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HomeMy WebLinkAboutBlue Cross and Blue Shield of Georgia Augusta Richmond GA DOCUMENT NAME: l)U>6 0.p"ossft"'f) ~ Ct>€ s;'li./ ~LS) 6~ G- ~OR~'~ DOCUMENT TYPE: A~~~~oVTo YEAR: I ~ q 9 BOX NUMBER: l.p FILE NUMBER: J Lf D~S- . NUMBER OF PAGES: ,. ... .1. , .. " .. 'i"' ';' EXCESS LOSS AGREEMENT By and Between (Herein calle~%~~~'i:g~:~:~lan Sponsor) COP Y . And BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC. (Herein called the insurer or BCBSGA) WHEREAS, the EMPLOYER has adopted for certain of its employees and their dependents an employee welfare benefit plan (herein called "the Plan" or "Plan Document") more thoroughly described below and incorporated herein by reference; and WHEREAS, the EMPLOYER recognizes "the Plan" is an employee welfare benefit plan and the EMPLOYER, as a named fiduciary with respect to the "the Plan", wishes to accept liability for direct funding of a certain portion of the claims arisirig out of some of the benefits provided by "the Plan" and covered by this agreement; and WHEREAS, BCBSGA agrees to provide insurance for a certain portion of the claims arising out of "the Plan" and covered by this agreement. NOW, THEREFORE, in consideration of the mutual covenants contained herein, including th,;: payment of premiums when due to BCBSGA, the EMPLOYER, and BCBSGA agree as follows: SECTION 1. THE TABLE Benefits of "the Plan" Subiect to This Agreement: Comprehensive Major MedicalExpenseBenefits with a Separate Prescription Card; if applicable. Effective Da.te: January I, 1999 Accumulation Period: Incurred From: January 1, 1998 through December 31, 1999 Paid From: January 1,1999 through December 31,1999 I BCBSGA Monthly Premium Rates: Per Individual..........$1O.04 Per Family.............. $29.53 .. I ~ AUGUSTA, GEORGIA - 2 - SECTION II: BENEFITS The benefits described in the "Table" are only benefits under "the Plan" affected by this agreement and are affected only to the extent of the method of funding such benefits. SECTION III: EFFECTIVE DATE This agreement will be effective frorJ? the Effective Date shown in the Table. SECTION IV: AGREEMENT YEAR An agreement year is a period of twelve consecutive months beginning on the Effective Date of this agreement. SECTION V. AUGUST A GEORGIA While this agreement is in force, AUGUST A, GEORGIA agrees to be liable for and to fund all claims paid on behalf of their employees and/or dependents under the Comprehensive Major Medil;al benefits, subject to AUGUST A-GEORGIA's Individual Stop-Loss Limit outlined below: a. ~;100.000.00 Individual Agreement Year Stop-Loss Limit-Major Medical Paid Claims in excess of$100,000.00 on an individual during an agreement year will be the responsibility ofBCBSGA during continuance of this agreement. This $100,000.00. agreement year deductible will be automatically reinstated at the beginning of each subsequent agreement year and will again become the obligation of the EMPLOYER. SECTION VI. EXCLUSIVITY OF OBLIGATIONS AND REIMBURSEMENTS BCBSGA's LIABILITY for claims for benefits subject to this agreement shall exist only when the paid claims exceed the EMPLOYER'S Liability set forth in Section V. In nOr case shall BCBSGA be liable for the payment of benefits in excess of those payable under the "P'!an Document" pursuant to this agreement, nor shall the EMPLOYER be liable for any benefits ipayable by BCBSGA under the "Plan Document" pursuant to this Agreement, it being undedtood and agreed that the obligations of the EMPLOYER under their "Plan Document" ~lnd ofBCBSGA under the "Plan Document" pursuant to this Agreement are and shall be mutually I~xclusive. If the EMPLOYER pays any amount of benefits which is an obligation of BCBSGA pursuant to this Agreement, BCBSGA shall reimburse the EMPLOYER for such payment. IfBCBSGA pays any amount of benefits which is an obligation of the EMPLOYER, the EMPLOYER shall reimburse BCBSGA for such payment. .. AUGUSTA, GEORGIA - 3 - SECTION VII. CLAIMS DETERMlNATION AND CLAIMS PAYMENT BCBSGA shall have the exclusive right to make a final determination of the amount of benefits, if any, to which any employee and/or dependent may become entitled under the "Plan Document" to the extent and for the purpose of establishing BCBSGA's LIABILITY as outlined in SECTIONS V and VI above the EMPLOYER agrees to accept such determination. The determination of the BCBSGA's