Travel Insurance Conditions And General Provisions
CONDITIONS AND GENERAL PROVISIONS: The following Terms are conditions precedent to the Company's liability under the insurance provided to the Insured Person pursuant to and in accordance with the Terms of this insurance:
(1) ENTIRE AGREEMENT: The Master Policy, the Application, the Declaration and any Riders shall constitute the entire agreement among the Company, the Assured and the Insured Person. This Certificate is an outline and evidence of the insurance provided by the Master Policy. This Certificate does not extend or change the coverage provided by the Master Policy. The insurance evidenced by this Certificate is subject to all Terms of the Master Policy, the Application, the Declaration and any Riders.
(2) PREMIUM: Payment of required Premium shall be remitted to the Company:
(a) on or before the Due Date(s) specified on the Declaration
(b) on or before any renewal date subject to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision
(3) CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator at the contact information below, or online at www.imglobal.com/member as soon as possible:
International Medical Group
Attn: Claims Department
PO Box 9162
Farmington Hills, MI 48333-9162
Proof of Claim: When the Insured Person receives Treatment or the Company receives notice of a claim for benefits under this insurance, the Insured Person shall submit an International Medical Group (IMG) Claim Form as a necessary component of the Proof of Claim. An IMG Claim Form may be obtained from the form’s library on IMG’s website at www.imglobal.com or completed online via the MyIMG customer portal.
(a) A Proof of Claim shall not be effective and will not satisfy the Terms of this insurance unless it includes all the following:
(i) a duly completed, timely submitted and signed IMG Claim Form for each new Illness, diagnosis or Injury unless the Company waives such requirement in writing
(ii) an Authorization for Release of Medical Information when specifically requested by IMG
(iii) all original Universal Billing Forms, Superbill and statements of service rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim
(iv) all original receipts for any costs, prescription medications, fees or expenses that have been incurred or paid by, or on behalf of, the Insured Person with respect to the claims, including without limitation all original receipts for any cash and/or credit card payments. The provider of service’s full name, address, telephone number (including area/country code), date of service, description of service (applicable procedure codes), and diagnosis codes must be included on the receipts.
(v) If the claims are submitted electronically, copies of the above items are acceptable; however, the Company reserves the right to request the original documents.
(b) The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim. The Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage due to any of the following:
(i) IMG’s receipt of an incomplete Proof of Claim
(ii) failure to submit any Proof of Claim
(iii) Insured Person’s, Physician’s or Hospital’s failure to submit a timely Proof of Claim
(c) The Company may require the Insured Person to sign an Authorization for Release of Medical Information to request medical records on their behalf or supply us with additional documentation if we are unable to make a benefit determination based on the submitted Proof of Claim. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have sixty (60) days from the date of the request to submit the requested information. If the information is not received within the designated time period, previously submitted and subsequent claims will be denied.
(4) APPEALING A CLAIM: In the event the Company denies all or part of a claim, the Insured Person shall have sixty (60) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination. The Insured Person must file an appeal prior to bringing any legal action under the contract of insurance. The Insured Person should submit a written request for an appeal along with comments, all relevant, pertinent or related documents, medical records and other information relating to the claim.
The appeal must be sent to:
International Medical Group
Attn: Benefit Review
2960 N. Meridian Street
Indianapolis, IN 46208
The Company’s review will take into account all comments, documents, records and other information submitted by the Insured Person relating to the claim without regard to whether such information was submitted or considered in the initial claim determination. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the CONDITIONS AND GENERAL PROVISIONS, EXPLANATION OR VERIFICATION OF BENEFITS provision and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.
(5) ASSIGNMENT, CHANGE OR WAIVER: Notwithstanding any law, statute, judicial decision or rule to the contrary that may be or may purport to be otherwise applicable within the jurisdiction, locale or forum state of any healthcare or medical service provider, no transfer or assignment of any of the Insured Person's rights, benefits or interests under this insurance shall be valid, binding on or enforceable against the Company or Plan Administrator unless first expressly agreed and consented to in writing by the Company. Any such purported transfer or assignment not in compliance with the foregoing Terms shall be void ab initio and without effect as against the Company or Plan Administrator, and the Company shall have no liability of any kind under this insurance to any such purported transferee or assignee with respect thereto. The Terms of the Master Policy as evidenced by this Certificate shall not be waived or modified except by the express written agreement of the Company.
