SSMC Employee Health Benefit Plan
82
SECTION IX - OTHER PROCEDURES AND PROVISIONS
A. Not an Employment Contract
All rights accruing to any person under the Plan shall be subject to the terms and conditions of the Plan. The
Plan shall not constitute a contract between the Plan Administrator, Plan Sponsor or the Claims
Administrator, and any Covered Employee or Dependent, nor shall it be considered an inducement for the
initial, or continued, employment of any Employee. Likewise, maintenance of the Plan shall not be construed
to give any Employee the right to be retained as an Employee by the Plan Sponsor, or to any benefits not
specifically provided by the Plan.
B. Verification of Claim Information
The Plan Administrator and the Claims Administrator have the right to request, from you or your Dependents,
Hospitals, approved facilities, Physicians or other Providers, any medical records or information that is
necessary for the proper handling of claims. When you become covered under the Plan, you automatically
give permission to the Plan Administrator and the Claims Administrator to obtain, and use, those records and
that information. Failure to release such information on a timely basis, or failure by the Enrollee, patient,
parent, or guardian to authorize the release of appropriate information, could result in denial of benefits. The
Claims Administrator confidentially maintains all medical records.
C. Right of Examination
The Plan Administrator or the Claims Administrator shall have the right, to require an independent medical
examination for you or your Eligible Dependent when, and so often as, it may reasonably require such
examin ation during the determination of a claim. The Plan Administrator will pay all such examinations in
full. Failure of the Covered Person to be examined when required could result in denial of benefits.
D. Indemnity Benefits
Benefits under the Plan are only payable for services actually rendered or delivered. Except as otherwise
specified, benefits cannot be pre-approved. Benefit determination will be based on Plan limitations
(eligibility, benefits, etc.) and exclusions in effect at the time services are rendered.
E. Misrepresentation/Fraud
If it is found that a claim for benefits, or any materials provided for evaluating a claim for benefits under the
Plan, contains false information, or that you or your Dependent or a Provider conceals, for the purpose of
misleading, information concerning any fact material to a claim for benefits thereto, such claim may be
denied in total and the Plan Administrator and/or the Claims Administrator may recover any benefits paid to
you and/or a Provider. This paragraph does not affect the right of the Plan Administrator to pursue any
criminal or civil remedies that may exist under applicable state or federal law.
F. Refund Due to Overpayment of Benefits
If payment has been made for Covered Services or Supplies under the Plan that are more than the benefits
that should have been paid, or for Services or Supplies that should not have been paid, according to Plan
provisions, the Plan Administrator or the Claims Administrator shall have the right to demand a full refund,
or may cause the deduction of the amount of such excess or improper payment from any subsequent benefits
payable to such Covered Person or other present or future amounts payable to such person, or recover such
