If you are covered by more than one group medical plan (e.g., your spouse's employer's medical plan), to the extent possible, the Plan will attempt to coordinate benefits. When the Plan is the primary plan, it will pay medical claims first as if there is no other coverage. When the Plan is the secondary plan, it will pay benefits after the primary plan and that payment amount will be the lesser of: a) what the Plan would have paid if it had been primary, or b) the Plan would have paid less the primary plan's payment.
However, if you or a family member is covered under an individual medical plan (e.g., auto insurance, homeowners insurance personal injury protection, etc.), the coordination of benefits provision does not apply.
One of the plans covering you is the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits indicating the amount paid by the primary plan.
For example, if you, as an employee in this option, incur covered expenses, this Plan is primary and your spouse's plan is secondary. However, if your spouse incurs the expenses, their plan is primary and this Plan is secondary.
This plan is primary to Medicare as long as you remain an active employee.
Coverage of a child
When a child is covered under both parents' plans, the "birthday rule" is used: the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or the spouse's plan has not adopted the birthday rule, the Plan will consider the plan that has covered the child longer as primary.
There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary, and the plan of the non-custodial parent is last.
If payment for covered medical expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.
Incorrect computation of benefits
If you believe that the amount of the benefit you receive from the Plan is incorrect, you should notify Cigna in writing or contact Cigna Customer Service.
If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. See Claims and Administrative and ERISA information sections.
Effect on the benefits of this Cigna option
If this Cigna Option is the Secondary Group Health Plan, this Group Health Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than one hundred percent (100%) of the total of all Allowable Expenses.
The difference between the amount that this Cigna Option would have paid if this Cigna OAPIN Option had been the Primary Group Health Plan, and the benefit payments that this Cigna Option had actually paid as the Secondary Group Health Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.
As each claim is submitted, Cigna will determine the following:
- Cigna obligation to provide services and supplies under this Cigna Option ;
- Whether a benefit reserve has been recorded for you; and
- Whether there are any unpaid Allowable Expenses during the Claims Determination Period.
If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to one hundred percent (100%) of the total of all Allowable Expenses. At the end of the Claim Determination Period, your benefit reserve will return to zero (0) and a new benefit reserve shall be calculated for each new Claim Determination Period.
Recovery of excess benefits
If Cigna pays charges for benefits that should have been paid by the Primary Group Health Plan, or if Cigna pays charges in excess of those for which we are obligated to provide under the plan, Cigna will have the right to recover the actual payment made or the Reasonable Cash Value of any services.
Cigna will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If we request, you shall execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery.
Right to receive and release information
Cigna, without consent or notice to you, may obtain information from and release information to any other Group Health Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide us with any information we request in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the "other coverage" information, (including an Explanation of Benefits paid under the Primary Group Health Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.
Subrogation and right of reimbursement
If a Participant incurs a Covered Expense for which, in the opinion of the plan or its claim administrator, another party may be responsible or for which the Participant may receive payment as described above:
- Subrogation: The Plan shall, to the extent permitted by law, be subrogated to all rights, claims or interests that a Participant may have against such party and shall automatically have a lien upon the proceeds of any recovery by a Participant from such party to the extent of any benefits paid under the Plan. A Participant or his/her representative shall execute such documents as may be required to secure the Plan’s subrogation rights.
- Right of Reimbursement: The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan.
The Cigna Option does not cover:
- Expenses for which another party may be responsible as a result of liability for causing or contributing to the injury or illness of you or your Family Member(s).
- Expenses to the extent they are covered under the terms of any automobile medical, automobile no fault, uninsured or underinsured motorist, workers' compensation, government insurance, other than Medicaid, or similar type of insurance or coverage when insurance coverage provides benefits on behalf of you or your Family Member(s).
If you or a Family Member incurs health care Expenses as described above, Cigna shall automatically have a lien upon the proceeds of any recovery by you or your Family Member(s) from such party to the extent of any benefits provided to you or your Family Member(s) by the Plan. You or your Family Member(s) or their representative shall execute such documents as may be required to secure Cigna’s rights. Cigna shall be reimbursed the lesser of:
- The amount actually paid by Cigna under the Plan; or
- An amount actually received from the third party;
- At the time that the third party's liability is determined and satisfied; whether by settlement, judgment, arbitration or otherwise.
- The Plan hereby disavows all equitable defenses in pursuit of its right of recovery. The Plan’s subrogation or recovery rights are neither affected nor diminished by equitable defenses.
- Participants must assist the Plan in pursuing any subrogation or recovery rights by providing requested information.
Payment of benefits
Payment of benefits on the ExxonMobil Medical Plan - Cigna OAPIN Network Only option
To whom payable
At the option of Cigna and with the consent of the Employer, all or any part of medical benefits may be paid directly to the person or institution on whose charge claim is based. Otherwise, medical benefits are payable to you.
If any person to whom benefits are payable is a minor or, in the opinion of Cigna, is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support.
If you die while any of these benefits remain unpaid, Cigna may choose to make direct payment to any of your following living relatives: spouse, mother, father, child or children, brothers or sisters, or to the executors or administrators of your estate.
Payment as described above will release Cigna from all liability to the extent of any payment made.
Time of payment
Benefits will be paid by Cigna when it receives due proof of loss.
Recovery of overpayment
Payments are made in accordance with the provisions of the Plan. If it is determined that overpayment has been made by Cigna, Cigna will have the right at any time to: (a) recover that overpayment from the person to whom or on whose behalf it was made, or (b) offset the amount of that overpayment from a future claim payment. In addition, the Plan has the right to engage an outside collection agency to recover overpayments on the Plan’s behalf if the Plan’s collection effort is not successful. The Plan may also bring a lawsuit to enforce its rights to recover overpayments. If the overpayment is made to a provider, the Plan (or any third-party administrator) may reduce or deny benefits, in the amount of the overpayment, for otherwise covered services for current or future claims with the provider on behalf of any participant, beneficiary, or dependent in the Plan.