LIABILITY, as outlined in SECTIONS V and VI above, shall be made in the same manner as such determination would be made under the "Plan Document" in the absence of tIlls agreement. Payment of benefits which are the obligation of the EMPLOYER shall be paid from funds provided by the EMPLOYER. Payment of claims which are the obligation ofBCBSGA will be paid from funds provided by BCBSGA. SECTION VIII. LITIGATION In the event of litigation with respect to any claim for benefits which are the liability of BCBSGA pursuant to this agreement, BCBSGA will, at its option, undertake the defense of such suit and will have the right to settle any such suits when, in its sole judgement, settlement appears to be advisable. BCBSGA agrees to provide periodic reports to the EMPLOYER at reasonable intervals of any such claims/litigation. SECTION IX. BCBSGA INDEMNIFICATION OF THE EMPLOYER BCBSGA will indemnify the EMPLOYE~ and hold it harmless against any claims, lawsuits,.settlements,.judgement, costs, penalties and expenses, including attorney's fees, with respect to this agreement resulting from or arising out of the dishonest, fraudulent, negligent or criminal acts ofBCBSGA or BCBSGA's employees, acting alone or in collusion with others. SECTION X. THE EMPLOYER INDEMNIFICATION OF BCBSGA The EMPLOYER will indemnify BCBSGA and hold it harmless against any claims, lawsuits, set{lements, judgement, costs, penalties and expenses, including attorney's fees, with respect to thIS agreement resulting from or arising out of the dishonest, fraudulent, negligent or criminal acts of EMPLOYER or EMPLOYER's employees, acting alone or in collusion with others. . .. ~ AUGUSTA, GEORGIA - 4- SECTION XI. NOTICE TO EMPLOYEES Within 30 days of the date this agreement becomes effective as to each employee, the EMPLOYER will furnish all employees covered by "the Plan" a written notice that the EMPLOYER is liable for funding a portion of the benefits described in the "Plan Document." The EMPLOYER will indemnify BCBSGA for losses incurred by BCBSGA as a result of any failure by the EMPLOYER to furnish such notice in the time and manner prescribed. SECTION XII. SEVERABILITY In the event any provision of this Agreement shall be held invalid or illegal for any reason by law or by a court of competent jurisdiction, said invalidity or illegality shall not affect the remaining parts of this Agreement,. and this Agreement shall be construed and enforced as if its said invalid or illegal provisions had not been included in this Agreement; provided the basic purposes of this Agreement can be effectuated through the remaining valid and legal provisions. SECTION XIII. ADDITIONAL COSTS In the event that for any reason by law, regulation, or decision of any administrative body or court of competent jurisdiction, additional cost shall be determined to be due in connection with this Agreement, or the "Plan Document", such additional costs shall be the responsibility of the EMPLOYER. Nothing contained in this paragraph changes the obligations set out in SECTIONS IX and X herein. SECTION XIV. CONTRACT COMPLIANCE - NON- WAIVER Failure by the EMPL.O)'ER or by BCBSGA to insist upon compliance with any provision of this agreement at any .given time. or under any given set of circ:umstarices shall not operate to waive or modify such provision or in any manner render to unenforceable, as to any other time or as to any other occurrence, whether the circumstances are or are not the same, and no waiver of any of the terms or conditions of this Agreement shall be valid or of any force or effect unless in each instancl~ it is communicated in writing expressing such alternation or modification and executed for: the EMPLOYER and for BCBSGA pursuant to the provision of SECTION XVII of this Agreement. ., . '- AUGUSTA, GEORGIA - 5 - SECTION XV. RIGHT TO CONTRACT I BCBSGA may with reasonable notice to the EMPLOYER contract with another organization to perform all or part of its duties under this Agreement. However, any such action on the part ofBCBSGA will not relieve BCBSGA of its duties and obligations under this Agreement. ~ Pursuant to this Agreement, BCBSGA has designated Southern Administrative Services (SAS), Post Office Box 8069, Columbus, Georgia 31908-8069, to perform certain duties more specifically described (and incorporated herein by reference) in the Administrative Services Agreement between AUGUST