Currentculinary health fundPolicy N/A

Reimbursement and Subrogation (Reimbursement Agreement / Right of Retention)

Governs the Culinary Health Fund's process and legal agreement requiring members (or their representatives) to reimburse the Fund from third‑party recoveries for benefits paid related to an accident; applies to plan participants and eligible dependents involved in claims or lawsuits.

Policy Summary

Payerculinary health fund

PolicyReimbursement and Subrogation (Reimbursement Agreement / Right of Retention)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionParticipant (and attorney, if any) must complete and sign the Reimbursement Agreement and Statement of Facts before the Fund will process related medical claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

first-priority recoveryPlan has first right to reimbursement from any third‑party recovery

member obligation to signSignature requirement before processing

possible reductionAdministrators may reduce reimbursement for hardship

recovery cap ruleReimbursement limited to lesser of benefits paid or recovery

failure consequencesNoncompliance may result in benefit denial

Policy Summary

Payerculinary health fund

PolicyReimbursement and Subrogation (Reimbursement Agreement / Right of Retention)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionParticipant (and attorney, if any) must complete and sign the Reimbursement Agreement and Statement of Facts before the Fund will process related medical claims.

SourceLink

On This Page

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Reimbursement and Subrogation Criteria

Requirements and conditions for Fund reimbursement and subrogation when third‑party recovery exists:

Participant (or dependent) must complete and sign the Reimbursement Agreement and Statement of Facts before the Fund will process related medical claims.

If the participant has retained an attorney, the attorney must also sign the Reimbursement Agreement before the Fund will process related medical claims.

Prior to settlement negotiations the participant or their attorney must contact the Fund to obtain the total amount of benefits paid by the Fund to date for inclusion in settlement discussions.

Reimbursement amount equals the lesser of: (a) total Benefits paid by the Fund related to the Accident, or (b) total Recovery obtained by the participant.

Participant must cooperate fully with the Fund, including providing requested information and documents, signing and delivering assignments or other documents, and notifying the Fund immediately upon initiation of any claim, lawsuit, negotiation or settlement related to the Accident.

Fund enforcement rights (one of)

The Fund may intervene in any lawsuit that includes a recovery claim related to the Accident and the participant waives any right to object to such intervention.
The Fund may bring suit in the participant's name against any third party to recover the Fund's amount, plus expenses, costs and attorneys' fees.

If Recovery is paid to the participant's attorney or representative, counsel is required to remit the Fund's share (the amount of the Fund's Right of Retention) to the Fund before distributing any Recovery to the participant or others; the attorney acknowledges this by signing the Agreement.

Administrators may, in special circumstances (for example loss of earnings, disability, inadequate recovery or other factors), reduce the required reimbursement; participant must submit a written request stating reasons for reduction.

Failure to comply with this Agreement, the Plan or its rules may be grounds to deny benefits, including benefits unrelated to the Accident or future claims.

The participant irrevocably assigns to the Fund the portion of any Recovery equal to the Fund's Right of Retention, and will not retain any portion of Recovery until the Fund's Right of Retention has been paid in full.

The Fund may notify others and assert its Right of Retention as necessary to protect its rights; the Right of Retention applies whether recovery is obtained by judgment, settlement or otherwise.

For questions, participants may contact Customer Service at 888-468-4742 ext-251.

Coding and Reimbursement Limits

Not applicablemixed

No codes listed

Reimbursement limit rule

Reimbursement limit ruleReimbursement is limited to the lesser of: (1) the total Benefits paid by the Plan related to the Accident, or (2) the total Recovery obtained by the participant.

ExampleIf the Fund paid $30,000 in medical expenses and the participant's settlement is $15,000, the participant must reimburse $15,000 (the lesser amount).

PurposeEnsures the Plan recovers up to the amount it paid without exceeding the participant's net recovery.

Pre-processing, Subrogation, and Noncompliance Actions

Prior Authorization

Pre-processing requirements and contact

Before the Fund will process any medical bills related to an accident when the participant has a third‑party claim, the participant (and their attorney, if retained) must complete and sign the Fund's Reimbursement Agreement and any required Statement of Facts. The Fund will not process medical claims for that accident until these pre‑processing requirements are received. After you or your attorney reach a settlement or other recovery, you or your attorney must contact the Culinary Health Fund to obtain the current total of medical expenses paid by the Fund so that this amount can be included in settlement negotiations.

Participant and attorney must sign the Fund's Reimbursement Agreement before processing.
Submit Statement of Facts along with the Agreement.
Notify the Fund before settling so the Fund can provide the current total of benefits paid.

Billing Rule

Defined Terms

Benefits paid by the Plan

Definition of BenefitsMedical, hospital, dental, vision and other covered expenses paid by the Plan that result from the Accident.

ScopeApplies to benefits paid to the participant or their dependent related to the specified Accident.

Relation to AgreementAcceptance of Plan Benefits creates the participant's obligation to reimburse the Plan from any Recovery.

Plan's first priority claim / Right of Retention

First priority claim (Right of Retention)The Plan has first priority on any Recovery up to the amount of Benefits paid by the Plan, or, if less, the total Recovery.

Enforcement actionsThe Plan may intervene in lawsuits or bring suit in the participant's name to recover its amount, plus costs and attorney fees.

Subrogation and intervention rights

The Fund has first rights of lien, subrogation, and may intervene in any lawsuit or claim related to the accident to protect its recovery rights. The participant irrevocably assigns to the Fund an amount equal to the Fund's lien/subrogation (up to the amount of benefits paid or the amount recovered, whichever is less). The Fund may: (1) notify relevant parties of its lien; (2) intervene in any action asserting recovery related to the accident without objection from the participant; and (3) bring suit against any third party on the participant's behalf to recover the Fund's full lien amount plus costs and attorney fees if the participant fails to pursue recovery. If recovery is paid to the participant's attorney or representative, that attorney/representative is required to remit the Fund's full lien/subrogation amount to the Fund before distributing settlement proceeds to the participant or any other party.

Fund has first rights of lien and subrogation up to benefits paid or amount recovered, whichever is less.
Fund may intervene in or pursue litigation to recover the Fund's lien and may require counsel to remit recovery prior to distributing proceeds.
Attorney or representative must pay the Fund's recovery amount before distributing settlement funds.

Denial Risk

Noncompliance consequences

Failure to comply with the Reimbursement Agreement or the Fund's rules — including failing to provide required information or documents, failing to notify the Fund of a claim or settlement, obstructing the Fund's right to recover, or failing to remit the Fund's recovery when funds are received — may result in denial of benefits. Such noncompliance may be grounds to deny payment of current claims related to the accident and may also be a basis to deny future benefits for you or your dependents under the Plan.

Noncompliance may lead to denial of benefits for the related accident and may affect unrelated future claims.
Obligations include cooperating with requests, signing and delivering documents, and promptly notifying the Fund of claims, suits, or settlements.

Notification and cooperationParticipant must not interfere with enforcement and must cooperate by providing information and executing assignments as requested.

Recovery definition

Recovery (Recuperación)Any compensatory funds obtained from a third party by judgment, settlement, or otherwise related to the Accident.

Includes payments by insurersRecovery includes amounts recovered from another person or an insurance company as a result of the Accident.

Treatment in distributionsIf Recovery is paid to the participant's attorney or representative, they must pay the Plan's share before distributing funds to the participant.