SSMC Employee Health Benefit Plan
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amounts by any other appropriate method that the Plan Administrator, in its sole discretion, shall decide.
Each Covered Person hereby authorizes the deduction of such excess payment from such benefits, or other
present or future benefit payments. Payments made in error for Services or Supplies not Covered by this Plan
shall not be considered certification of coverage and will not limit the enforcement of any provision of this
Plan for any and all claims submitted under the Plan.
G. Right of Subrogation/Reimbursement
The conditions shown below do not apply to benefits paid under Medicare coverage nor to any payments
made under any insurance policy, plan or certificate issued to you or your Dependents.
This Plan specifically does not provide any coverage with respect to any Illness or Injury for which a third
party may be liable or legally responsible. If you or your Dependent receive payment or expect payment from
a third-party insurance, surety or other type plan, not owned by or issued to you or your Dependent, for
medical expenses resulting from such Illness or Injury, you should not submit a claim under this Plan for such
medical expenses. Any Plan benefits paid against such claims will be considered an overpayment. The Plan
will exercise its right to full reimbursement for resulting overpayments. However, if for some reason the
third-party claim payment or settlement is delayed for an extended time, the Plan Administrator may, at its
option, authorize Plan benefits for medical expenses that would otherwise be covered by this Plan. The rules
shown below govern how this Plan pays benefits in such situations.
1. Conditional Benefit Payment. If a Covered Person has medical expenses resulting from an Injury,
accident or Illness for which a third party is, or may be, held responsible and such third-party payment or
settlement is withheld for an extended period, the Plan Administrator may, at its option, authorize
conditional interim benefit payments for medical expenses that would otherwise be covered by the Plan.
However, any advance payments are subject to the Plan's subrogation or reimbursement rights. Before
such benefits are conditionally made, you and/or your Eligible Dependent, or authorized representative, if
a minor, must execute an agreement that acknowledges and affirms (a) the conditional nature of such
benefit payments and (b) the Plan's rights of subrogation/reimbursement, as shown below.
2. Reimbursement
Agreement. If benefits are paid or payable by this Plan as the result of an action of a
third party, this Plan will be subrogated to all rights of recovery of any Covered Person under this Plan in
respect to such action. In addition, once it is determined that a third party is liable in any way for the
Injuries or Illness giving rise to these expenses, in order to receive benefits, or to continue receiving
benefits from this Plan, you must take the following steps or all benefit payments to you will be stopped.
You are required to advise this Plan in writing of any expenses for which a third party may be liable. You
and/or your Eligible Dependent, or authorized representative if a minor or if unable to sign, must execute
and deliver such documents, notices or papers as may be required and must do whatever else is needed to
secure the Plan rights, including the following:
a. You and/or your Eligible Dependent, or legal representative must agree, in writing, to provide the
Claims Administrator with written notice whenever a claim is asserted or could be asserted against
and/or recovery is received from any third party (or insurer or surety thereof) for damages as the
result of the Illness or Injury; and
b. You and/or your Eligible Dependent, or legal representative must agree, in writing, on a form
acceptable to the Claims Administrator, to reimburse this Plan for any benefits paid by this Plan due
to such Illness or Injury for which a third party recovery is received. Such Plan benefits must be
reimbursed 100% from any settlement, judgments or other payment that you obtain from the liable
third party, before they take out any other expenses, including attorney's fees, court costs or other
disbursements; and
