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Blue Cross Rights and Obligations

No-Obligation Review Period

After you enroll in a Blue Cross health plan, you will receive an Evidence of Coverage policy booklet that explains the exact terms and conditions of coverage, including the plan’s exclusions and limitations. You have 10 full days to examine your plan’s features. During that time, if you are not fully satisfied, you may decline by returning your Evidence of Coverage booklet along with a letter notifying us that you wish to discontinue coverage. Evidence of Coverage booklets are available for you to examine prior to enrolling. Ask your agent or Blue Cross.

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Guarding Your Privacy

Blue Cross is fully committed to protecting our members' privacy. Our complete Notice of Privacy Practices provides a comprehensive overview of the policies and practices we enforce to preserve our members' privacy rights and control use of their health care information, including: the right to authorize release of information; the right to limit access to information; protection of oral, written and electronic information; use of data; and information share with employers. You may obtain our complete Notice of Privacy Practices from our Web site at http://www.bluecrossca.com. You may also call the Customer Service number listed on your member ID card, or prospective members may call 1-800-333-0912.

Requirement for Binding Arbitration

If you are applying for coverage, please note that Blue Cross requires binding arbitration to settle all disputes, including claims of medical malpractice. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: “It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Both parties also agree to give up any right to pursue on a cal basis any claim or controversy against the other.

Grievances

All complaints and disputes relating to your coverage must be resolved in accordance with Blue Cross’ grievance procedure. Grievances may be made by telephone or in writing; the phone number and address are located on your Blue Cross ID card. All grievances received by Blue Cross will be answered in writing, together with a description of how Blue Cross proposes to resolve the grievance.

Department of Managed Health Care

The California Department of Managed Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 333-0912 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions on-line.

Third-Party Liability

Blue Cross of California is entitled to reimbursement of benefits paid if you recover damages from a legally liable third party. Examples of third-party liability include car accidents and work-related injuries. For complete information about third-party liability, refer to the plan Evidence of Coverage booklet.

Loss Ratio

As required by law, we are advising you that Blue Cross of California’s incurred loss ratio for 2002 was 80.81 percent. This loss ratio was calculated after provider discounts were applied.