Summary Plan Description
Trust's Right To Reimbursement
The plan excludes benefits for any injury or illness caused by the act or omission of another person (known as the "third party") where a potential opportunity for recovery exists, including, but not limited to, an injury or illness potentially covered by any liability policy of a third party or first party coverage available under an automobile insurance policy (i.e. coverage for underinsured or uninsured motorist), homeowners or renters policy or commercial premises policy. If a participant, retiree or dependent ("eligible individual") has a potential right of recovery for which a third party or insurer may have legal responsibility, the plan, as a convenience to the eligible individual, may advance benefits pending the resolution of the claim. However, the plan's payment of benefits is conditioned upon reimbursement from any judgment, settlement, disputed claim settlement, or other recovery, up to the full amount of all benefits provided by the plan, but not to exceed the amount of the recovery. In other words, by this agreement, the plan shall have an equitable lien in the eligible individual's recovery.
The plan is entitled to reimbursement regardless of whether the eligible individual is made whole by the recovery, and regardless of the characterization of the recovery, except that the plan will deduct reasonable attorney fees and a pro rata share of the costs from the reimbursement amount, as described below, if the eligible individual complies with the terms of the plan and any agreement to reimburse.
Prior to advancing funds on the eligible individual's behalf, the plan can require that an eligible individual and the eligible individual's attorney execute an agreement acknowledging this plan's reimbursement right, including the obligation to hold an amount sufficient to satisfy the plan's reimbursement amount in a trust account or escrow until the plan's claims are resolved by mutual agreement or court order. Also prior to advancing funds on the eligible individual's behalf, the plan can require that the eligible individual provide the name and address of the party at fault, the name of any insurance company through which coverage may be available, the name of any other lien holders involved, the factual description of the accident and/or injury or illness and any other information requested by the plan to determine and secure its reimbursement interest.
When any recovery is obtained from a third party or insurer the eligible individual or the eligible individual attorney's shall notify the plan immediately. No funds may be distributed to any party prior to notification to the plan and written agreement by the plan.
When any recovery is obtained from a third party or insurer an amount sufficient to satisfy the plan's reimbursement amount must be paid into a trust account or escrow and held there until the plan's claims are resolved by mutual agreement or court order. The obligation to place the reimbursement amount in trust is independent of the obligation to reimburse the plan. If the funds necessary to satisfy the plan's reimbursement amount are not placed in trust, the participant, retiree or dependent or the individual named to hold the funds in trust shall be liable for any loss the plan suffers as a result.
If reasonable attorney fees are incurred in recovering from the third party or insurer, the plan agrees to pay a percentage of attorney fees on the amount reimbursed to the plan, not to exceed the percentage actually charged by the attorney. If reasonable costs are incurred in recovering from the third party or insurer, the plan agrees to pay a pro rata share of the costs, based upon the plan's gross reimbursement lien to the eligible individual's total gross recovery. Notwithstanding the foregoing, the plan's payment of attorney fees and costs is contingent on compliance with the plan's reimbursement provisions and/or the agreement to reimburse.
If the plan is forced to bring a legal action to enforce the terms of this plan provision or the reimbursement agreement, the plan shall be entitled to its reasonable attorney fees, costs of collection and court costs.
The plan may cease advancing benefits if there is a reasonable basis to determine this provision is not enforceable, or if there is a reasonable basis to believe that the parties involved will not honor the terms of this provision or the reimbursement agreement, or the Board of Trustees modify this provision related to advancing benefits. The plan may also deny coverage for expenses incurred after recovery on the third-party claim, if such expenses are related to the third-party recovery and known or reasonably expected at the time of the settlement.
If the plan is not reimbursed upon recovery on a third-party claim, the plan may bring an action to enforce its right to reimbursement and/or the agreement to reimburse, or to seek a constructive trust, or in the alternative may elect to recoup the reimbursement amount by requesting provider refunds, offsetting future benefit payments, including those of family members, or by recovery from the source to which benefits were paid.
In any legal action under this provision venue may be laid in King County Superior Court or in the United States District Court for the Western District of Washington, at Seattle at the option of the Trust.
Motor Vehicle Accidents
The plan will not pay benefits for health care costs to the extent that the eligible individual is able to, or is entitled to, recover from motor vehicle insurance, including payments under a PIP policy. Benefits will not be provided to the extent an eligible individual has failed to acquire PIP coverage where required to do so by law or PIP coverage has been terminated before being exhausted for failure to cooperate or otherwise for cause. The plan will pay benefits toward expenses over the amount covered by motor vehicle insurance subject to the plan's Third-Party Reimbursement Provision.
If the plan pays benefits before motor vehicle insurance payments are made, the plan is entitled to reimbursement out of any subsequent motor vehicle insurance payments made to the eligible individual and, when applicable, the plan may recover benefits the plan has paid directly from the motor vehicle insurer or out of any settlement or judgment which the eligible individual obtains in accordance with the plan's Third-Party Reimbursement Provisions.
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