any payment prior to the initiation of a lawsuit or in settlement of a lawsuit. If you do not, and you accept payment that is less than the full amount of the benefits that the Fund has advanced you, you will still be required to repay the Fund, in full, for any benefits it has paid. The Fund may withhold benefits if you or your dependent waives any of the Fund’s rights to recovery or fails to cooperate with the Fund in any respect regarding the Fund’s subrogation rights.
Failure to Comply with Third Party Liability Procedures
Any refusal by you or your dependent to allow the Fund a right to subrogation or to reimburse the Fund from any recovery you receive, no matter how characterized, up to the full amount paid by the Fund on your or your dependent’s behalf relating to the applicable injury or illness, will be considered a breach of the agreement between the Fund and you that the Fund will provide the benefits available under the Plan and you will comply with the rules of the Fund. Further, by accepting benefits from the Fund, you and your dependent affirmatively waive any defenses you may have in any action by the Fund to recover amounts due under this Section or any other rule of the Plan, including but not limited to a statute of limitations defense or a preemption defense, to the extent permissible under applicable law. Because benefit payments are not payable unless you sign a Subrogation Agreement, your or your dependent’s claim will not be considered filed and will not be paid if the period for filing claims passes before your Subrogation Agreement is received.
If you or your dependent refuse to reimburse the Fund from any recovery or refuse to cooperate with the Fund regarding its subrogation or reimbursement rights, the Fund has the right to recover the full amount of all benefits paid by any and all other methods which include, but are not necessarily limited to, offsetting the amounts paid against your and/or any of your dependents’ future benefit payments under the Plan. “Non-cooperation” includes the failure of any party to execute a Subrogation Agreement and the failure of any party to respond to the Fund’s inquiries concerning the status of any claim or any other inquiry relating to the Fund’s rights of reimbursement and subrogation.
If the Fund is required to pursue legal action against you or your dependent to obtain repayment of the benefits advanced by the Fund, you or your dependent shall pay all costs and expenses, including attorneys’ fees and costs, incurred by the Fund in connection with the collection of any amounts owed the Fund or the enforcement of any of the Fund’s rights to reimbursement. In the event of legal action, you or your dependent shall also be required to pay interest at the rate determined by the Trustees from time to time from the date you become obligated to repay the Fund through the date that tthe Fund is paid the full amount owed. the Fund has the right to file suit against you in any state or federal court that has jurisdiction over the Fund’s claim.
Recovery Incentive Program
The Recovery Incentive Program provides a cash incentive to participants who discover and arrange for recovery of overcharges made on their own hospital bills that, in turn, result in savings dollars for the Plan. The rules of the program are as follows:
- The cash incentive paid to a participant for recovering an amount that was initially overcharged on a hospital bill for that participant or his or her dependent is 25% of the actual amount of the overcharge that the hospital agrees is invalid as a result of direct negotiations between the participant and the hospital;
- The maximum paid by the Plan in any calendar year to a participant under this program may not exceed $500. Hospital overcharges totaling less than $25 are not eligible for the recovery incentive;
- The Trustees and administrative staff of the Plan may not get involved in resolving any differences between the participant and the hospital with respect to disputed charges. Participants are solely responsible for handling such disputes; and
- For purposes of the cash incentive, only hospital expenses that the Plan covers are included. It does not include amounts for telephone bills, television rental, newspapers, etc., for purposes of determining the amount payable to the participant under this program.
Proof of eligibility for a cash incentive must be submitted to the Plan in the form of a copy of the initial itemized hospital bill with the overcharges circled, and a copy of the adjusted bill showing that the hospital corrected the discrepancy. Such proof must be submitted to the Fund Office within 45 days following the date of discharge from the hospital. Within 30 days after receipt of proof and verification that the overcharge was recovered, the Fund will write the participant a check in the amount of the cash incentive.
The Trustees have the sole right at any time to amend or modify these rules or terminate the Recovery Incentive Program entirely.