Citi Benefits Handbook
Recovery Provisions
Refund of Overpayments
Whenever payments have been made by any of the Citigroup Health and Welfare Plans for covered or non-covered expenses in a total amount, at any time, in excess of the maximum amount payable under the Plan's provision (overpayment), the person(s) receiving benefits under the Plan(s) (the covered person(s)) must refund to the Plan(s) the applicable overpayment and help the Plan(s) obtain the refund of the overpayment from another person or organization. This includes any overpayments resulting from retroactive awards received from any source, fraud or any error made in processing your claim.
In the case of a recovery from a source other than the Plan(s), overpayment recovery will not be more than the amount of the payment. An overpayment also occurs when payment is made from the Plan(s) that should have been made under another group plan. In that case, the Plan(s) may recover the payment from one or more of the following: any other insurance company, any other organization or any person to or for whom payment was made.
The Plan(s) may, at their option, recover the overpayment by reducing or offsetting against any future benefits payable to the covered person or his/her survivors; stopping future benefit payments that would otherwise be due under the Plan(s) (payments may continue when the overpayment has been recovered); or demanding an immediate refund of the overpayment from the covered person.
The Plan Administrator of the Citigroup Disability Plan reserves the right to recover funds related to disability benefits for any overpayment when a covered person receives state benefits, including Workers' Compensation and Social Security benefits.
Reimbursement for Citigroup Health Benefit Plan
This section applies when a covered person recovers damages — by settlement, verdict or otherwise — for an injury, sickness or other condition. If the covered person has made — or in the future may make — such a recovery, including a recovery from an insurance carrier, the Plan will not cover either the reasonable value of the services to treat such an injury or illness or the treatment of such an injury or illness.
However, if the Plan does pay for or provide benefits for such an injury, sickness or other condition, the covered person — or the legal representatives, estate or heirs of the covered person — will promptly reimburse the Plan from all recovery amounts (whether or not characterized as related to medical expenses) from any settlement, verdict or insurance proceeds received by the covered person (or by the legal representatives, estate or heirs of the covered person) to the extent that medical benefits have been paid for or provided by the Plan to the covered person.
If the covered person receives payment from a third party or his or her insurance company as a result of an injury or harm due to the conduct of another party, and the covered person has received benefits from the Plan, the Plan must be reimbursed first. In other words, the covered person's recovery from a third party may not compensate the covered person fully for all the financial expenses incurred because acceptance of benefits from the Plan constitutes an agreement to reimburse the Plan for any benefits the covered person receives.
The covered person also must take any reasonably necessary action to protect the Plan's subrogation and reimbursement right. That means by accepting benefits from the Plan, the covered person agrees to notify the Plan Administrator if and when the covered person institutes a lawsuit or other action or enters into settlement negotiations with another party (including his or her insurance company) in connection with or related to the conduct of another party.
The covered person also must cooperate with the Plan Administrator's reasonable requests concerning the Plan's subrogation and reimbursement rights and must keep the Plan Administrator informed of any important developments in his or her action. The covered person also agrees that the Plan Administrator may withhold any future benefits paid by the Plan to the extent necessary to reimburse the Plan under the Plan's subrogation or reimbursement rights.
To secure the rights of the Plan under this section, the covered person hereby:
  • Grants to the Plan a first-priority lien against the proceeds of any such settlement, verdict or other amounts received by the covered person to the extent of all benefits provided in an effort to make the Plan whole;
  • Assigns to the Plan any benefits the covered person may have under any automobile policy or other coverage; the covered person shall sign and deliver, at the request of the Plan or its agents, any documents needed to protect such lien or to effect such assignment of benefits; and
  • Will cooperate with the Plan and its agents and will:
    • Sign and deliver such documents as the Plan or its agents reasonably request to protect the Plan's right of reimbursement;
    • Provide any relevant information; and
    • Take such actions as the Plan or its agents reasonably request to assist the Plan in making a full recovery of the value of the benefits provided.
If the covered person does not sign and deliver any such documents for any reason (including, but not limited to, the fact that the covered person was not given an agreement to sign or is unable or refuses to sign), the Plan Administrator, in its sole discretion, may or may not advance benefits to the covered person under the Plan.
If the Plan Administrator has advanced benefits, it has the right to subrogation and reimbursement whether or not the covered person has signed the agreement. The covered person shall not take any action that prejudices the Plan's right of reimbursement.
For information on the Plan's funding status, visit "Plan Information."
Subrogation
This section applies when another party is, or may be considered, liable for a covered person's injury, sickness or other condition (including insurance carriers that are so liable) and the Plan has provided or paid for benefits.
The Plan is subrogated to all the rights of the covered person against any party, including any insurance carrier, liable for the covered person's injury or illness or for the payment for the medical treatment of such injury or occupational illness to the extent of the value of the medical benefits provided to the covered person under the Plan. The Plan may assert this right independently of the covered person.
The Plan has a first-priority right to receive payment on any claim against a third party before you receive payment from that third party. The Plan's subrogation and reimbursement rights apply to full and partial settlements, judgments or other recoveries paid or payable to you or your representative, no matter how those proceeds are captioned or characterized. Payments include, but are not limited to, economic, non-economic and punitive damages.