(6) SERVICE OF SUIT; VENUE; CHOICE OF LAW: No action or proceeding of any kind can be brought by an Insured Person to recover on the contract of insurance prior to the later of (a) expiration of sixty (60) days after written Proof of Claim has been furnished in accordance with the contract of insurance or (b) exhaustion of one (1) appeal under the CONDITIONS AND GENERAL PROVISIONS, APPEALING A CLAIM provision above. No action or proceeding can be brought after the expiration of three (3) years after the time written Proof of Claim is required to be furnished under the contract of insurance. The contract of insurance between the Insured Person and the Company, as evidenced by the Master Policy and this Certificate, shall be deemed issued, finalized and made in Indianapolis, Indiana. Sole and exclusive jurisdiction and venue for any action or proceeding of any kind relating to or arising from this insurance and/or the Terms and conditions of this Certificate (including any amendment thereto) shall be in Marion County, Indiana, for which the Company and the Insured Person expressly consent. The subjects, risks and benefits of insurance covered by the Master Policy and evidenced by this Certificate are not intended or considered by the Insured Person or the Company (or the Plan Administrator) to be resident, located, or performed in any particular State of the United States. Indiana surplus lines law shall govern all rights and claims relating to or arising from this insurance and/or this Certificate (including any amendment thereto).
In the event of the failure of the Company to provide benefits or pay or reimburse any amount claimed to be due under this insurance, the Company, at the request of the Insured Person and upon receipt of lawful process or summons, will submit to the jurisdiction of a court of competent subject matter jurisdiction located in Marion County, Indiana, provided there exists an independent statutory and constitutional basis for in personam jurisdiction over the Company in said court and by said forum State. The Company and the Insured Person consent to personal jurisdiction and venue in the Circuit and/or Superior Courts of Marion County, Indiana, and in the United States District Court for the Southern District of Indiana, Indianapolis Division (assuming that federal jurisdiction is otherwise appropriate and lawful). The Company reserves the right, acting by and through the Plan Administrator or otherwise, to initiate and pursue actions for declaratory judgment and/or other appropriate relief with respect to the validity, binding effect, administration of and/or any dispute, claim, or controversy relating to or arising from this insurance. In any suit instituted by or against the Company or the Insured Person pursuant to the Terms of this provision, the Company and the Insured Person will abide by the final decision of such Indiana court or of any appellate court in the event of an appeal. Nothing in this provision constitutes or should be deemed, considered or understood to constitute a waiver of the Company's or the Insured Person’s rights to: (i) oppose venue or jurisdiction in any forum other than the Circuit or Superior Courts of Marion County, Indiana, or the United States District Court for the Southern District of Indiana, Indianapolis Division (assuming that federal jurisdiction is otherwise appropriate and lawful), or (ii) remove an action to the United States District Court for the Southern District of Indiana, Indianapolis Division (assuming that federal jurisdiction is otherwise lawful and appropriate); all of which rights are expressly reserved and retained.
Subject to and without limiting, expanding, superseding, modifying or waiving any of the foregoing Terms contained in this provision pursuant to any statute of any State, territory or district of the United States which makes provision thereof, the Company hereby designates the Superintendent, Commissioner, or Director of Insurance (or such other officer specified for that purpose in the statute), or their successor or successors in office, as its true and lawful attorney, under a special power of attorney, upon whom may be served any lawful process issued in connection with the initiation of any action, suit or proceeding instituted by or on behalf of the Insured Person arising out of this insurance, including specifically the Commissioner of Insurance for the Indiana Department of Insurance, 311 West Washington Street, Suite 300, Indianapolis, IN 46204, and hereby designates and appoints John N. Emmanuel, Locke Lord, LLP, Brookfield Place, 200 Vesey Street, 20th Floor, New York, New York 10281-2101, as its attorney-in-fact and agent for service of process to whom said officer or Commissioner is authorized to mail or serve any such process or a true copy thereof.
In the event that the Company is the prevailing party in any litigation, arbitration, or other proceeding of any kind relating to or arising from this insurance and/or the Terms and conditions of this Certificate (including any amendment thereto), regardless of the nature of the claim, the Company shall be awarded its reasonable attorney fees, and costs and expenses incurred in addition to any compensatory damages or other remedies in law or equity.
