If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. Other group plans include any other plan coverage provided by:
- Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured, and
- No-fault and traditional fault auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.
Determination of primary plan
To find out if benefits under the EMRMP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:
- The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
- The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
- The plan that covers the person as a dependent of a working spouse will pay first,
- Medicare will pay second, and
- The plan that covers the person as a retired employee will pay third.
- Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
- When the parents of a child are divorced or separated:
- If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
- If a court decree gives financial responsibility for the child’s medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
- If there is no such court decree, the order of benefits will be determined as follows:
- the plan of the natural parent with whom the child resides,
- the plan of the stepparent with whom the child resides,
- the plan of the natural parent with whom the child does not reside, or
- the plan of the stepparent with whom the child does not reside.
- If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
- The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
- If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.
If it is determined that the other plan pays first, the benefits paid under the EMRMP will be reduced. Aetna will calculate this reduced amount as follows:
- The amount normally reimbursed for covered benefits under the EMRMP,
- Benefits payable from your other plan(s).
If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.
Calculation of Benefits
When the Plan is your primary plan, the Plan will pay your medical claims first, as if there is no other coverage. When the Plan is your secondary plan, the Plan will pay benefits after the primary plan, and that payment amount will be the lesser of:
- What the Plan would have paid if it had been primary, or
- What the Plan would have paid less the primary plan’s payment.
Incorrect computation of benefits
If you believe that the amount of benefit you receive from the ExxonMobil Medical Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services. 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.)
Recovery of overpayment
Payments are made in accordance with the Provisions of the Plan. Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these overpayments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. The Administrator-Benefits may also make reasonable arrangements with you for repayment. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered. See Fraud against the plan section. 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.
Right of recovery (subrogation and/or reimbursement)
If you or a covered family member receives benefits from this plan as the result of an illness or injury caused by another person, the EMRMP has the right to be reimbursed for those benefits from any settlement or payment you receive from the person who caused the illness or injury. This means the EMRMP may recover costs from all sources (including insurance coverage) potentially responsible for making any payment to you or your covered family member as a result of an injury or illness, including:
- Uninsured motorist coverage,
- Underinsured motorist coverage,
- Personal umbrella coverage,
- Med-pay coverage,
- Workers’ Compensation coverage,
- No-fault automobile coverage, or
- Any first party insurance coverage.
What you need to know
Here are some important points about the right of subrogation:
The Plan has a lien on any payments you receive.
The EMRMP automatically has a lien, to the extent of any benefits it has paid, on any payment you’ve received from a third party, his/her insurer or any other source. The lien is in the amount of benefits paid by Aetna under this plan for treatment of the illness, injury or condition for which the other person is responsible.
Your cooperation is required.
You may not do anything to interfere or affect the EMRMP’s subrogation rights.
You also must fully cooperate with the EMRMP’s efforts to recover benefits it has paid. This includes providing all information requested by the Claims Administrator or its representatives. As part of this process, Aetna may ask you to complete and submit certain applications or other forms or statements. If you fail to provide this information, it will be considered a breach of contract and may result in the termination of your health benefits or the instigation of legal action against you.
You must notify Aetna.
If a lawsuit or any other claim is filed to recover damages due to injuries sustained by you or a covered family member, you must notify Aetna. This must be done within 30 days of the date the notice of the lawsuit or claim is given to a person, including an attorney.
The Plan is paid first.
The EMRMP’s subrogation rights are a first priority claim against all potentially responsible person(s), and must be paid before any other claim for damages.
The Plan is entitled to full reimbursement.
The EMRMP is entitled to full reimbursement first from any payments made by any responsible person(s). This reimbursement must be made, even if the payment is not enough to compensate you or your covered family member in part or in whole for damages. The terms of this plan provision apply and the EMRMP is entitled to full recovery whether or not any liability for payment is admitted by any potentially responsible person(s), and whether or not the settlement or judgment you receive identifies the medical benefits provided by the plan. The EMRMP may be reimbursed from any and all settlements and judgments, even those for pain and suffering or non-economic damages only.
Aetna chooses the court for any legal action.
Any legal action or proceeding with respect to this provision may be brought in any court of competent jurisdiction that Aetna selects. When you receive benefits under this plan, you agree to this rule and waive whatever rights you have by reason of your present or future place of residence.
The Plan is not responsible for your attorneys’ fees.
The EMRMP is not required to participate in or pay attorney fees to the attorney you hire to pursue your claim for damages.
Interpreting this provision.
If there is any question about the meaning or intent of this plan provision or any of its terms, the EMRMP will have the sole authority and discretion to resolve all disputes as to how this provision will be interpreted.