Common use of Subrogation and Reimbursement Clause in Contracts

Subrogation and Reimbursement. Subrogation is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right. We shall be subrogated to and shall succeed to all rights of recovery, under any legal theory of any type, for any actual payments made by us for services and benefits provided by us to any Covered Person as a result of the occurrence that gave rise to a cause of action in which the Covered Person has recovered for medical expenses from: (i) third parties, including any person alleged to have caused the Covered Person to suffer injuries or damages; (ii) the employer of the Covered Person or (iii) any person or entity obligated to provide benefits or payments to Covered Persons, including benefits or payments for underinsured or uninsured motorist protection (these third parties and persons or entities are collectively referred to as "Third Parties"); provided, however, that we will not seek to recover payments made to a Covered Person under a personal injury protection policy. The Covered Person agrees to assign to us all rights of recovery against Third Parties, to the extent of the actual payments made us for the services and benefits that we provided. The Covered Person shall cooperate with us in protecting our legal rights to subrogation and reimbursement. The Covered Person shall do nothing to prejudice our rights under this provision, either before or after the need for services or benefits under the Policy. We may, at our option, take necessary and appropriate action to preserve our rights under these subrogation provisions, including filing suit in the name of the Covered Person. For the actual payments made by us for services provided under the Policy, we may collect, at our option, amounts from the proceeds of any settlement (whether before or after any determination of liability) or judgment that may be recovered by the Covered Person or his or her legal representative, regardless of whether or not the Covered Person has been fully compensated. Any proceeds of settlement or judgment shall be held in trust by the Covered Person for our benefit under these subrogation provisions. Proceeds received by us will be reduced by a pro rata share of the court costs and legal fees incurred by the Covered Person applicable to the portion of the settlement returned to us. The Covered Person agrees to execute and deliver such documents (including a written confirmation of assignment, and consents to release medical records), and provide such help (including responding to requests for information about any accident or injuries and making court appearances) as we may reasonably request. Refund of Overpayments If we pay Benefits for expenses incurred on account of a Covered Person, that Covered Person, or any other person or organization that was paid, must make a refund to us if any of the following apply: • All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by the Covered Person. Such refund is not required if the Benefits were paid under Medicaid or for the treatment of tuberculosis, mental illness, or another illness covered under the Policy that is received in a hospital or other institution of the state or of a county or municipal corporation of the state, whether or not the hospital or other institution is deemed charitable. • All or some of the payment we made exceeded the Benefits under the Policy. • All or some of the payment was made in error. The refund equals the amount we paid in excess of the amount we should have paid under the Policy. If the refund is due from another person or organization, the Covered Person agrees to help us get the refund when requested. When the refund is due from the Covered Person and the Covered Person does not promptly refund the full amount, we may reduce the amount of any future Benefits for the Covered Person that are payable under the Policy. The reductions will equal the amount of the required refund. We may have other rights in addition to the right to reduce future benefits.

Subrogation and Reimbursement. We have the right to subrogation and reimbursement. References to “you” or “your” in this Subrogation and Reimbursement section shall include you, your Estate and your heirs and beneficiaries unless otherwise stated. Subrogation applies when we have paid Benefits on your behalf for a Sickness or Injury for which any third party is the substitution of one person or entity in the place of another with reference allegedly responsible. The right to a lawful claim, demand or right. We shall be subrogated subrogation means that we are substituted to and shall succeed to any and all rights legal claims that you may be entitled to pursue against any third party for the Benefits that we have paid that are related to the Sickness or Injury for which any third party is considered responsible. Subrogation Example: Suppose you are injured in a car accident that is not your fault, and you receive Benefits under the Policy to treat your injuries. Under subrogation, the Policy has the right to take legal action in your name against the driver who caused the accident and that driver's insurance carrier to recover the cost of recoverythose Benefits. The right to reimbursement means that if it is alleged that any third party caused or is responsible for a Sickness or Injury for which you receive a settlement, under judgment, or other recovery from any legal theory third party, you must use those proceeds to fully return to us 100% of any type, Benefits you receive for any actual payments made by us for services and benefits provided by us that Sickness or Injury. The right of reimbursement shall apply to any Covered Person benefits received at any time until the rights are extinguished, resolved or waived in writing. Reimbursement Example: Suppose you are injured in a boating accident that is not your fault, and you receive Benefits under the Policy as a result of your injuries. In addition, you receive a settlement in a court proceeding from the occurrence that gave rise individual who caused the accident. You must use the settlement funds to a cause return to the Policy 100% of action in which the Covered Person has recovered for medical expenses from: (i) any Benefits you received to treat your injuries. The following persons and entities are considered third parties, including any : • A person or entity alleged to have caused the Covered Person you to suffer injuries a Sickness, Injury or damages; (ii) , or