For Florida residents only: Any dispute, claim, or controversy of any kind, whether sounding in contract, tort, or otherwise, relating to or arising from this insurance and/or the Terms and conditions of this Certificate may be resolved by binding arbitration upon the request of the Company, the Assured, or the Insured Person. Any such arbitration shall be conducted in accordance with the procedures of the American Arbitration Association. Any such arbitration shall be held within fifty (50) miles of the Insured Person’s residence, with the Company to pay costs and fees (not including any attorney fees) of the proceeding in excess of five hundred dollars ($500.00).
(7) WAIVER OF ANY RIGHT TO JURY TRIAL: THE COMPANY AND THE INSURED PERSON EACH KNOWINGLY, VOLUNTARILY, AND IRREVOCABLY WAIVE ANY RIGHT TO A TRIAL BY JURY FOR ANY CLAIM, DEMAND, ACTION, OR PROCEEDING OF ANY KIND, WHETHER SOUNDING IN CONTRACT, TORT, OR OTHERWISE, RELATING TO OR ARISING FROM: (I) THIS INSURANCE; AND/OR (II) THIS CERTIFICATE, INCLUDING ANY AMENDMENT THERETO.
THE COMPANY AND THE INSURED PERSON EACH KNOWINGLY, VOLUNTARILY AND IRREVOCABLY AGREE THAT ANY SUCH CLAIM, DEMAND, ACTION, OR PROCEEDING SHALL BE EXCLUSIVELY PRESENTED TO AND DETERMINED SOLELY BY THE COURT AS THE TRIER OF FACT, AND NOT BEFORE A JURY. NO ATTEMPT SHALL BE MADE TO CONSOLIDATE, BY COUNTERCLAIM OR OTHERWISE, ANY ACTION OR PROCEEDING WITH ANY OTHER ACTION OR PROCEEDING IN WHICH THERE IS A TRIAL BY JURY OR IN WHICH A JURY TRIAL CANNOT OR HAS NOT BEEN WAIVED. THE COMPANY AND THE INSURED PERSON EACH AGREE THAT A COPY OF THIS PROVISION MAY BE FILED WITH ANY COURT AS WRITTEN EVIDENCE OF THE AGREEMENT OF THE WAIVER OF ANY RIGHT TO TRIAL BY JURY.
(8) ECONOMIC SANCTIONS: The Company will not cover any person as an Insured Person if such cover would result in the Company being exposed to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws, or regulations of the European Union, United Kingdom or the United States of America.
(9) MISREPRESENTATION: Any false representation, incomplete information, misleading statement, misstatement, omission, concealment or fraud, whether or not innocently made, either in the Insured Person's Application or in relation to any claim form, statement, certification or warranty made by the Insured Person or their representatives, agents or proxies, whether in writing or otherwise, to the Company or the Plan Administrator or their respective agents, employees or representatives, or in connection with the making of any claim under this insurance, shall render the Declaration and this Certificate null and void and all claims and benefits under this insurance shall be forfeited and waived.
(10) INSOLVENCY: The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors or dissolution of the Assured or any Insured Person shall not impose upon the Company any liability or obligation other than that specifically included in this insurance.
(11) SUBROGATION CLAUSE: The Insured Person shall undertake to pursue in their own name and stead, and to fully cooperate with the Company in the pursuit and prosecution of, any and all valid claims that the Insured Person may have against any third party who may be liable or responsible for any loss or damage arising out of any act, omission or occurrence that results or may result in a loss payment, provision of benefits or coverage of claim by the Company under this insurance and to fully account to the Company for any amounts recovered or recoverable in connection therewith, on the basis that the Company shall be reimbursed and entitled to recover first in full for any sums paid or to be paid by it before the Insured
Person shares in any amount so recovered, regardless of whether or not the Insured Person has been made whole or has been fully compensated for their injuries. The Insured Person further agrees and understands that the Company requires the Insured Person to complete a subrogation questionnaire, sign an acknowledgment of the Company's subrogation rights and sign an agreement before the Company considers paying, or continues to pay, any claims. Should the Insured Person fail to so cooperate, account or prosecute any valid claims against any such third party or parties, and the Company thereupon or otherwise becomes liable or otherwise obligated to make payment under the Terms of this insurance, then the Company shall be fully subrogated to all rights and interests of the Insured Person with respect thereto and may prosecute such claims in its own name as subrogee.
