Third Party Lien
Subrogation and Reimbursement
If a Participant is injured through the act or omission of another party, benefits are provided only on certain conditions. A Participant is required to promptly reimburse the Trust Fund from any proceeds received by way of settlement, verdict, judgment or otherwise (including receipt of proceeds under any uninsured motorists coverage or other insurance) arising out of a medical claim by the Participant or his heirs, parents or legal guardians, to the extent of benefits paid or to be paid by the Trust Fund for which the third party is responsible.
Any Participant who accepts Trust Fund benefits agrees that by doing so he is making a present assignment of his rights against a third party to the extent of the payments made by the Trust Fund (and any attorney’s fees and costs incurred by the Trust Fund). These rules are automatic, but the Trust Fund will require that a Participant sign an agreement to reimburse or assignment of recovery form(s). Any Participant who refuses to sign an agreement or assignment shall not be eligible for Trust Fund benefit payments related to the injury involved. Any Participant who receives benefits and later fails to reimburse the Trust Fund will be ineligible for future Trust Fund benefits until the Trust Fund has withheld an amount equal to the amount which the Participant failed to reimburse. This amount may also include reasonable interest on such unpaid funds and reimbursement for any attorney fees and costs incurred by the Trust Fund.
By accepting benefits provided by the Plan, a Participant agrees that:
- The Plan has the right to intervene, independently of the Participant, in any legal action brought against the third party or any insurance company, including the Participant’s own carrier for uninsured motorist’s coverage.
- An equitable lien by agreement shall exist in favor of the Trust Fund upon all funds recovered by the Participant against the third party. The lien shall apply whether or not the recovery is in the possession of the Participant, including situations in which the recovery has been placed in a special needs trust. The lien may be filed with the third party, the third party’s agent, or the court. The Participant shall provide the Trust Fund with all relevant information or documents requested.
- The Trust Fund’s Subrogation and Reimbursement rights shall be considered as a first priority claim against another person or entity, to be reimbursed before any other claims (including claims for general damages).
- The Participant will not release any party from liability for payment of medical expenses without first obtaining written consent from the Trust Fund.
- If the Participant enters into litigation or settlement negotiations regarding obligations of or claims against another party, the Participant will notify the Trust Fund and shall take no action to prejudice the Trust Fund’s rights.
- The Participant agrees that the Trust Fund shall be responsible only for those legal fees and expenses to which the Trust Fund agrees in writing. Unless the Trust Fund agrees otherwise, the rights of the Trust Fund to recover the amount of benefits issued shall in no way be diminished by the cost of a Participant’s legal representation.
- The Participant agrees to hold proceeds of any settlement, verdict, judgment, or other recovery in trust for the benefit of the Trust Fund, and that the Trust Fund shall be entitled to recover reasonable attorney fees incurred in collecting reimbursement of benefits issued.
- In addition to all other remedies that the Trust Fund may have, the Trust Fund shall be subrogated to the rights of the Participant or his beneficiary against the responsible third party or its insurer.
- Any “make-whole” rule of federal or state law is expressly rejected and shall not be applicable to this Trust Fund, so that a Participant need not be made whole before the Trust Fund can enforce its Right of Reimbursement.
Right to Recover Excess Payments
If a benefit payment has been made by this Trust Fund which exceeds the amount that should have been paid under the Trust Fund, the Trust Fund has the right to recover (including the right to offset against future benefit payments) overpaid amounts from any person or organization to, or for whom, said payments were made, or from any person whose intentional or negligent acts, omissions, or representations caused overpaid amounts to be paid. No Participant shall be required to pay more than the amount actually overpaid. In the event the Trust Fund brings legal action to recover any overpayment, the Trust Fund is entitled to recover its costs and attorney’s fees incurred in such action. (Refer also to Subrogation and Reimbursement above).