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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 - BOX NUMBER: ':J FILE NUMBER: \ 31 \ 0 NUMBER OF PAGES: /0 .\ 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 . (' , . o o o ~. o Q o c > p AUGUSTA, GEORGIA - 2 - 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 - 3 - 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. ',. AUGUSTA, GEORGIA - 4 - 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. 'J, ~ , AUGUSTA, GEORGIA - 5 - 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 - 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 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. :".' ..- 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. AUGUSTA, GEORGIA I B~ TITLE . BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC. &III/(}~ TITLE ~_vA-P c.M DATE 3 -I '7 0" qt DATE this doeuInent approved es Z~t~~' - 4j Ie ~ 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, ~~ ~ 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, .~ ..' I v~:: .. V ctLt:.'rU 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 f1ur 4~":/qS ~-J . John Etheridge, Director Room 601 - Municipal Building 530 Greene Street -Augusta, GA 30911 (706) 821-2303 - FAX (706) 821-2867 pIr\Yt~jl 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. c \J~Y/ ~~l (\ \ f\ J 0-- \ j~IS.. (l;O~ ~ V l) O~ rv\'). ()\' ~~\ ~ \}'7 ~