The Insured Person’s submission of Proof of Claim or acceptance of coverage or benefits under this insurance shall be deemed to constitute an authorization, consent and assignment of such subrogation rights by the Insured Person to the Company. The Insured Person agrees that the Company has a secured proprietary interest in any settlement proceeds the Insured Person receives or may be entitled to receive.
The Insured Person understands and agrees that the Company is entitled to a constructive trust interest in the proceeds of any settlement or recovery. The Insured Person agrees to include the Company as a co-payee on any settlement check or check from any third party or insurer. The Insured Person agrees he/she will not release any party or their insured without prior written approval from the Company and will take no action that prejudices the Company's rights.
The Insured Person is obligated to inform their legal representative of the Company’s rights and lien and to make no distributions from any settlement or judgment that will in any way result in the Company receiving less than the full amount of its lien without the written approval of the Company. Any amount recovered by the Company in accordance with the foregoing shall first be used to pay in full the costs and expenses of collection incurred by the Company, including reasonable attorneys’ fees, and for reimbursement to the Company for any amount that it may have paid or become liable to pay under this insurance. Any remaining amounts recovered shall be paid to the Insured Person or other persons lawfully entitled thereto, as applicable. In the event that the Insured Person receives any form or type of settlement and either fails or refuses to abide by the Terms of this insurance contract, in addition to any other remedies the Company may have, the Company retains a right of equitable offset against future claims.
(12) OTHER INSURANCE: The Company shall not be liable or obligated to provide any coverage or benefits or to pay or reimburse any claim under this insurance if there is any other insurance, membership benefit, workers’ or workplace compensation coverage program or other government programs, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or any other third-party obligation or liability for provision of benefits (“Other Coverage”) that would, or would but for the existence of this insurance, be available or obligated to provide such benefit or to pay or reimburse or provide indemnity for such claim, except in respect of any excess beyond the amount payable or provided under such Other Coverage had this insurance not been effected. Notwithstanding the foregoing, the Company shall not be liable or obligated to provide any benefit or to pay or reimburse any claim for any Insured Person in respect to Treatment or supplies furnished by any program or agency funded by any government or governmental authority.
The Company reserves the right to cancel any and all coverage if it is determined an Insured Person has Stacked Insurance.
(13) CANCELLATION BY INSURED PERSON: The Insured Person shall have three (3) days from the Initial Effective Date of Coverage (the “Review Period”) to review the benefits, conditions, limitations, exclusions and all other Terms of the Master Policy as evidenced and outlined by this Certificate. If not completely satisfied, the Insured Person may request cancellation of this insurance retroactive to the Initial Effective Date of Coverage by sending a written request to the Company by email, mail or fax and received by the Company within the Review Period, thereby qualifying to receive a full refund of Premium paid. Upon effectuation of such cancellation and refund, neither the Company nor the Insured Person shall have any further rights, liabilities or obligations under this insurance. After the Review Period, the Insured person may request cancellation by sending a written request to the Company by email, mail or fax. However, the following conditions apply for Premium refund:
(a) If any claims have been filed with the Company, the Premium is fully earned and is non-refundable.
(b) If no claims have been filed with the Company:
(i) a cancellation fee of fifty dollars ($50.00 USD) will be charged regardless of the reason for cancellation
(ii) only Premium covering time periods after cancellation are refundable
(14) APPLICABLE CURRENCY: All benefit amounts, coverage, monetary limits and sub-limits, and other amounts stated in the Master Policy, the Application, the Declaration, this Certificate, and in any Riders, including Premium, are in USD (United States Dollars).
(15) COOPERATION: The Insured Person and their Physicians, Hospitals and other healthcare and medical service providers and suppliers shall undertake to cooperate fully with the Company and the Plan Administrator in reviewing, investigating, adjudicating, considering an appeal of, and/or administering any claim for benefits under this insurance, including granting full right of access to all relevant, pertinent or related records, medical documentation, medical histories, reports, laboratory or test results, x-rays, and all other available evidence relating to or affecting the review, investigation, adjudication or administration of the claim. The Company at its own expense shall have the right and opportunity to examine all evidence related to a claim when and as often as it may reasonably require during the pendency of a claim hereunder. The Company at its option may suspend or pend adjudication of a claim and/or may deny benefits and/or coverage for a claim when any of the following has occurred:
(a) a refusal to so cooperate
(b) an unreasonable delay in such cooperation
(c) any other act or omission on the part of the Insured Person and/or their healthcare providers which hinders, delays, impairs or otherwise prejudices the performance of the Company’s obligations under this insurance.