The covered person is obligated to cooperate with the Plan and its agents to protect the Plan's subrogation rights. Cooperation means complying with the terms of this section, providing the Plan or its agents with relevant information requested by them; signing and delivering such documents as the Plan or its agents reasonably request to secure the Plan's subrogation claim; responding to requests for information; appearing at requested medical examinations or depositions; and obtaining the consent of the Plan or its agents before releasing any party from liability for payment.
If the covered person enters into litigation or settlement negotiations regarding the obligations of other parties, the covered person must not prejudice, in any way, the subrogation rights of the Plan under this section. Further, the covered person agrees to notify the Plan Administrator if and when the covered person institutes a lawsuit or other action or enters into settlement negotiations with another party (including his or her insurance company) in connection with or related to the conduct of another party.
Upon the Plan's request, you will assign to the Plan all rights of recovery against third parties to the extent of benefits the Plan has provided for a sickness or injury caused by a third party. The Plan may, at its own option, take necessary and appropriate action to assert its rights under this section, including filing suit in your name, which does not obligate it in any way to pay you part of any recovery the Plan might obtain. The Plan's rights will not be reduced due to your own negligence.
The costs of legal representation retained by the Plan in matters related to subrogation shall be borne solely by the Plan. If the Plan incurs attorney's fees and costs in order to collect third-party settlement funds held by you or your representative, the Plan has the right to recover those fees and costs from you. The costs of legal representation retained by the covered person shall be borne solely by the covered person.
The Plan has the sole authority and discretion to resolve all disputes regarding the interpretation of the language stated herein.
For information on the Plan's funding status, visit the "Plan Information" section.
Aetna ChoicePlan 500 and Aetna HDHP only:
The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by the Plan. The Plan's right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your decedents, minors, and incompetent or disabled persons. "You" or "your" includes anyone on whose behalf the plan pays benefits. No covered adult may assign any rights that it may have to recover medical expenses from any individual or company found to have committed wrong doing, or to any other person or entity, including any minor child or children of said adult covered person without the prior express written consent of the Plan.
The Plan's rights of subrogation and reimbursement, below, extend to all insurance coverage available to you due to an injury, illness or condition for which the Plan has paid medical claims (including, but not limited to, liability coverage, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no fault automobile coverage or any first party insurance coverage).
Your health plan is always secondary to automobile no-fault coverage, personal injury protection coverage, or medical payments coverage.
No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the health plan's subrogation and reimbursement interest are fully satisfied.
Subrogation
The right of subrogation means the plan is entitled to pursue any claims that you may have in order to recover the benefits paid by the Plan. Immediately upon paying or providing any benefit under the Plan, the Plan shall be subrogated to (stand in the place of) all of your rights of recovery with respect to any claim or potential claim against any party, due to an injury, illness or condition to the full extent of benefits provided or to be provided by the Plan. The Plan may assert a claim or file suit in your name and take appropriate action to assert its subrogation claim, with or without your consent. The Plan is not required to pay you part of any recovery it may obtain, even if it files suit in your name.
Reimbursement
If you receive any payment as a result of an injury, illness or condition, you agree to reimburse the Plan first from such payment for all amounts the plan has paid and will pay as a result of that injury, illness or condition, up to and including the full amount of your recovery.
Constructive Trust
By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any provider) you agree that if you receive any payment as a result of an injury, illness or condition, you will serve as a constructive trustee over those funds. Failure to hold such funds in trust will be deemed a breach of your fiduciary duty to the plan. No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the health plan's subrogation and reimbursement interest are fully satisfied.
Lien Rights
Further, the Plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the illness, injury or condition upon any recovery whether by settlement, judgment or otherwise, related to treatment for any illness, injury or condition for which the Plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to, you, your representative or agent, and/or any other source that possessed or will possess funds representing the amount of benefits paid by the Plan.
Assignment
In order to secure the plan's recovery rights, you agree to assign to the plan any benefits or claims or rights of recovery you have under any automobile policy or other coverage, to the full extent of the Plan's subrogation and reimbursement claims. This assignment allows the Plan to pursue any claim you may have, whether or not you choose to pursue the claim.
First-Priority Claim
By accepting benefits from the Plan, you acknowledge that the Plan's recovery rights are a first priority claim and are to be repaid to the plan before you receive any recovery for your damages. The Plan shall be entitled to full reimbursement on a first-dollar basis from any payments, even if such payment to the Plan will result in a recovery which is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The Plan is not required to participate in or pay your court costs or attorney fees to any attorney you hire to pursue your damage claim.
Applicability to All Settlements and Judgments
The terms of this entire subrogation and right of recovery provision shall apply and the Plan is entitled to full recovery regardless of whether any liability for payment is admitted and regardless of whether the settlement or judgment identifies the medical benefits the Plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The Plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic damages and/or general damages only. The Plan's claim will not be reduced due to your own negligence.
Cooperation
You agree to cooperate fully with the Plan's efforts to recover benefits paid. It is your duty to notify the Plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or condition. You and your agents agree to provide the Plan or its representatives notice of any recovery you or your agents obtain prior to receipt of such recovery funds or within 5 days if no notice was given prior to receipt. Further, you and your agents agree to provide notice prior to any disbursement of settlement or any other recovery funds obtained. You and your agents shall provide all information requested by the plan, the Claims Administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements as the Plan may reasonably request and all documents related to or filed in personal injury litigation. Failure to provide this information, failure to assist the Plan in pursuit of its subrogation rights or failure to reimburse the Plan from any settlement or recovery you receive may result in the denial of any future benefit payments or claim until the plan is reimbursed in full, termination of your health benefits or the institution of court proceedings against you.
You shall do nothing to prejudice the Plan's subrogation or recovery interest or prejudice the Plan's ability to enforce the terms of this Plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan or disbursement of any settlement proceeds or other recovery prior to fully satisfying the health plan's subrogation and reimbursement interest.
You acknowledge that the Plan has the right to conduct an investigation regarding the injury, illness or condition to identify potential sources of recovery. The plan reserves the right to notify all parties and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys.
You acknowledge that the Plan has notified you that it has the right pursuant to the Health Insurance Portability & Accountability Act ("HIPAA"), 42 U.S.C. Section 1301 et seq, to share your personal health information in exercising its subrogation and reimbursement rights.
Anthem ChoicePlan 500 and Anthem HDHP only:
These provisions apply when Plan benefits are paid as a result of injuries or illness you sustained and you have a right to a recovery or have received a recovery.
Subrogation
The Plan Administrator has the right to recover Plan payments made on your behalf from any party responsible for compensating you for your injuries. The following apply:
  • The Plan has the first priority for the full amount of benefits paid by the Plan from any recovery regardless of whether you are fully compensated, and regardless of whether the payments you receive make you whole for your losses and injuries.
  • You and your legal representative must do whatever is necessary to enable the Plan Administrator to exercise the Plan's rights and must do nothing to prejudice such rights.
  • The Plan Administrator has the right to take whatever legal action they see fit against any party or entity to recover the benefits paid under the Plan. To the extent that the total assets from which a recovery is available are insufficient to satisfy in full the Plan's subrogation claim and any claim still held by you, the Plan's subrogation claim shall be first satisfied before any part of a recovery is applied to your claim, your attorney fees, other expenses or costs. The Plan is not responsible for any attorney fees, other expenses or costs without its prior written consent. The Plan further agrees that the "common fund" doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan.
Reimbursement
If you obtain a recovery and the Plan has not been repaid for the benefits the Plan paid on your behalf, the Plan shall have a right to be repaid from the recovery in the amount of the benefits paid on your behalf and the following apply:
  • You must reimburse the Plan to the extent of Plan benefits the Plan paid on your behalf from any recovery.
  • Notwithstanding any allocation made in a settlement agreement or court order, the Plan shall have a right of recovery, in first priority, against any recovery.
  • You and your legal representative must hold in trust for the Plan the proceeds of the gross recovery (i.e., the total amount of your recovery before attorney fees, other expenses or costs) to be paid to the Plan immediately upon your receipt of the recovery. You must reimburse the Plan, in first priority and without any set-off or reduction for attorney fees, other expenses or costs. The "common fund" doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan.
  • If you fail to repay the Plan, the Plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Plan has paid or the amount of your recovery whichever is less, from any future benefit under the Plan if:
1. The amount the Plan paid on your behalf is not repaid or otherwise recovered by the Plan; or
2. You fail to cooperate.
In the event that you fail to disclose to the Plan Administrator and/or Citigroup, the amount of your settlement, the Plan shall be entitled to deduct the amount of their lien from any future benefit under the Plan.
  • The Plan shall also be entitled to recover any of the unsatisfied portion of the amount paid by the Plan or the amount of your settlement, whichever is less, directly from the providers to whom the Plan has made payments. In such a circumstance, it may then be your obligation to pay the provider the full billed amount, and the Plan would not have any obligation to pay the provider.
The Plan is entitled to reimbursement from any recovery, in first priority, even if the recovery does not fully satisfy the judgment, settlement or underlying claim for damages or fully compensate or make you whole.
The Plan Sponsor has sole discretion to interpret the terms of the Subrogation and Reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary.
If the covered person is a minor, any amount recovered by the minor, the minor's trustee, guardian, parent, or other representative, shall be subject to this provision. Likewise, if the covered person's relatives, heirs, and/or assignees make any recovery because of injuries sustained by the covered person, that recovery shall be subject to this provision.
The Plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary. The Plan shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.
The Plan is entitled to recover its attorney's fees and costs incurred in enforcing this provision.
Your Duties
  • You must notify the Plan Administrator promptly of how, when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved.
  • You must cooperate with the Plan Administrator in the investigation, settlement and protection of Citigroup's rights of the Plan.
  • You must not do anything to prejudice the rights of the Plan.
  • You must send the Plan Administrator copies of all police reports, notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you.
  • You must promptly notify the Plan Administrator if you retain an attorney or if a lawsuit is filed on your behalf.
For information on the Plan's funding status, visit the "Plan Information" section.