who is legally responsible for the employer Sickness, Injury or damages. • Any insurer or other indemnifier of the Covered Person or (iii) any person or entity alleged to have caused or who caused the Sickness, Injury or damages. • Your employer in a workers’ compensation case or other matter alleging liability. • Any person or entity who is or may be obligated to provide benefits or payments to Covered Personsyou, including benefits or payments for underinsured or uninsured motorist protection protection, no-fault or traditional auto insurance, medical payment coverage (these auto, homeowners or otherwise), workers' compensation coverage, other insurance carriers or third parties and persons party administrators. • Any person or entities are collectively referred to as "Third Parties"); provided, however, that we will not seek to recover payments made entity against whom you may have any claim for professional and/or legal malpractice arising out of or connected to a Covered Person under a personal injury protection policySickness or Injury you allege or could have alleged were the responsibility of any third party. The Covered Person agrees • Any person or entity that is liable for payment to assign to us all rights of recovery against Third Parties, to the extent of the actual payments made us for the services and benefits that we providedyou on any equitable or legal liability theory. The Covered Person shall You agree as follows: • You will cooperate with us in protecting our legal and equitable rights to subrogation and reimbursementreimbursement in a timely manner, including, but not limited to:  Notifying us, in writing, of any potential legal claim(s) you may have against any third party for acts which caused Benefits to be paid or become payable. The Covered Person  Providing any relevant information requested by us.  Signing and/or delivering such documents as we or our agents reasonably request to secure the subrogation and reimbursement claim.  Responding to requests for information about any accident or injuries.  Making court appearances.  Obtaining our consent or our agents' consent before releasing any party from liability or payment of medical expenses.  Complying with the terms of this section. Your failure to cooperate with us is considered a breach of contract. As such, we have the right to terminate or deny future Benefits, take legal action against you, and/or set off from any future Benefits the value of Benefits we have paid relating to any Sickness or Injury alleged to have been caused or caused by any third party to the extent not recovered by us due to you or your representative not cooperating with us. If we incur attorneys' fees and costs in order to collect third party settlement funds held by you or your representative, we have the right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been returned to us. • We have a first priority right to receive payment on any claim against any third party before you receive payment from that third party. Further, our first priority right to payment is superior to any and all claims, debts or liens asserted by any medical providers, including but not limited to hospitals or emergency treatment facilities, that assert a right to payment from funds payable from or recovered from an allegedly responsible third party and/or insurance carrier. • Our subrogation and reimbursement rights apply to full and partial settlements, judgments, or other recoveries paid or payable to you or your representative, your Estate, your heirs and beneficiaries, no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic, pecuniary, consortium and punitive damages. We are not required to help you to pursue your claim for damages or personal injuries and no amount of associated costs, including attorneys’ fees, shall do nothing to prejudice be deducted from our rights under recovery without our express written consent. No so-called “Fund Doctrine” or “Common Fund Doctrine” or “Attorney’s Fund Doctrine” shall defeat this provisionright. • Regardless of whether you have been fully compensated or made whole, we may collect from you the proceeds of any full or partial recovery that you or your legal representative obtain, whether in the form of a settlement (either before or after the need for services any determination of liability) or benefits judgment, no matter how those proceeds are captioned or characterized. Proceeds from which we may collect include, but are not limited to, economic, non-economic, and punitive damages. No "collateral source" rule, any “Made-Whole Doctrine” or “Make-Whole Doctrine,” claim of unjust enrichment, nor any other equitable limitation shall limit our subrogation and reimbursement rights. • Benefits paid by us may also be considered to be Benefits advanced. • If you receive any payment from any party as a result of Sickness or Injury, and we allege some or all of those funds are due and owed to us, you and/or your representative shall hold those funds in trust, either in a separate bank account in your name or in your representative’s trust account. • By participating in and accepting Benefits under the Policy, you agree that (i) any amounts recovered by you from any third party shall constitute Policy assets (to the extent of the amount of Benefits provided on behalf of the Covered Person), (ii) you and your representative shall be fiduciaries of the Policy (within the meaning of ERISA) with respect to such amounts, and (iii) you shall be liable for and agree to pay any costs and fees (including reasonable attorney fees) incurred by us to enforce its reimbursement rights. • Our right to recovery will not be reduced due to your own negligence. • By participating in and accepting Benefits from us, you agree to assign to us any benefits, claims or rights of recovery you have under any automobile policy - including no-fault benefits, PIP benefits and/or medical payment benefits - other coverage or against any third party, to the full extent of the Benefits we have paid for the Sickness or Injury. By agreeing to provide this assignment in exchange for participating in and accepting benefits, you acknowledge and recognize our right to assert, pursue and recover on any such claim, whether or not you choose to pursue the claim, and you agree to this assignment voluntarily. • We may, at our option, take necessary and appropriate action to preserve our rights under these subrogation provisions, including but not limited to, providing