Welfare Summary Plan Description

15.2 SUBROGATION AND REIMBURSEMENT

The Plan and the Welfare Trust have the right to pursue a Participant's legal claims or rights against another party, or any insurance company, when Plan benefits are or will be paid or provided to the Participant and the condition for which the benefits are paid either was caused by another party or is covered by insurance or workers' compensation.

This would occur, for example, if a Participant is injured in an accident that is caused by another party. If the Plan covers benefits for the treatment of the Participant's injuries arising from the accident, the Plan and the Welfare Trust have the right to pursue the Participant's legal claims against the other party and any insurance company, including the Participant's. By accepting Plan benefits the Participant subrogates the Plan to all of the Participant's rights against any other party or under any insurance coverage or workers' compensation with respect to a condition for which the Plan provided benefits.

In addition, by accepting Plan benefits the Participant agrees that if he or she recovers damages, (including fees and costs) or insurance proceeds by settlement, verdict or otherwise for a condition, the Plan and the Welfare Trust have the right to be reimbursed by the Participant, his legal representatives, estate, heirs, guardian, and dependents, the value of any benefits paid or to be paid or provided by the Plan and/or Welfare Trust in relation to such condition. These rights of reimbursement apply whether or not such payment is for covered Plan benefits, and disregarding equitable, state and common law doctrines such as unjust enrichment, common fund and the make-whole doctrine.

The following are:

  • the Plan and Welfare Trust's rules regarding its rights to pursue claims of Participants and to receive reimbursement; and
  • the obligations of Participants who accept benefits for the treatment of conditions that are caused by other parties.

Subrogation applies whenever: (1) another person, entity, workers' compensation program, or insurance carrier is or may be considered liable for damage or to pay proceeds or benefits with respect to a Participant's condition; and (2) the Plan has provided or paid or is responsible in the future to provide or pay for benefits or medical services in relation to such condition. By accepting benefits under the Plan, the Participant agrees that, to the extent of the value of any such benefits or medical services paid or to be provided by the Plan, the Plan is subrogated to all rights against any party or insurance company who: (1) is or may be liable for the Participant's condition or is or may have an obligation to pay insurance proceeds or workers' compensation in relation to the Participant's condition; or (2) is or may be liable or have an obligation for payment for medical treatment of such condition.

By accepting benefits under the Plan:

  • The Participant agrees that the Plan and Welfare Trust may assert the Plan's subrogation rights independently of the Participant, his or her legal representatives, estate, heirs, dependents, or guardian ("related parties").
  • The Participant and related parties agree, and are obligated to cooperate with the Plan and its agents in order to pursue and protect the Plan's and Welfare Trust's subrogation rights. Among other things, the Participant and related parties shall provide the Plan or its agents any relevant information requested by them and shall sign and deliver any documents the Plan or its agent's request.
  • The Participant and related parties agree that the Plan's and Welfare Trust's rights of subrogation shall be considered as a first priority claim and lien against any other person or entity to be paid before any other claims are paid from any fund or recovery related to a condition, including claims by the Participant for general damages.
  • The Participant and related parties agree that he or she will not release any party from liability for the payment of medical expenses without first obtaining the written consent of the Plan or its agents.
  • The Participant and related parties agree that, if he or she enters into litigation or settlement negotiations regarding obligations of or claims against other parties, he or she will notify the Plan or its agents and will not prejudice, in any way, the Plan's subrogation rights.
  • The Participant and related parties agree that the Plan or its agents may take any lawful action to pursue and protect the Plan's subrogation rights.
  • The Participant and related parties agree that the cost of legal representation of the Plan in matters related to subrogation shall be borne solely by the Plan and that the cost of legal representation of the Participant shall be borne solely by the Participant, subject to the Procedures and Guidelines Regarding Subrogation/Reimbursement, available from the Trust Customer Service Office.

By accepting benefits for a minor, a guardian or Participant consents to these terms on behalf of the minor whether or not the minor is a Participant. These subrogation terms apply equally to all Participants.

Reimbursement applies whenever: (1) a Participant recovers damages or insurance proceeds by settlement, verdict or otherwise for or in relation to a condition; and (2) the Plan and/or Welfare Trust has paid or provided or is responsible in the future to pay or provide benefits in relation to such condition. Reimbursement also applies if a Participant has paid an improper self-payment amount, or the Plan has overpaid benefits.

By accepting benefits under the Plan:

  • The Participant and related parties agree, on behalf of himself or herself that the Plan and/or Welfare Trust shall be reimbursed promptly by the Participant and or related parties, from any settlement, verdict, insurance and workers' compensation proceeds or other recovery, the value of the benefits paid or provided by the Plan or for which the Plan is responsible in the future to pay or provide to or on behalf of the Participant and related parties in connection to such condition.
  • The Participant and related parties agree that the Plan or Welfare Trust, at their option, may collect amounts from the proceeds of any settlement, verdict, judgment, insurance and workers' compensation coverage or other recovery by the Participant or related parties, regardless of whether or not the Participant and such related parties have been fully compensated.
  • The Plan has a first priority lien, to the extent of the Plan and/or Welfare Trust's claim for reimbursement against the proceeds of any such settlement, verdict, insurance and workers' compensation proceeds or other recoveries or amounts received by or on behalf of the Participant or such legal representatives, and other related parties.
  • The Participant and related parties assign to the Plan and Welfare Trust any benefits the Participant and related parties may have or be entitled to under any automobile policy or any other coverage, to the extent of the Plan's claim for reimbursement.
  • The Participant and related parties agree to sign and deliver, at the request of the Plan or its agents, any documents that are needed to protect such lien or effect such assignment of benefits.
  • The Participant and related parties agree to cooperate with the Plan and its agents; to sign and deliver such documents as the Plan or its agents request; to provide any requested information; and to take such actions as the Plan or its agents request, all to protect the right of reimbursement of the Plan and/or Welfare Trust and to assist the Plan and/or Welfare Trust in making a full recovery of the value of the benefits paid or provided or for which the Plan is liable in the future to pay or provide.
  • The Participant and related parties agree to take no action that would prejudice the Plan's and/or Welfare Trust's rights of reimbursement.
  • The Participant and related parties agree that the Plan and Welfare Trust shall be responsible only for those legal fees and expenses to which they agree in writing.
  • The Participant and related parties agree to hold any proceeds of any settlement, verdict, judgment, insurance coverage or other recovery in trust for the benefit of the Plan and Welfare Trust and that the Plan and Welfare Trust shall be entitled to recover from the Participant reasonable attorney's fees incurred in collecting such proceeds from the Participant.
  • By accepting benefits for a minor, a guardian, or Participant consents to these terms on behalf of the minor whether or not the minor is a Participant. The reimbursement terms apply equally to all Participants.
  • If the Plan and Welfare Trust's right to reimbursement exceeds 1/3 of the total recovery, including any and all attorney's fees and expenses payments, the Trustees may, in their sole and exclusive discretion, compromise the Plan's and Welfare Trust's right to reimbursement. Such compromise shall be considered on a case–by–case basis subject to any policies adopted by the Trustees.
  • All amounts recovered by the Participant or any individual in the Participant's family or who is a dependent of the Participant in connection with the condition of the Participant shall be regarded as a recovery by the Participant, regardless of how the recovery is characterized. Likewise, the characterization by the parties or the Court of the amounts paid to the Participant shall not be binding on the Plan or Welfare Trust.
  • If the Plan has overpaid benefits or the Participant has paid an improper self-payment amount, the Plan is entitled to recover overpaid amounts from Participants, persons or organizations to whom such amount was paid, or others whose acts caused amounts to be overpaid. The right of recovery includes costs and attorney's fees.