CurrentCulinary Health FundPolicy N/A

Reimbursement Agreement — Recovery/Subrogation Process

Governs the Culinary Health Fund's right to process medical claims related to third‑party recoveries and the member's contractual obligation to reimburse the Fund from any settlement or judgment arising from an accident; applies to participants and their dependents who received Plan benefits for an accident and/or their attorneys.

Policy Summary

PayerCulinary Health Fund

PolicyReimbursement Agreement — Recovery/Subrogation Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMember (and attorney, if retained) must sign the Reimbursement Agreement and submit a Statement of Facts before the Fund will process accident-related medical claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

first priorityPlan priority

must signSigned agreement required

two optionsReimbursement rule

possible reductionPossible reduction

denial riskNoncompliance

Reimbursement & Subrogation Criteria

Reimbursement and subrogation criteria

Conditions under which the Fund will seek reimbursement and member obligations:

Member (and attorney, if retained) must complete and sign the Reimbursement Agreement and submit a Statement of Facts before the Fund will process accident-related medical claims; absent these documents the Fund will deny those medical claims.

Member or member's attorney must contact the Fund prior to settling any claim or lawsuit to obtain the total current amount of medical benefits paid by the Fund so that amount can be included in settlement negotiations.

Member must reimburse the Fund from any settlement, judgment, or other recovery; the Fund's right of retention (Derecho de Retención) equals the lesser of: (1) the total benefits the Plan has paid related to the Accident, or (2) the total Recovery amount received by the member.

Possible administrative adjustment: Administrators may reduce the required reimbursement in special circumstances (for example, insufficient recovery or consideration of other losses) upon written request explaining the reasons for reduction.

Policy Summary

PayerCulinary Health Fund

PolicyReimbursement Agreement — Recovery/Subrogation Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMember (and attorney, if retained) must sign the Reimbursement Agreement and submit a Statement of Facts before the Fund will process accident-related medical claims.

SourceLink

On This Page

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Coding and Reimbursement Limits

No billing or procedure codes specifiedmixed

No codes listed

Reimbursement cap rule — limited to lesser of total benefits paid or amount recovered

Reimbursement capReimbursement is limited to the lesser of: (1) the total benefits paid by the Plan or (2) the total amount recovered by the member.

ExampleIf recovery is $15,000 and the Fund paid $30,000 in medical expenses, the member must reimburse $15,000 (the lesser amount).

Application timingThis cap is applied at the time of settlement or recovery and determines the maximum the Fund may retain from recovery proceeds.

Plan priorityThe Fund’s reimbursement right is a first priority against any compensation the member receives related to the Accident.

Potential reductionAdministrators may reduce the required reimbursement in special circumstances (e.g., insufficient recovery), per Fund discretion and upon written request.

Provider & Attorney Requirements

Prior Authorization

Signed Reimbursement Agreement required before processing

Providers and attorneys: do not expect the Fund to process medical bills related to a claim or lawsuit until the member (and, if retained, the member's attorney) has signed the required Reimbursement Agreement and provided the Statement of Facts. If those documents are not submitted, the Fund will deny the related medical claims. Once received, the Fund will process bills under Plan terms and provide the current total of medical payments paid to assist in settlement negotiations.

Member (and attorney, if retained) must sign the Reimbursement Agreement before processing will occur.
Providers should request the member/attorney submit the completed Statement of Facts and signed Reimbursement Agreement prior to billing the Fund.
If documents are not received, related medical claims will be denied.

Denial Risk

Subrogation, lien and recovery enforcement

The Fund has primary rights of lien, subrogation and recovery and may enforce those rights. Members agree to irrevocably assign to the Fund an amount equal to the Fund’s lien (up to the Fund’s total paid benefits or the total recovery, whichever is less), to cooperate with the Fund (provide information, sign assignments, notify the Fund at the start of any claim, lawsuit or settlement negotiations), and not to take actions that interfere with the Fund’s recovery rights. The Fund may intervene in suits, require attorneys or representatives who receive recovery funds to pay the Fund the full lien amount before distributing any settlement proceeds, and may sue third parties in the member’s name to recover amounts due plus costs and fees if the member does not pursue recovery.

The Fund’s lien equals the total benefits paid by the Plan for the incident, or the total recovery if less.
If recovery proceeds are paid to an attorney/representative, they must pay the Fund the lien amount before distributing proceeds to the member.
Failure to comply with the Agreement or Plan rules may be grounds to deny benefits (including future benefits).

Defined Terms

inv-06: Derecho de Retención — Right of Retention definition

TermDerecho de Retención (Right of Retention): the Plan’s right to the amount recovered from another party due to the Accident.

Amount coveredThe Derecho de Retención equals either the total Benefits paid by the Plan for the Accident or, if less, the total Recovery amount.

Scope of recoveryApplies whether recovery is obtained by judgment, settlement, or otherwise.

EnforcementThe Plan may notify others of the Derecho de Retención and assert it as necessary to protect its rights, including intervening in litigation or suing third parties.

inv-07: Beneficios — definition of benefits covered related to the Accident

DefinitionBeneficios: medical, hospital, dental, vision and other covered expenses paid by the Plan that result from the Accident.

Relation to AgreementBy accepting Beneficios, the member agrees to reimburse the Plan from any compensation received as first priority of recovery proceeds.

ScopeIncludes benefits paid or to be paid by UNITE HERE HEALTH (the Culinary Health Fund) related to the specified Accident.