(16) CLAIM SETTLEMENT: Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have previously been paid by or on behalf of the Insured Person at the time of the Company’s favorable adjudication thereof will be reimbursed by the Company directly to the Insured Person, by check, at their last known residence or mailing address. While this insurance is in effect, in order to effectuate proper administration, the Insured Person shall undertake to promptly notify the Company of any change in such addresses. Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have not been paid by or on behalf of the Insured Person at the time of adjudication will be paid by the Company by check or electronic funds transfer to the Insured Person at their last known residence or mailing address, or, at the sole option and discretion of the Company (but without obligation to do so), and as an accommodation to the Insured Person, directly to the provider(s), as applicable. All claim settlements, payments and reimbursements are subject to the insurance plan shown in the Declaration and all other Terms of this insurance. No healthcare or medical service provider or supplier, or any other third-party, shall have any direct or indirect interest, claim or right of action against the Company under this Certificate, the Declaration or the Master Policy, whether by purported assignment of benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Company, and notwithstanding the Company’s exercise or failure to exercise any option or discretion under this provision regarding the method of claim payment. No such provider, supplier or other third-party is intended to have or shall have any rights as a third-party beneficiary under this Certificate, the Declaration, or the Master Policy.
(17) FRAUDULENT CLAIMS: A person who knowingly and with intent to defraud the Company files a statement of claim containing any false, incomplete, or misleading information commits a felony. If any claim or request for benefits under this insurance shall knowingly be in any respect false, incomplete, misleading, concealing, fraudulent or deceitful or if the Insured Person or anyone acting for or on their behalf under this insurance knowingly uses any false, incomplete, misleading, concealing, fraudulent or deceitful statements regarding the Insured Person, the insurance contract and all coverage thereunder may be cancelled, voided, rescinded and terminated by the Company in its sole and absolute discretion, and the Company shall have no obligation or liability for any such benefits, coverage or claims.
(18) ARBITRATION: With the exception of Florida residents’ option to refer to arbitration, no claim for benefits for which liability, eligibility, or coverage under this insurance has been denied in whole or in part by the Company nor any other dispute or controversy arising under or related to this insurance shall be arbitrable or subject to arbitration under any circumstances or for any reason.
(19) TERMINATION OF MASTER POLICY: The Master Policy can be terminated at any time by either the Company or the Assured by giving at least thirty (30) days written notice to the other and to the Insured Person. Such termination will have no effect on this Certificate prior to the date of the termination or on eligible coverage or benefits under this insurance accrued prior thereto. No additional Certificates will be issued or further Applications accepted for the plan after the date the Master Policy is terminated.
(20) TERMINATION OF COVERAGE FOR INSURED PERSONS: Coverage and benefits for the Insured Person under this insurance will terminate effective at 12:01 AM EST on the earliest of the following dates:
(a) the date the Master Policy is terminated pursuant to the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision
(b) the next day following the end of the coverage period for which Premium has been fully and timely paid
(c) the termination date as shown on the Declaration for this Certificate
(d) the date the Insured Person first fails to meet or no longer meets the eligibility requirements for this insurance as set forth in the Master Policy and outlined in this Certificate
(e) the date on which the Insured Person is in the United States and has exceeded the Maximum Limit as shown in the BENEFIT SUMMARY pursuant to the EMERGENCY TREATMENT WHILE TRAVELING THROUGH THE UNITED STATES and the EMERGENCY MEDICAL EVACUATION TO THE UNITED STATES AND ASSOCIATED TREATMENT provision
(f) the date on which the Insured Person is in the United States and has exceeded the permitted length and Maximum Limit as shown in the BENEFIT SUMMARY pursuant to the EMERGENCY TREATMENT DURING INCIDENTAL TRIP TO COUNTRY OF RESIDENCE provision
(g) the date the Insured Person returns to their Country of Residence unless covered as an EMERGENCY TREATMENT
DURING INCIDENTAL TRIP TO COUNTRY OF RESIDENCE
(h) the date the Company, at its sole option, elects to cancel from this plan all Insured Persons of the same sex, age, class or geographic location as the Insured Person, provided the Company gives no less than thirty (30) days advance written notice by mail to the Insured Person's last known residence or mailing address of its intent to exercise such option
(i) the cancellation date specified by the Company pursuant to the CONDITIONS AND GENERAL PROVISIONS, CANCELLATION BY INSURED PERSON provision
(j) the cancellation date specified by the Insured Person pursuant to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision
(k) the next day following the maximum time period pursuant to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision
(l) the date specified by the Company in any notice of cancellation, forfeiture or rescission issued pursuant to or as a result of the circumstances described in the MISREPRESENTATION, FRAUDULENT CLAIMS and RIGHT OF RECOVERY subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, or as otherwise permitted by the Terms of this insurance.
