Other Party Liability
Other Insurance
If the member has another insurance plan that provides coverage for hospital or medical expenses,
the benefits described in this Benefit Description, Affiliate Medical Plan, will be reduced by the
benefits provided by those plans. The benefits under the Plan are secondary to or in excess of those
benefits provided by any private insurance plan or other governmental plan. Other insurance plans
include: personal injury insurance; automobile insurance; or homeowner’s insurance.
Medicare Program
When you are eligible for the Medicare program and Medicare is allowed by federal law to be the
primary payer, the benefits provided by this health plan will be reduced by the amount of benefits
allowed under Medicare for the same covered services. This reduction will be made whether or not
you actually receive the benefits from Medicare. It is your responsibility to notify the Health Plan
of your Medicare eligibility and effective dates of Medicare A and B.
Subrogation
If you are injured by any act or omission of another person, the benefits under this medical plan
will be subrogated. This means that this medical plan and The MIT Medical Department, as this
medical plan’s representative, may use your right to recover money from the person(s) who caused
the injury or from any insurance company or other party. If you recover money, you must reimburse this medical plan up to the charged amount for any services rendered. This is true even if you
do not recover the total amount of your claim against the other person(s). This is also true if the
payment you receive is described as payment for other than health care expenses. The amount you
must reimburse this medical plan will not be reduced by any attorney’s fees or expenses you incur.
You must give The MIT Medical Department, as this medical plan’s representative, information
and help. This means you must complete and sign all necessary documents to help The MIT Medical Department get this money back on behalf of this medical plan. This also means that you must
give The MIT Medical Department notice before settling any claim arising out of injuries you
sustained by an act or omission of another person(s) for which this medical plan paid benefits. You
must not do anything that might limit this medical plan’s right to full reimbursement.
Workers’ Compensation
No benefits are provided for health care services and supplies to treat an illness or injury for which
you have the right to benefits under any workers’ compensation act or equivalent employer liability or indemnification law.Effective 9/1/2009 · Words in italics are defined in Part 2 11
All employers provide their employees with workers’ compensation insurance. This is done to protect employees in case of work related illness or injury. All medical claims related to the illness or
injury must be billed to the employer’s workers’ compensation carrier. It is up to you to use workers’ compensation insurance. If this medical plan provides or pays for covered services that are
covered by workers’ compensation, The MIT Medical Department on behalf of this medical plan
has the right to get paid back from the party that legally must pay for the health care services.
If you have recovered the value of services from workers’ compensation or another employer liability program, you will have to pay the amount recovered for medical services that were paid by
this medical plan. If The MIT Health Plans is billed in error for directly paid services, you must
promptly call or write The MIT Health Plans Claims and Member Services Office at:
(617) 253-5979 or
MIT Health Plans
Claims & Member Services
E23-191
77 Massachusetts Avenue
Cambridge, MA 02139
mservices@med.mit.edu
If the MIT Medical Department is billed in error for these services, you must promptly call or
write the MIT Medical Department Billing office at:
(617) 258-5336 or
MIT Medical Department Billing Office
E23-398
77 Massachusetts Avenue
Cambridge, MA 02139
