Community First Health Plans - EOC:Subrogation and Reimbursement Rights

Sometimes another person or entity may be liable to You for medical services covered by Community First under this Certificate. For example, if a Member is injured in an automobile accident caused by another driver, the other driver or that driver’s automobile insurance carrier may be liable to the Member for medical expenses incurred because of the injuries. If Community First pays or provides benefits for Member under this Group Health Care Coverage, Community First is subrogated to all rights of recovery which Member has in contract, tort or otherwise against any person, organization or insurer for the amount of benefits Community First has paid or provided. That means Community First may pursue Member’s rights in its own name or the name of Member, to recover money through judgment, settlement or otherwise from any person, organization or insurer.

Upon receiving any benefits from Community First, you are considered to have assigned your rights of recovery to Communtiy First to the extent of such benefits. If you have retained an attorney to pursue your rights of recovery, Community First is not responsible for paying any portions of your attorney’s fees or costs. Community First’s rights will not be affected by any release that is entered into without the consent of Communtiy First.

Each Member agrees to reimburse Community First as described in these provisions in return for Community First providing services, supplies or benefits for a Member’s Illness or Injury:

1.	for which another person, corporation, or other entity (called Third Party below) is considered responsible; or

2.	that arises out of, or in the course of, any work for wage or profit and is covered by any workers' compensation law, occupational disease law, or similar law.

Such reimbursement will be made only to the extent of any such payments or collections actually received from or for a responsible Third Party as a settlement, judgment, or in any other way. If You receive any such payments or collections and You do not reimburse Community First for amounts due, Your coverage could be terminated for cause. See "WHEN YOUR COVERAGE ENDS, Nonpayment of Amounts Due Under the Contract".

Such reimbursement will be made whether or not liability for the payments is admitted by the Third Party. It will be made whether or not such payments are itemized.

Community First will have a lien on any such payments or collections to the extent of the amount or reimbursement to which it is entitled under these provisions.

Community First also has a right of reimbursement where Member has recovered amounts from any sources due to an injury, illness or ommision for any sources including but not limited to:

1.	Payment made by a Third Party or any insurance company on behalf of the Third Party;

2.	Uninsured or underinsured motorist coverage policy;

3.	Workers’ Compensation or disability award or settlement;

4.	Automobile policy medcial payments coverage;

5.	Premises or homeowners medical payments coverage;

6.	Premises or homeowners insurance coverage;

7.	Any other payments from a source intended to compensate a Member for Third Party injuries.

Immediately upon receipt of any payments or collection of damages (as a settlement, award, judgment or in any other way) with respect to such Illness or Injury, the Member involved (or if incapable, that person’s legal representative) will reimburse Community First for:


1.	The actual costs incurred for any benefits provided directly by Community First as a result of the Illness or Injury; and

2.	The actual costs paid by Community First for medical services required by the Member as a result of the Illness or Injury.

Such reimbursement will be made only to the extent of any such payments or collections actually received from a responsible Third Party as a settlement, judgment, or in any other way.

Workers’ Compensation. If benefits are provided to Community First Members for Basic Health Care Services covered under Workers’ Compensation benefits, Community First will seek reimbursement from the financially responsible party. The Member will cooperate with Community First to ensure that Community First is reimbursed for the actual cost paid for any benefits provided to the Member. The Member must complete forms and provide any information as may be necessary to assist Community First in obtaining reimbursement.
With respect to subrogation and reimbursement by Community First under these provisions, Community First will not be responsible for any legal fees and expenses unless specifically agreed to in writing.
Member agrees to cooperate with Community First in order to protect Community First’s subrogation and reimbursement rights. Member agrees to promptly furnish to Community First all information which Member has concerning Member’s rights of recovery from a Third Party, including information on any claims made or suits filed, and to fully assist and cooperate with Community First in protecting and obtaining its reimbursement and subrogation rights. The Member involved will execute
and deliver to Community First such documents, agreements and information requested by Community First in order to enforce its rights hereunder. The Member agrees to obtain the consent of Community First before settling any claim or suit or releasing a party from liability for payment of medical expenses resulting from the Illness or Injury. The Member also agrees to refrain from taking any action or making any statement to prejudice Community First’s recovery rights under these provisions.
Nothing in these provisions requires Community First to pursue the Member’s claim against any Third Party for damages or claims or causes of action that the Member might have against such Third Party as a result of the Illness or Injury.
Community First may designate a person, agency or organization to act for it in matters related to subrogation or reimbursement, and Member agrees to cooperate with such designated person, agency, or organization the same as if dealing with Community First itself.