or exchanging medical payment information with an insurer, the insurer’s legal representative or other third party; filing an ERISA reimbursement lawsuit to recover the full amount of medical benefits you receive for the Sickness or Injury out of any settlement, judgment or other recovery from any third party considered responsible; and filing suit in your name or your Estate’s name, which does not obligate us in any way to pay you part of any recovery we might obtain. Any ERISA reimbursement lawsuit stemming from a refusal to refund Benefits as required under the name terms of the Covered PersonPolicy is governed by a six-year statute of limitations. For • You may not accept any settlement that does not fully reimburse us, without our written approval. • We have the actual payments made authority to resolve all disputes regarding the interpretation of the language stated herein. • In the case of your death, giving rise to any wrongful death or survival claim, the provisions of this section apply to your estate, the personal representative of your estate, and your heirs or beneficiaries. In the case of your death our right of reimbursement and right of subrogation shall apply if a claim can be brought on behalf of you or your estate that can include a claim for past medical expenses or damages. The obligation to reimburse us is not extinguished by a release of claims or settlement agreement of any kind. • No allocation of damages, settlement funds or any other recovery, by you, your estate, the personal representative of your estate, your heirs, your beneficiaries or any other person or party, shall be valid if it does not reimburse us for services provided 100% of our interest unless we provides written consent to the allocation. • The provisions of this section apply to the parents, guardian, or other representative of a Dependent child who incurs a Sickness or Injury caused by any third party. If a parent or guardian may bring a claim for damages arising out of a minor's Sickness or Injury, the terms of this subrogation and reimbursement clause shall apply to that claim. • If any third party causes or is alleged to have caused you to suffer a Sickness or Injury while you are covered under the Policy, the provisions of this section continue to apply, even after you are no longer covered. • In the event that you do not abide by the terms of the Policy pertaining to reimbursement, we may collectterminate Benefits to you, at our optionyour dependents or the policyholder, amounts deny future Benefits, take legal action against you, and/or set off from any future Benefits the proceeds value of Benefits we have paid relating to any settlement (whether before Sickness or after Injury alleged to have been caused or caused by any determination of liability) or judgment that may be third party to the extent not recovered by us due to your failure to abide by the Covered Person terms of the Policy. If we incur attorneys' fees and costs in order to collect third party settlement funds held by you or his or her legal your representative, regardless of whether or not we have the Covered Person has right to recover those fees and costs from you. You will also be required to pay interest on any amounts you hold which should have been fully compensated. Any proceeds of settlement or judgment shall be held in trust by the Covered Person for our benefit under these subrogation provisions. Proceeds received by us will be reduced by a pro rata share of the court costs and legal fees incurred by the Covered Person applicable to the portion of the settlement returned to us. The Covered Person agrees • We and all Administrators administering the terms and conditions of the Policy’s subrogation and reimbursement rights have such powers and duties as are necessary to execute discharge its duties and deliver such documents functions, including the exercise of our final authority to (including a written confirmation 1) construe and enforce the terms of assignment, the Policy’s subrogation and consents reimbursement rights and (2) make determinations with respect to release medical records), the subrogation amounts and provide such help (including responding reimbursements owed to requests for information about any accident or injuries and making court appearances) as we may reasonably requestus. Refund When Do We Receive Refunds of Overpayments Overpayments? If we pay Benefits for expenses incurred on account of a Covered Personyour account, that Covered Personyou, or any other person or organization that was paid, must make a refund to us if any of the following apply: • All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by the Covered Person. Such refund is not required if the Benefits were paid under Medicaid or for the treatment of tuberculosis, mental illness, or another illness covered under the Policy that is received in a hospital or other institution of the state or of a county or municipal corporation of the state, whether or not the hospital or other institution is deemed charitableyou. • All or some of the payment we made exceeded the Benefits under the this Policy. • All or some of the payment was made in error. The refund equals the amount we paid in excess of the amount we should have paid under the this Policy. If the refund is due from another person or organization, the Covered Person agrees you agree to help us get the refund when requested. When If the refund is due from the Covered Person you and the Covered Person does you do not promptly refund the full amount, we may reduce recover the overpayment by reallocating the overpaid amount of any to pay, in whole or in part, your future Benefits for the Covered Person that are payable under the Policy. If the refund is due from a person or organization other than you, we may recover the overpayment by reallocating the overpaid amount to pay, in whole or in part; (i) future Benefits that are payable in connection with services provided to other Covered Persons under the Policy; or (ii) future Benefits that are payment in connection with services provided to persons under other plans for which we make payments, pursuant to a transaction in which our overpayment recovery rights are assigned to such other plans in exchange for such plans' remittance of the amount of the reallocated payment. The reductions will equal the amount of the required refund. We may have other rights in addition to the right to reduce future benefits.. Is There a Limitation of Action?