Coverage for the Insured Person shall remain in full force and effect unless terminated pursuant to this provision, except as otherwise provided in the Master Policy, the Declaration, or this Certificate.
(21) RENEWAL; AMENDMENTS: Subject to the Terms of the TERMINATION OF MASTER POLICY and TERMINATION OF COVERAGE FOR INSURED PERSONS subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, an Insured Person can request coverage under this insurance plan to be extended a minimum of five (5) days for up to a three hundred sixty-five (365) day period until reaching a maximum of twenty-four (24) continuous months in accordance with and subject to the Terms of the plan then in effect (including the Terms of the then applicable Master Policy) and so long as extension Premium is paid when due and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan.
The Company’s commitment and the Insured Person’s ability to request extension is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. The Company reserves the right in its sole discretion to make changes, additions, and/or deletions to the Terms of the Master Policy, this Certificate, extensions or replacements of either, and/or to the insurance plan (including the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of this Certificate, upon no less than thirty (30) days prior written notice to the Assured and the Insured Person (Notice of Amendment). The Notice of Amendment shall include a complete description of the changes, additions, and/or deletions to be made, the Effective Date thereof (the Change Date), and notice of the Insured Person’s cancellation rights and shall be sent first class mail, postage prepaid, to the last known residence or mailing address of the Insured Person. Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate, at any time prior to the Change Date; provided, however that cancellation under this provision shall be at the option of the Insured Person and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the Terms of the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS provision). If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions, and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.
(22) PATIENT ADVOCACY: Neither the Company nor the Plan Administrator shall have any right, obligation, or authority of any kind to ultimately select Physicians, Hospitals or other healthcare or health service providers for the Insured Person or to make any medical Treatment decisions for or on behalf of the Insured Person, and all such decisions shall be made solely and exclusively by the Insured Person and/or their guardians, Relatives, Treating Physicians and other healthcare providers. Subject to the foregoing, the Company may determine that a particular claim, benefit, Treatment or diagnosis occurring under or relating to this insurance may be placed under the Company’s Patient Advocacy program to ensure that Medically Necessary Treatment and supplies are provided in the most cost-effective manner. In the event the Company determines that a claim, benefit, Treatment, or diagnosis meets the Company’s Patient Advocacy program guidelines, the Company will notify the Insured Person as soon as reasonably practicable, and a Patient Advocate will be assigned to the Insured Person. Thereafter, the Company’s Patient Advocate may make evaluations and/or recommendations of Treatment settings, procedures and/or supplies that may be more cost effective for the Company and/or the Insured Person. Such recommendations will be made with input from the Insured Person and/or the Insured Person's guardians, Relatives, Treating Physicians and/or other healthcare providers and will be made only when it can be reasonably demonstrated that the Medically Necessary Treatment and/or supplies can be provided in a more cost-effective manner to the Company and/or the Insured Person. The Company will use its best efforts to evaluate and recommend Treatment settings, procedures and/or supplies that can reasonably be expected to result in the same or better care of the Insured Person. The Insured Person is under no obligation to accept or follow any of the Company’s recommendations. However, if the Insured Person accepts and follows any of the Company's recommendations, the Insured Person agrees to hold the Company and the Company’s agents and representatives, including the Patient Advocate, harmless from same, and the Company shall not be held liable or otherwise responsible for any Treatment or supply provided to the Insured Person except for the payment of claims and benefits eligible for coverage under the Terms of this insurance. After the Insured Person has been notified that the claim, Treatment, benefit or diagnosis meets the Company’s Patient Advocacy program guidelines, the Company reserves the right, at its option and in its sole discretion without liability:
(a) to make payment for Treatment and/or supplies that, although not expressly covered under this insurance, may be beneficial to the Insured Person and cost-effective to the Company
(b) to deny coverage and/or benefits for any Charges, including Eligible Medical Expenses otherwise eligible for coverage but for the Terms of this provision, which exceed the amount the Company would have covered had the Insured Person accepted and followed the recommendations of the Patient Advocacy program.
