If you or a dependent require services or supplies as a result of a sickness or injury which is covered by workers’ compensation, or where a claim for workers’ compensation coverage has been filed, charges for such services or supplies or time loss payments are not covered by this Plan.

Similarly, if you or a dependent require services or supplies as a result of a sickness or injury which is, or appears to be, the responsibility of one or more third parties and for which payment is or may be made by a third party, or by one or more insurance companies whose insurance policies have become applicable, charges for such services or supplies are not covered by this Plan. The term insurance includes, but is not limited to, automobile liability, automobile no-fault, uninsured or underinsured motorist, business or commercial liability, homeowner’s liability, umbrella liability, and medical payments or PIP coverages, regardless of whether such insurance is maintained by the injured person, by a third party, or by any other person or entity.

However, if you or a dependent submit a claim for Trust benefits and there is a contested worker’s compensation claim pending or a third party liability claim pending, benefits will be advanced for you or your dependent if you will sign the Trust’s Agreement to Reimburse Form incorporating the following conditions:

1. The amount of all Trust benefits advanced will be included in the pending claim;
2. The injured person, or his/her attorney, will provide the Trust, upon request, with updates on the status of the claim and the achievement of any recovery; and
3. When any recovery is obtained, whether by direct payment or settlement (including a “disputed claim” settlement), or by award, judgment, or in any other way, the injured person or his/her attorney will promptly reimburse the Trust the full amount of all benefits advanced to the date of recovery, less only a deduction representing the Trust’s proportionate share of the injured person’s reasonable attorney’s fees and costs (if any). It shall not be necessary for the Trust to file a “lien” in order to obtain reimbursement.

The Agreement to Reimburse shall apply whether or not liability is admitted by the responsible party or insurance company and whether or not reimbursement of the Trust’s benefit payments is mentioned in the payment or settlement documents or in the award or judgment. The Trust reserves the right to first and full reimbursement out of any recovery obtained by the injured person regardless of how such recovery has been calculated or is described. The Trust may waive or modify this right, through Trust policy, where the circumstances warrant.

In the event the Trust discovers that it has unknowingly advanced benefits in a workers’ compensation or third party liability situation, or where the situation is known but the injured person declines to sign an Agreement to Reimburse, the Trust will deny payment of all benefits and assess an overpayment for benefits already paid. Failure to reimburse benefits previously advanced will be considered an unauthorized benefit payment.

To obtain an Agreement to Reimburse, or for additional information on this subject, contact your Area Administrative Office.

RECOVERY OF UNAUTHORIZED BENEFIT PAYMENTS
The Trust provides benefits only pursuant to the written terms of this Plan. If the Trust has mistakenly made benefit payments to or for an ineligible person, or payments exceeding those authorized by this Plan, or if a participant or dependent fails to reimburse advanced benefits pursuant to an agreement to reimburse, the individual profiting therefrom shall be obligated, upon notice from the Trust, to make restitution of the overpayment. Should restitution not be made, the Trust shall be entitled to bring legal action to recover the overpayment from the individual profiting therefrom, and if misrepresentation is involved, from any individual or entity par ticipating in the misrepresentation. In any such legal action the court may award the Trust its reasonable attorney fees and court costs in addition to the amount of the overpayment.

The Trust shall also have the right to deduct the amount of a benefit overpayment from any future benefit payments owing to the individual or others claiming eligibility through the same individual.

USE OF MEDICAL AND DENTAL CONSULTANTS
The Board of Trustees has authorized the Area Administrative Offices to refer claims for medical benefits which involve difficult issues as to medical necessity, the nature, classification, scope or duration of care, and the qualification of providers to outside doctors, dentists or other professionals for their review and advice, and to follow such advice in the adjudication of the referred claims. In determining the issues presented to them, the outside consultants may rely on their own expertise and on professional standards, procedures and protocols to which they have access.

Any claim denial which incorporates or is based on medical consulting advice may, as any other claim denial, be reviewed in accordance with the Trust’s appeals procedures.