HomeMy WebLinkAboutExcess Loss Agreement (2)
Augusta Richmond GA
DOCUMENT NAME: Ex: Ce5S Los S Aj Y--e.e~ t-
DOCUMENT TYPE: ~1'ee:fI)en-r
YEAR: lOJC)95
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BOX NUMBER: ':J
FILE NUMBER: \ 31 \ 0
NUMBER OF PAGES:
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EXCESS LOSS AGREEMENT
By and Between
AUGUSTA, GEORGIA
(Herein called the EMPLOYER or Plan Sponsor)
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 arising 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 the payment of premiums when due to BCBSGA, the EMPLOYER, and BCBSGA
agree as follows:
SECTION I. THE TABLE
Benefits of "the Plan" SuQ,ject to This Agreement:
Compreh::msive Major Medical Expense Benefits with a Separate Prescription Card, if
applicable.
Effective.Date: January 1, 1998
Accumulation Period:
Incurred From: October 1, 1997 through December 31, 1998
Paid From: January 1, 1998 through December 31, 1998
BCBSGA Monthly Premium Rates:
Pt~r Individual..........$ 8.96
Per Family............. .$26.37
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AUGUSTA, GEORGIA
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SECTION IT: BENEFITS
The benefits described in the "Table" are only benefits under "the Plan" affected by this
agreemen.t and are affected only to the extent of the method of funding such benefits.
SECTION ITI: EFFECTIVE DATE
This agreement will be effective from 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. AUGUSTA, GEORGIA
While this agreement is in force, AUGUSTA, GEORGIA agrees to be liable for and to
fund all claims paid on behalf of their employees and/or dependents under the Comprehensive
Major MI~ica1 benefits, subject to AUGUSTA-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 of BCBSGA 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.
c.
AUGUSTA, GEORGIA
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In no case shall BCBSGA be liable for the payment of benefits in excess of those
payable under the "Plan Document" pursuant to this agreement, nor shall the EMPLOYER be
liable for any benefits payable by BCBSGA under the "Plan Document" pursuant to this
Agreement, it being understood and agreed that the obligations of the EMPLOYER under their
"Plan Do<:ument" and of BCBSGA under the "Plan Document" pursuant to this Agreement are
and shall be mutually exclusive. 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. If BCBSGA pays any amount of benefits which is an
obligation of the EMPLOYER, the EMPLOYER shall reimburse BCBSGA for such payment.
SECTION VII. CLAIMS DETERMINATION AND CLAIMS PAYMENT
BCBSGA shall have the exclusive right to make a final determination of the amount of
benefits, jf 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 this agreement.
Pa.yment of benefits which are the obligation of the EMPLOYER shall be paid from
funds provided by the EMPLOYER.
Pa.yment of claims which are the obligation of BCBSGA will be paid from funds
provided :oy 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
reasonabll~ intervals of any such claims/litigation.
SECTION IX. BCBSGA INDEMNIFICATION OF THE EMPLOYER
BCBSGA will indemnify the EMPLOYER 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 of BCBSGA or BCBSGA's employees, acting alone or in collusion with
others.
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AUGUSTA, GEORGIA
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SECTION X. THE EMPLOYER INDEMNIFICATION OF BCBSGA
The EMPLOYER will indemnify BCBSGA 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 of EMPLOYER or EMPLOYER's employees, acting alone or in collusion
with othe:rs.
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 EMPLOYER or by BCBSGA to insist upon compliance with any
provision of this agreement at any given time or under any given set of circumstances 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 instance 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.
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AUGUSTA, GEORGIA
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SECTION XV. RIGHT TO CONTRACT
BCBSGA may with reasonable notice to the EMPLOYER contract with another
organizati.on to perform all or part of its duties under this Agreement. However, any such
action on the part of BCBSGA 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 AUGUSTA, 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 writi.ng by BCBSGA.
SECTION XVII. AMENDMENT
TIlis 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. By 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.