Subrogation and Reimbursement. Subrogation is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right. We shall be subrogated to and shall succeed to all rights of recovery, under any legal theory of any type, for any actual payments made by us for services and benefits provided by us to any Covered Person as a result of the occurrence that gave rise to a cause of action in which the Covered Person has recovered for medical expenses from: (i) third parties, including any person alleged to have caused the Covered Person to suffer injuries or damages; (ii) the employer of the Covered Person or (iii) any person or entity obligated to provide benefits or payments to Covered Persons, including benefits or payments for underinsured or uninsured motorist protection (these third parties and persons or entities are collectively referred to as "Third Parties"); provided, however, that we will not seek to recover payments made to a Covered Person under a personal injury protection policy. The Covered Person agrees to assign to us all rights of recovery against Third Parties, to the extent of the actual payments made us for the services and benefits that we provided. The Covered Person shall cooperate with us in protecting our legal rights to subrogation and reimbursement. The Covered Person shall do nothing to prejudice our rights under this provision, either before or after the need for services or benefits under the Policy. We may, at our option, take necessary and appropriate action to preserve our rights under these subrogation provisions, including filing suit in the name of the Covered Person. For the actual payments made by us for services provided under the Policy, we may collect, at our option, amounts from the proceeds of any settlement (whether before or after any determination of liability) or judgment that may be recovered by the Covered Person or his or her legal representative, regardless of whether or not the Covered Person has been fully compensated. Any proceeds of settlement or judgment shall be held in trust by the Covered Person for our benefit under these subrogation provisions. Proceeds received by us will be reduced by a pro rata share of the court costs and legal fees incurred by the Covered Person applicable to the portion of the settlement returned to us. The Covered Person agrees to execute and deliver such documents (including a written confirmation of assignment, and consents to release medical records), and provide such help (including responding to requests for information about any accident or injuries and making court appearances) as we may reasonably request. Refund of Overpayments If we pay Benefits for expenses incurred on account of a Covered Person, that Covered Person, or any other person or organization that was paid, must make a refund to us if any of the following apply: •  All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by the Covered Person. Such refund is not required if the Benefits were paid under Medicaid or for the treatment of tuberculosis, mental illness, or another illness covered under the Policy that is received in a hospital or other institution of the state or of a county or municipal corporation of the state, whether or not the hospital or other institution is deemed charitable. •  All or some of the payment we made exceeded the Benefits under the Policy. •  All or some of the payment was made in error. The refund equals the amount we paid in excess of the amount we should have paid under the Policy. If the refund is due from another person or organization, the Covered Person agrees to help us get the refund when requested. When the refund is due from the Covered Person and the Covered Person does not promptly refund the full amount, we may reduce the amount of any future Benefits for the Covered Person that are payable under the Policy. The reductions will equal the amount of the required refund. We may have other rights in addition to the right to reduce future benefits.

Subrogation and Reimbursement. Subrogation If we make Claims payment on your behalf for Injury or Illness for which another party is the substitution of one person liable, or entity in the place of another with reference to a lawful claimfor which uninsured/underinsured motorist (UIM) or personal injury protection (PIP) insurance exists, demand or right. We shall we will be subrogated to any rights that you may have to recover compensation or damages from that liable party related to the Injury or Illness, and shall succeed we would be entitled to all rights of recovery, under any legal theory be repaid for payments we made on your behalf out of any type, recovery that you obtain from that liable party after you have been fully compensated for your loss. The liable party is also known as the "third party" because it is a party other than you or us. This party includes a UIM carrier because it stands in the shoes of a third party tort feasor and because we exclude coverage for such benefits. Definitions The following terms have specific meanings in this contract:  Subrogation means we may collect directly from third parties or from proceeds of your recovery from third parties to the extent we have paid on your behalf for Illnesses or Injury caused by the third party and you have been fully compensated for your loss.  Reimbursement means that you are obligated under the contract to repay any actual payments made monies advanced by us from amounts you have received on your claim after you have been fully compensated for services and benefits provided by us to any Covered Person as a result of the occurrence that gave rise to a cause of action in which the Covered Person has recovered for medical expenses from: (i) third parties, including any person alleged to have caused the Covered Person to suffer injuries or damages; (ii) the employer of the Covered Person or (iii) any person or entity obligated to provide benefits or payments to Covered Persons, including benefits or payments for underinsured or uninsured motorist protection (these third parties and persons or entities are collectively referred to as "Third Parties"); provided, however, that we will not seek to recover payments made to a Covered Person under a personal injury protection policyyour loss. The Covered Person agrees to assign to us  Restitution means all equitable rights of recovery against Third Parties, that we have to the extent of the actual payments made us monies advanced under your plan. Because we have paid for the services and benefits that we provided. The Covered Person shall cooperate with us in protecting our legal rights to subrogation and reimbursement. The Covered Person shall do nothing to prejudice our rights under this provision, either before your Illness or after the need for services or benefits under the Policy. We may, at our option, take necessary and appropriate action to preserve our rights under these subrogation provisions, including filing suit in the name of the Covered Person. For the actual payments made by us for services provided under the PolicyInjury, we may collectare entitled to recover those expenses from any responsible third‐party once you have been fully compensated for your loss. To the fullest extent permitted by law, at our option, amounts from we are entitled to the proceeds of any settlement (whether before or after any determination of liability) or judgment that may be recovered by results in a recovery from a third party, up to the Covered Person or his or her legal representative, amount of payments we have made on your behalf after you have been fully compensated for your loss. Our right to recover exists regardless of whether it is based on subrogation, reimbursement or restitution. In recovering payments made on your behalf, we may at our election hire our own attorney to prosecute a subrogation claim for recovery of payments we have made on your behalf directly from third‐parties, or be represented by your attorney prosecuting a claim on your behalf. Our right to prosecute a subrogation claim against third‐parties is not contingent upon whether or not you pursue the Covered Person has been fully compensatedparty at fault for any recovery. Any proceeds of settlement or judgment shall be held If you recover from a third party and we share in trust by the Covered Person for recovery, we will pay our benefit under these subrogation provisions. Proceeds received by us will be reduced by a pro rata share of the court costs and legal fees incurred by expenses. Our share is that percentage of the Covered Person applicable legal expenses necessary to secure a recovery against the liable party that the amount we actually recover bears to the portion total recovery. Before accepting any settlement on your claim against a third party, you must notify us in writing of any terms or conditions offered in a settlement, and you must notify the third party of our interest in the settlement returned to usestablished by this provision. The Covered Person agrees to execute and deliver such documents (including a written confirmation of assignment, and consents to release medical records), and provide such help (including responding to requests for information about any accident or injuries and making court appearances) as we may reasonably request. Refund of Overpayments If we pay Benefits for expenses incurred on account In the event of a Covered Persontrial or arbitration, that Covered Person, or any other person or organization that was paid, you must make a refund to claim against, or otherwise pursue recovery from third‐parties payments we have made on your behalf, and give us if any reasonable notice in advance of the following apply: • All trial or some arbitration proceeding. You must also cooperate fully with us in recovering amounts paid by us on your behalf. If you retain an attorney or other agent to represent you in the matter, you must require your attorney or agent to reimburse us directly from the settlement or recovery. If you fail to cooperate fully with us in the recovery of the expenses were not payments we have paid by on your behalf, you are responsible for reimbursing us for payments we have made on your behalf. You agree, if requested, to hold in trust and execute a trust agreement in the Covered Person or did not legally have to be paid by the Covered Person. Such refund is not required if the Benefits were paid under Medicaid or for the treatment full amount of tuberculosis, mental illness, or another illness covered under the Policy that is received in a hospital or other institution of the state or of a county or municipal corporation of the state, whether or not the hospital or other institution is deemed charitable. • All or some of the payment payments we made exceeded the Benefits under the Policy. • All on your behalf from any recovery you obtain from any third‐party until such time as we have reached a final determination or some of the payment was made in error. The refund equals the amount we paid in excess of the amount we should have paid under the Policy. If the refund is due from another person or organization, the Covered Person agrees to help us get the refund when requested. When the refund is due from the Covered Person and the Covered Person does not promptly refund the full amount, we may reduce settlement regarding the amount of any future Benefits your recovery that fully compensates you for the Covered Person that are payable under the Policy. The reductions will equal the amount of the required refund. We may have other rights in addition to the right to reduce future benefitsyour loss.