If You Have Other Coverage

Definitions
Determining which plan pays first
Coordination with Medicare
Third party liability and subrogation
Overpayment and underpayment of benefits

Most insurance companies and providers cooperate with each other to avoid duplicate payments. If you or your dependents have medical or dental coverage in addition to your Canon Medical Systems coverage, one of the plans will pay the benefits first and that plan is considered primary. Secondary plans pay benefits after the primary plan, and coordinate their benefits based on what the primary plan paid.

When a Company medical or dental plan is the secondary plan, the Company plan will pay only up to the amount that it would have paid if it were the primary payer. For example, if the primary plan pays 70% and the Company (secondary) plan normally pays 80%, the Company plan will pay 10%. If the primary plan pays 80% and the Company plan normally pays 80%, the Company plan will pay 0%.

The plan has the right to obtain any benefit information necessary to determine whether the coordination provision applies and release it to any insurance company, claims administrator, organization, or person.

Definitions

Allowable expense. When this plan is secondary, the allowable expense is the primary plan's network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan's reasonable and customary charge. If both the primary plan and this plan do not have a contracted rate, the allowable expense will be the greater of the two plans' reasonable and customary charges.

Custodial parent. The custodial parent is the parent who is awarded custody by a court decree. If there is no court decree, the custodial parent is the parent with whom the child resides for more than half of the calendar year regardless of visitation rights.

Health care plan. Health care plan means medical (including integrated mental health and substance abuse), dental, prescription drug, or vision coverage under the following types of plans:

Another employer-sponsored health care plan
Medical care components of a group long-term care plan, such as skilled nursing care
Medical benefits under a group or individual automobile contract
Medical payments under a premises liability or other types of liability coverage
Medicare or other governmental benefits, as permitted by law

The plan will not coordinate with the following types of health care plans:

Any type of individual or family insurance health care program
School accident coverage
Benefits for the non-medical components of a group long-term care plan
Medicare supplement policies, Medicaid policies, and coverage under other governmental plans unless permitted by law

To obtain all the benefits for which you are eligible, claims should be filed with each of your sources of coverage.

Primary Plan. The primary plan pays benefits without regard to any other benefit program.

Secondary Plan. The secondary plan pays benefits after the primary plan has paid benefits. The secondary plan benefits are reduced by what the primary plan has paid.

Determining Which Plan Pays First

When a claim is made, the primary plan pays its benefits as if the secondary plan did not exist. Then, the secondary plan reduces its benefits by what the primary health plan has paid. When determining whether this plan or another group plan is the primary payer, one of the following coordination rules will apply:

This plan
If the other plan does not have a coordination of benefits provision or one that is consistent with this plan's provision, it will be primary. (It will not be primary if other coverage is obtained through a group membership and is a plan that supplements a larger overall program of benefits.)
The plan that covers the person as an employee pays benefits before the plan that covers the person as a dependent (however, special provisions may apply if the person is also a Medicare beneficiary—see the following section Coordination with Medicare for details).
The plan that covers the person as an active employee pays benefits before the plan that covers the person as a laid off or retired employee.
The plan that covers the person as an employee pays benefits before the plan that covers the person under a state or federal continuation provision.
The plan that covered the person the longest is primary.
If the preceding rules do not determine which plan pays first, the allowable expenses will be shared equally between the health care plans. This plan will not pay more than it would have had it been primary.

In addition to the preceding rules, the following guidelines apply to eligible dependent children:

When the parents are married, not legally separated, or have joint custody:
- If neither parent has responsibility to provide health care coverage, the plan of the parent whose birthday (month and day) occurs earlier in the calendar year will pay first. When parents have the same birthday (month and day), the plan of the parent who has been covered longer will pay first.
- If one of the parents has responsibility to provide health care coverage and the parent's plan is aware of the court decree, that plan is primary.
When the parents are divorced or legally separated (even if they have never been married) and there is no court decree specifying which parent has responsibility for providing health care coverage, the order of benefits is:
- The plan of the parent with custody
- The plan of the spouse of the parent with custody
- The plan of the parent without custody
- The plan of the spouse of the parent without custody
When parents are separated/divorced, have joint custody, and the court decree does not specify who has financial responsibility for the dependents' health care coverage, the plan will follow the birthday rule outlined earlier to determine which plan pays first. If a court decree specifies that one parent has financial responsibility for providing health care coverage, the plan of that parent will be primary.
The plan that covers a person as an employee, or as that employee's dependent, will determine its benefits before those of a plan covering a person as a laid off or retired employee, or as that employee's dependent.
If none of these rules decide which plan's benefits are payable first, the plan that has covered the person for the longest time will be primary.

Coordination With Medicare

At Age 65—As an active employee or covered spouse/domestic partner age 65 or older, you may be eligible to enroll for Medicare. As long as you are covered under a Company medical plan for active employees and you and/or your spouse/domestic partner has enrolled for Medicare, your Company plan coverage will be the primary payer of benefits. If you elect in writing to terminate coverage under a Company medical plan, then Medicare will be primary.

Upon Disability—If you or a covered dependent become eligible for Medicare Disability benefits, Medicare will be the primary payer of benefits. This plan will be secondary and will coordinate its benefit with the full amount of estimated Medicare benefits—even if you are not enrolled in Medicare or certain services or facilities are not eligible for Medicare reimbursement.

Third Party Liability and Subrogation

There may be circumstances when Anthem pays benefits that should legally be paid by a third party. For example, if you are involved in a car accident, Anthem may pay benefits before issues of liability are worked out. In those types of situations, subrogation means that Anthem has the right to recover any money it has paid when a third party is legally responsible. Recovery of payments include reimbursements from a third party who has not yet made a payment, or from you if you have already received a payment from a third party.

The following information is Anthem's own language about this provision. If a third party is responsible for your medical expenses, you may request a copy of the official plan documents from the Benefits Department.

Subrogation and reimbursement

These provisions apply when the plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a recovery or have received a recovery from any source. A “recovery” includes, but is not limited to, monies received from any person or party, any person’s or party’s liability insurance, uninsured/underinsured motorist proceeds, worker’s compensation insurance or fund, “no-fault” insurance and/or automobile medical payments coverage, whether by lawsuit, settlement or otherwise. Regardless of how you or your representative or any agreements characterize the money you receive as a recovery, it shall be subject to these provisions.

Subrogation

The plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries. The following apply:

The plan has first priority from any recovery for the full amount of benefits it has paid regardless of whether you are fully compensated, and regardless of whether the payments you receive make you whole for your losses, illnesses and/or injuries.
You and your legal representative must do whatever is necessary to enable the plan to exercise the plan's rights and do nothing to prejudice those rights.
In the event that you or your legal representative fails to do whatever is necessary to enable the plan to exercise its subrogation rights, the plan shall be entitled to deduct the amount the plan paid from any future benefits under the plan.
The plan has the right to take whatever legal action it sees fit against any person, party or entity to recover the benefits paid under the plan.
To the extent that the total assets from which a recovery is available are insufficient to satisfy in full the plan's subrogation claim and any claim held by you, the plan's subrogation claim shall be first satisfied before any part of a recovery is applied to your claim, your attorney fees, other expenses or costs.
The plan is not responsible for any attorney fees, attorney liens, other expenses or costs you incur. The ''common fund'' doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the plan.

Reimbursement

If you obtain a recovery and the plan has not been repaid for the benefits the plan paid on your behalf, the plan shall have a right to be repaid from the recovery in the amount of the benefits paid on your behalf and the following provisions will apply:

You must reimburse the plan from any recovery to the extent of benefits the plan paid on your behalf regardless of whether the payments you receive make you whole for your losses, illnesses and/or injuries.
Notwithstanding any allocation or designation of your recovery (e.g., pain and suffering) made in a settlement agreement or court order, the plan shall have a right of full recovery, in first priority, against any recovery. Further, the plan’s rights will not be reduced due to your negligence.
You and your legal representative must hold in trust for the plan the proceeds of the gross recovery (i.e., the total amount of your recovery before attorney fees, other expenses or costs) to be paid to the plan immediately upon your receipt of the recovery. You and your legal representative acknowledge that the portion of the recovery to which the plan’s equitable lien applies is a plan asset
Any recovery you obtain must not be dissipated or disbursed until such time as the plan has been repaid in accordance with these provisions.
You must reimburse the plan, in first priority and without any set-off or reduction for attorney fees, other expenses or costs. The ''common fund'' doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the plan.
If you fail to repay the plan, the plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the plan has paid or the amount of your recovery whichever is less, from any future benefit under the plan if:
- The amount the plan paid on your behalf is not repaid or otherwise recovered by the plan; or
- You fail to cooperate.
In the event that you fail to disclose the amount of your settlement to the plan, the plan shall be entitled to deduct the amount of the plan’s lien from any future benefit under the plan.
The plan shall also be entitled to recover any of the unsatisfied portions of the amount the plan has paid or the amount of your recovery, whichever is less, directly from the providers to whom the plan has made payments on your behalf. In such a circumstance, it may then be your obligation to pay the provider the full billed amount, and the plan will not have any obligation to pay the provider or reimburse you.
The plan is entitled to reimbursement from any recovery, in first priority, even if the recovery does not fully satisfy the judgment, settlement or underlying claim for damages or fully compensate you or make you whole.

Your duties

You must promptly notify the plan of how, when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved and any other information requested by the plan.
You must cooperate with the plan in the investigation, settlement and protection of the plan's rights. In the event that you or your legal representative fails to do whatever is necessary to enable the plan to exercise its subrogation or reimbursement rights, the plan shall be entitled to deduct the amount the plan paid from any future benefits under the plan.
You must not do anything to prejudice the plan's rights.
You must send the plan copies of all police reports, notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you.
You must promptly notify the plan if you retain an attorney or if a lawsuit is filed on your behalf.
You must immediately notify the plan if a trial is commenced, if a settlement occurs or if potentially dispositive motions are filed in a case.

The plan administrator has sole discretion to interpret the terms of the subrogation and reimbursement provision of this plan in its entirety and reserves the right to make changes as it deems necessary.

If the covered person is a minor, any amount recovered by the minor, the minor’s trustee, guardian, parent, or other representative, shall be subject to this provision. Likewise, if the covered person’s relatives, heirs, and/or assignees make any recovery because of injuries sustained by the covered person, that recovery shall be subject to this provision.

The plan is entitled to recover its attorney’s fees and costs incurred in enforcing this provision.

The plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary. The plan shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.

Overpayment and Underpayment of Benefits

Whenever payment has been made in error, the claims administrator will have the right to make appropriate adjustment to claims, recover such payment from you or, if applicable, the provider, in accordance with applicable laws and regulations. In the event the claims administrator recovers a payment made in error from the provider, except in cases of fraud or misrepresentation on the part of the provider, they will only recover such payment from the provider within 365 days of the date the payment was made on a claim submitted by the provider. The claims administrator reserves the right to deduct or offset any amounts paid in error from any pending or future claim.

Under certain circumstances, if the claims administrator pays your healthcare provider amounts that are your responsibility, such as deductibles, copayments, or coinsurance, they may collect such amounts directly from you. You agree that the claims administrator has the right to recover such amounts from you.

The claims administrator has oversight responsibility for compliance with provider and vendor and subcontractor contracts. The claims administrator may enter into a settlement or compromise regarding enforcement of these contracts and may retain any recoveries made from a provider, vendor, or subcontractor resulting from these audits if the return of the overpayment is not feasible.

The claims administrator has established recovery policies to determine which recoveries are to be pursued, when to incur costs and expenses, and whether to settle or compromise recovery amounts. The claims administrator will not pursue recoveries for overpayments if the cost of collection exceeds the overpayment amount. The claims administrator may not provide you with notice of overpayments made by them or you if the recovery method makes providing such notice administratively burdensome.