CLAIMS WHERE THIRD PARTY IS LIABLE

This provision applies to all Participants (and retirees) and their covered Dependents, with respect to all of the benefits provided under this Plan. For the purposes of this provision, the terms “You” and “Your” refer to all Participants, retirees and covered Dependents.

Occasionally, a third party may be liable for Your medical expenses. This may occur when a third party is responsible for causing Your illness or injury or is otherwise responsible for Your medical bills. The Trustees, in their sole discretion, may determine to not provide benefits under the Plan for any Participant who may have a third party responsible for the payment of medical benefits until a determination is made by the proper and final decision maker regarding the third party’s responsibility to the Participant. The rules in this section govern how the Fund pays benefits, if at all, in such situations.

This provision has two purposes. First, this provision ensures that Your benefits will be paid promptly. Often, where there is a question of third party liability, many months pass before the third party actually pays. This provision permits this Fund to pay Your covered expenses until Your dispute with the third party is resolved.

Second, this provision protects this Fund from bearing the full expense in situations where a third party is liable. Under this provision, once it is determined that a third party is liable in any way for the injuries giving rise to these expenses, this Fund must be reimbursed for the relevant benefits it has advanced to You out of any recovery whatsoever that You receive that is directly or indirectly related to the event which caused You to incur the medical expenses.

RIGHTS OF SUBROGATION AND REIMBURSEMENT

If You incur covered expenses for which a third party may be liable, You are required to advise the Fund of that fact.

In addition to its subrogation rights, the Fund has the right to be reimbursed for payments made on Your behalf under these circumstances. The Fund must be reimbursed from any settlement, judgment or other payment that You obtain from the liable third party, before any other expenses, including attorneys’ fees, are taken out of the payment. The Fund has the right to full reimbursement even if, as a result of the Fund’s reimbursement, You are not made whole. The Fund has the right to full reimbursement from any recovery You make regardless of how such recovery may be characterized, including but not limited to, for medical expenses, pain and suffering and/or lost earnings.

The Trustees may, in their sole discretion, require the execution of this Fund’s subrogation forms by You (or Your authorized representative if You are a minor or if You cannot sign) before this Fund pays You any benefits related to such expenses and before this Fund provides any documents. If the Trustees have required execution of the Fund’s subrogation agreement, no benefits will be provided unless You sign the form. You must also notify the Fund before You retain another attorney or an additional attorney. In no event shall the failure of the Trustees to require execution of the subrogation agreement diminish or be considered a waiver of the Fund’s rights of subrogation and reimbursement.

RIGHTS OF FUTURE SUBROGATION AND REIMBURSEMENT

In addition to satisfaction of the existing lien from any recovery by the Participant and/or Dependent, the Fund is also entitled to a credit for future related Fund expenses equal to the net monies received by the Participant and/or Dependent. As such, the Participant and/or the Dependent must spend the net recovery on related Fund expenses until the amount of said net recovery is exhausted. It is only at that point that the Participant’s and/or Dependent’s further related Fund benefits will again be the responsibility of the Fund.

ASSIGNMENT OF CLAIM

The Trustees, in their sole discretion, may require You to assign Your entire claim against the third party to this Fund. If this Fund recovers from the third party any amount in excess of the benefits paid to You, plus the expenses incurred in obtaining the recovery, then the excess will be paid to You.

FAILURE TO DISCLOSE

If You fail to advise this Fund that You have a claim against a third party; if You fail to assign Your claim against the third party to this Fund when required to do so (and to cooperate with the Fund’s subsequent recovery efforts); if You and/or Your attorneys fail to reimburse this Fund out of any payment You obtain from the third party; and/or if You fail to fully reimburse the Fund (out of any settlement You receive, or otherwise, even if this Fund reduces the amount of its lien or otherwise limits its rights); then You are personally liable to this Fund for the reimbursement
owed to this Fund by the third party. This Fund may offset the amount You owe from any future benefit claims, or if necessary, take legal action against You.

NO-FAULT BENEFITS

If You have a claim which involves a motor vehicle accident covered by the “no-fault” insurance law of any state, the no-fault insurance carrier must reimburse health care expenses first. Only when You have exhausted Your health care benefits under the “no-fault” coverage will You be entitled to receive health care coverage under this Fund. If there are expenses for services which are covered by this Fund and which are not completely reimbursed by the “no-fault” carrier, this Fund will entertain claims for the difference up to the Fund maximums and subject to all the provisions hereof. No benefits will be payable under this Fund where a Participant is not covered under a no-fault policy in violation of state law.