AUGUSTA, GEORGIA
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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
EMPLOYER's liability as set 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
EMPLOYER for the recovered amount. If BCBSGA has reimbursed the EMPLOYER for all
or part of a particular payment and that payment is later recovered from a third party, the
EMPL01'ER 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 EMPLOYER 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
EMPLOYER 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, if any, before being applied to reduce the EMPLOYER's
liability, the liability of BCBSGA 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 1:0 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.
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AUGUSTA, GEORGIA
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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.
AUGUSTA, GEORGIA
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TITLE .
BLUE CROSS AND BLUE SHIELD OF
GEORGIA, INC.
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TITLE ~_vA-P c.M
DATE 3 -I '7 0" qt
DATE
this doeuInent approved es
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AUGUSTA-RICHMOND COUNTY COMMISSION
LEE BEARD
Mayor Pro Tllm
April 13, 1998
ULMER BRIDGES
JERRY BRIGHAM
HENRY H. BRIGHAM
FREDDIE 1. HANDY
WILLIAM B. KUHLKE. JR.
WM. "WIllIE" H. MAYS. ill
J. B. POWELL
STEPHEN E. SHEPARD
MOSES TODD
CHARLES R OUVER. P E. CPA
Admini.mator
LARRY E. SCONYERS
Mayor
ROOM 801 MUNICIPAL BLDG. (11)
AUGUSTA, GEORGIA 30911
Bus. (706) 821-2488
Fax No. (706) 722-5984
JAMES B. WALL
AllOmCy
Reply to:
P.O. BOX 2125
Augusta. GA. 30903
Mr. John Etheridge, Director
of Humcm Resources
Municipal Building (11)
Augusta, Georgia 30911
Re: Excess Loss Agreement
Dear John:
Enclosed please find the package from Buck Consultants which you
forwarded to me for review. Both originals of the Excess Loss Agreement have been
initialed, so that they are ready to be initialed by Randy Oliver and signed by the Mayor.
At that point, one fully-executed original may be returned to Buck and one maintained
by Lena for our records.
Please let me know should you have any questions or require anything
further.
With best personal regards, I am
Yours very truly,
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LORI S. D'ALESSIO
LSD:hbEi
Enclosul"e
CC: Mr. James B. Wall
BLJC' .
Ca~SULTANTS
200 Galleria Parkway, NW. Suite 1200
Atlanta, Georgia 30339-5945
March 27, 1998
John Etheridge
Augusta, Georgia
Human Resources Department
Room 601
530 Greene Street
AUguSl:a, GA 30911
Dear John:
Enclosed are two copies of the revised Stop Loss policy showing the name change to
Augusi:a, Georgia. Please have your legal counsel review the policy and if approved, sign
one copy and return it to us for processing. The other copy is for your records.
Let Susan or me know if you have questions.
Regards,
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Aileen Bodker
Assistant Benefit Consultant
c: Susan Snyder-Bass - Buck Consultants
Buck Consultants, Inc.
770 I 955-2488
Fax 770 I 933-8336
Human Resources
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. John Etheridge, Director
Room 601 - Municipal Building
530 Greene Street -Augusta, GA 30911
(706) 821-2303 - FAX (706) 821-2867
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APR 1 3 199J L--:
Date - 4-13-98
To - Randy Oliver, Administrator
Frol1l1 - John Etheridge, Director of Human Resources
RE - HEALTH INSURANCE EXCESS LOSS AGREEMENT
Attaehed to this memo are the final original copies of the Excess Loss
Agreement between Au . a and Blue Cross Blue Shield of
Georgia. . e initialed by you and
_~nce he has signed and you have initialed, please return
one original to me and provide the other original to Lena for our
records.
Also attached is the memo from Lori whereas she has reviewed these
documents and consequently I am sure Jim has also. Please get these
signed at your earliest convenience so that I may send BCBS their copy.
Should you have any questions, please call me.
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