(23) RIGHT OF RECOVERY: In the event of overpayment by the Company of any claim for benefits under this insurance, for any reason, including without limitation because of any of the following:
(a) all or part of the claim was not incurred by or paid by or on behalf of the Insured Person
(b) the Insured Person or any of the Insured Person's Relatives, whether or not the Relative is or was an Insured Person under this insurance plan, is repaid or is entitled to be repaid for all or part of the claim in accordance with the CONDITIONS AND GENERAL PROVISIONS, OTHER INSURANCE provision, for defective equipment or medical devices covered under a warranty, or by or from a source other than the Company
(c) all or part of the claim was not eligible for payment or coverage under the Terms of this insurance
(d) all or part of the claim was paid or reimbursed based on an incorrect or mistaken application of benefits under this insurance
(e) all or part of the claim has been excused, waived, abandoned, forfeited, discounted or released by the provider
(f) the Insured Person is not liable or responsible as a matter of law for all or part of a claim. The Company shall have the right to receive a refund and to recover the amount of overpayment from the Insured Person and/or the Hospital, Physician and/or other provider of services or supplies (as the case may be). The amount of the refund and recovery for overpayment of claims shall be the difference between the amount actually paid by the Company and the amount, if any, that should have been paid by the Company under the Terms of this insurance.
For all other overpayments, the amount of the refund and recovery shall be the amount overpaid.
If the Insured Person, Hospital, Physician, or other provider of services or supplies does not promptly make any such refund to the Company, the Company may, in addition to any other rights or remedies available to it (all of which are reserved):
(i) reduce or deduct from the amount of any future claim that is otherwise eligible for coverage or payment under this insurance, to the full extent of the refund due to the Company; and/or
(ii) cancel this Certificate and all further coverage of the Insured Person under the Master Policy by giving thirty
(30) days advance written notice by mail to the Insured Person at their last known residence or mailing address and offset against the amount of any refund of Premium due the Insured Person to the full extent of the refund due to the Company.
(24) EXPLANATION OR VERIFICATION OF BENEFITS: In the event of any verbal or telephone inquiry, every attempt will be made to help the Insured Person and their healthcare providers and suppliers understand the status, scope and extent of available benefits and coverage under this insurance, provided, however, that no statement made by any agent, employee or representative of the Company or the Plan Administrator will be deemed or construed as an actionable representation, promise or estoppel or will create any liability against the Company or the Plan Administrator or be deemed or construed to bind the Company or to modify, replace, waive, extend or amend any of the Terms of the Master Policy or this Certificate, unless expressly set forth in writing and signed by an authorized agent or representative of the Company. Actual eligibility determinations, benefit verifications, final coverage decisions, claim adjudications, final payments, reimbursements of benefits, or claims shall be determined and adjudicated only after or at the time a proper and complete Application and/or Proof of Claim is submitted (as the case may be), an opportunity for reasonable investigation and/or review is provided, cooperation required hereunder received, and all facts and supporting information, including relevant data, information and medical records when deemed necessary or appropriate by the Company, are presented in writing. Appealed claims may be further investigated and/or reviewed. The Terms of the Master Policy govern all available coverage and payments made or to be made. If a definite answer to a specific benefits or coverage question is required for any reason, the Insured Person or their healthcare providers may submit a written request to the Company, including all pertinent medical information and a statement from the attending Physician (if applicable), and a written reply will be sent by the Company and kept on file. If the Company elects to verify generally and/or preliminarily to a provider or the Insured Person that an Injury, Illness, diagnosis or proposed Treatment is or may be covered under this insurance, or that benefits for same are or may be available as outlined in this Certificate, any such verification of benefits does not guaranty either payment of benefits or the amount or eligibility of benefits. Final eligibility determinations, coverage decisions, claim appeals and actual reimbursement or payment of claims or benefits are subject to all Terms of this insurance, including without limitation filing a proper and complete Proof of Claim and complying with the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision.