When another party is responsible for injury or illness You may receive a letter from the plan asking if your injury or illness was the result of an accident or might be someone else’s responsibility. To make sure claims are paid in a timely manner, it is important that you respond as directed in the letter, even if the answer is no. If you do not, the plan may deny coverage. You may contact UMP Customer Service if you have questions. Occupational injury or illness (workers’ compensation) claims When a claim for occupational injury or illness (workers’ compensation) is accepted by your employer’s workers' compensation carrier, UMP will not cover any services related to that injury or illness, even if the compensation carrier denies some services. You must file a workers’ compensation claim with your workers’ compensation carrier. If your claim for workers’ compensation is denied because it is determined the injury or condition is not related to an occupational injury or illness, UMP will pay for covered services under the terms of this COC. Legal rights and responsibilities Coverage under the plan is not provided for medical, dental, prescription, or vision expenses you incur for treatment of an injury or illness if the costs associated with the injury or illness may be covered by another first party insurance or may be recoverable from any of the following: • A third party; • Any other source, including no fault automobile medical payments (Med-Pay), no fault automobile personal injury protection (PIP), homeowner’s no-fault coverage, commercial premises no-fault medical coverage, and sports policies. This includes excess, underinsured, or uninsured motorist coverage, or similar contract or insurance, when the contract or insurance is either issued to or makes benefits available to you, whether or not you make a claim under such coverage; or • Services or supplies for work-related injury or illness, even when the service or supply is not a covered workers’ compensation benefit under the workers’ compensation plan. ALERT! You must respond to any communication sent to you about other sources of benefits, or the plan may deny claims. However, after expiration or exhaustion of the above benefits, if you also have a potential right of recovery for illnesses or injuries from a third party who may have legal responsibility or from any other source, benefits may be provided or advanced by the plan pending the resolution of a claim to the right of recovery subject to all of the following conditions: • By accepting or claiming benefits, you agree that the plan is entitled to reimbursement of the full amount of benefits paid out of any settlement or recovery from any source to the extent that the settlement or recovery exceeds full compensation to you for the injury or illness that you sustained. This includes any arbitration award, judgment, settlement, disputed claim settlement, underinsured or uninsured motorist payment, or any other recovery related to the injury or illness for which benefits under the plan have been provided or advanced. • The plan may choose to recover expenses directly from the third party (or third party’s insurer) responsible for your injury or illness. This is called subrogation. The plan is authorized, but not 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 131