(a) By accepting payment of benefits pursuant to a plan authorized by this part, a plan participant has assigned to the plan the right of third-party insurance benefits or other recovery rights to which the plan participant may be entitled, which must be noted in plain language in the SPD.

Terms Used In Tennessee Code 8-27-904

  • Administrator: means :
    (A) An individual, either employed by, or contracted with, the sponsor or the plan to provide administrative services on behalf of the plan. See Tennessee Code 8-27-901
  • Days: means calendar days, unless otherwise noted. See Tennessee Code 8-27-901
  • Insured: means any individual, other than the primary insured, who receives benefits under the plan. See Tennessee Code 8-27-901
  • Plain language: means writing designed to ensure the reader understands the meaning of the passage as quickly, easily, and completely as possible, avoiding verbose, convoluted language, and jargon. See Tennessee Code 8-27-901
  • plan: includes those to which the primary insured pays to the plan a nominal fee for the primary insured and any insureds whose relationship to the primary insured allows them to receive benefits under the plan. See Tennessee Code 8-27-901
  • Plan participant: means either a primary insured or insured. See Tennessee Code 8-27-901
  • signed: includes a mark, the name being written near the mark and witnessed, or any other symbol or methodology executed or adopted by a party with intention to authenticate a writing or record, regardless of being witnessed. See Tennessee Code 1-3-105
  • SPD: means a summary of the plan document, which may or may not be part of the plan document. See Tennessee Code 8-27-901
  • Sponsor: means a county, municipality, municipal corporation, or special school district in this state that establishes and funds a plan. See Tennessee Code 8-27-901
  • third party: means a person or entity that contracts with either the plan or the third-party administrator to provide payment for claims of healthcare items or services for plan participants. See Tennessee Code 8-27-901
  • Third-party insurer: means an insurer that provides insurance coverage to a third-party tortfeasor, regardless of whether the coverage is personal or commercial, including, but not limited to, automobile, income replacement, premises liability, home owners, umbrella, group life, health, workers compensation, hospitalization, and disability. See Tennessee Code 8-27-901
  • Third-party tortfeasor: means an individual or entity who commits a tort against a plan participant that causes a plan participant to require medical treatment for which the plan makes payments to a provider of medical services for the benefit, or on behalf, of the plan participant. See Tennessee Code 8-27-901
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) By accepting payment of benefits pursuant to a plan authorized by this part, a plan participant acknowledges the plan’s right to reimbursement, which must be noted in plain language in the SPD.
(c) A plan under this part may deem a plan participant ineligible for continued or future coverage under the plan, if the plan participant:

(1) Receives payment from a third-party tortfeasor, third-party insurer, third party for medical payments, or other individual or entity originally paid by the plan for the benefit of, or on behalf of, the plan participant; and
(2) Fails or refuses to promptly reimburse the plan for the amounts paid by the plan.
(d) A plan shall not remove a plan participant under a plan pursuant to subsection (c) unless the plan or administrator provides the primary insured with written notice of intent to remove the plan participant. The plan or administrator shall send the notice at least ninety (90) days prior to the date the plan participant will lose benefits under the plan by certified mail with signed or electronic receipt. To be effective the notice must at a minimum include:

(1) The name of the plan participant to be removed from the plan;
(2) The date the plan participant will cease to be covered under the plan;
(3) The reason for removal from the plan;
(4) The name, title, phone number, mailing address, and email address of an individual with the authority to cancel or change the plan participant’s removal, if the removal violates the terms of the plan, or as the sponsor permits.
(e) The plan shall not prevent a provider from receiving payment for services already rendered to a provider even if the plan participant is removed from participation in a plan pursuant to subsection (c). However, this subsection (e) does not require the plan to pay benefits to medical services providers if the benefits have already been paid to a plan participant.
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