A, GEORGIA, and Southern Administrative Services effective February 1, 1997. SECTION XVI. "PLAN DOCUMENT" AMENDMENT No amendment, rider, or endorsement of the "Plan Document" effective subsequent to the Effective Date of this agreement shall change any provision or operation of this Agreement except as may be specifically provided in such amendment, rider, or endorsement and agreed to in writing by BCBSGA. SECTION XVII. AMENDMENT This Agreement may be amended at any time by written agreement between the EMPLOYER and BCBSGA executed by their authorized officers. However, any change in Monthly Premium Rates may be effected by a 60 day advance written notice from BCBSGA to the EMPLOYER of the change. SECTION XVIII. TERMINATIONS This Agreement may be terminated in the following manner: 1. By either party hereto giving 60 days written notice of the intent to terminate; 2. By either party if the other violates any terms or conditions of this agreement; 3. B:y BCBSGA if the EMPLOYER fails to make any and all premium payments when due; 4. If the "Plan Document" terminates, this Agreement will automatically terminate. , : " AUGUST A, GEORGIA - 6 - SECTION XIX. THE EMPLOYER'S LIABILITY UPON TERMINATION In the event of the termination of this Agreement or the termination of the "Plan Document" whichever occurs first, the EMPLOYER immediately becomes liable for all payable and unpaid claims on and after the effective date of the termination, regardless of the date such claim was incurred and regardless of the EMPLOYER having exceeded the E11PLOYER's liability as slet forth in SECTION V. In addition if any Extended Benefits are provided under the "Plan Document" the EMPLOYER shall pay all claims arising out of the Extended Benefit coverage on or after the date of termination. SECTION Xx. SUBROGATION In the event the EMPLOYER recovers damages, expenses or benefits from a third party relating to claims covered by this Agreement, BCBSGA will not reimburse the E11PLOYER for the recoven:d amount. IfBCBSGA has reimbursed the EMPLOYER for all or part of a particular payment and that payment is later recovered from a third party, the EMPLOYER must repay BCBSGA to the extent of the reimbursement (regardless of whether this Agreement is still in force). Repayment may be reduced by any reasonable and necessary expenses incurred by the E11PLOYER in recovering from the third party. The EMPLOYER agrees to enforce its right to subrogation relating to any benefit and agrees to diligently prosecute all claims arising out of such right. If the Employer is unwilling, unable, or neglects to enforce this right, BCBSGA is hereby empowered and authorized to instigate appropriate action in the name of the EMPLOYER. The subrogation provision of this SECTION XX and BCBSGA's rights shall survive the termination of this Agreement. The E11PLOYER shall notify BCBSGA of any third party action or obligation that affects or may affect the EMPLOYER's obligation under this Agreement. For the purposes of this Agreement, subrogated claim recoveries will be applied first to reduce BCBSGA's liability in full, i(any, before being' applied to reduce the EMPLOYER's liability, the liability ofBCBSGA and the liability of the EMPLOYER's being mutually exclusive. SECTION XXI. WAGE OR PROFIT EXCLUSION No payment will be made for or in connection with any expenses arising out of, or in the course of, any employment for wage or profit. SECTION XXII. REMEDIES It is the clear intent of the parties to this Agreement that the Employer shall have the primary liability for funding the payment of claims which may arise in connection with this Agreement. If the EMPLOYER does not make funds available as required hereunder, and BCBSGA should pay claims from its funds, BCBSGA in addition to any other remedies available to it, shall have the right to bring an action to recover such amounts paid by it and to recover all of its costs and attorneys' fees incurred in connection with such action. cr .~ AUGUSTA, GEORGIA - 7 - IN WITNESS WHEREOF, AUGUSTA, GEORGIA AND BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC. have caused this Agreement to be executed in their names by their undersigned officers, the same being duly authorized to do so, on the date and in the year designated below. BY /1 Ct.-l ~I/y ift , TITLE DATE BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC. ~1/la&/md'0 TITLE S~V-Pf CIfJ DATE 1,/2 ~~9