| Your
Right to Privacy
Personal information of any kind, including information
about your medical care or health status, is protected by Blue
Cross’ confidentially policies and procedures. While we need
such information to process your claims, we do not release information
that identifies you, your diagnosis or medical condition without
your consent.
Grievances
All complaints and disputes relating to your
coverage must be resolved in accordance with Blue Cross’
grievance procedure. Grievances may be made by the telephone or
in writing to the phone number or address located on the back
of your Blue Cross Identification Card. All grievances received
by Blue Cross that cannot be resolved by phone (when appropriate)
to the mutual satisfaction of the Member and Blue Cross will be
acknowledged in writing, together with a description of how Blue
Cross proposes to resolve the grievance. We will not respond in
writing following a regular telephone inquiry unless specifically
requested to do so by the Member. Grievances that cannot be resolved
by these procedures shall be resolved as indicated under Arbitration.
Department of Corporations
The California Department of Corporations is
responsible for regulating health care services plans. The department’s
Health Plan Division has a toll-free telephone number (1-800-400-0815)
to receive complaints regarding health plans. The hearing and
speech impaired may use the California Relay Service’s toll-free
telephone numbers (1-800-735-2929 (TTY) or 1-888-877-5378 (TTY))
to contact the department. The department’s Internet web
site (http://www.CORP.CA.GOV) has complaint forms and instructions
online.
If you have a grievance against us, you should
telephone us and use our grievance process before contacting the
Health Plan Division. If you need help with a grievance involving
an emergency, a grievance that has not been satisfactorily resolved
by your plan, or a grievance that has remained unresolved for
more than 30 days, you may call the Health Plan Division for assistance.
The plan’s grievance process and the Health Plan Division’s
complaint review process are in addition to any other dispute
resolution procedures that may be available to you, and your failure
to use these processes does not preclude your use of any other
remedy provided by law.
Binding Arbitration
Any dispute between the employer and/or covered
persons and Blue Cross must be resolved by binding arbitration
(not by lawsuit or trial by jury or other court process, except
as California law provides for judicial review of arbitration
proceedings), if the amount in dispute exceeds the jurisdictional
limit of the Small Claims Court. Under this coverage, both you
and Blue Cross are giving up the right to participate in class
arbitration or have any dispute decided in the court of law before
a jury.
Medicare
Under TEFRA/DEFRA, Medicare is the primary coverage
for groups of less than 20 employees. Blue Cross is considered
primary coverage for groups of less than 20 employees. Blue Cross
is considered primary coverage for groups of 20 or more employees.
This Blue Cross coverage is NOT a supplement to Medicare, but
provides benefits according to Non-Duplication of Medicare Claims.
This means that when Medicare is the primary health coverage,
benefits will be provided in accordance with the benefits of the
plan less any amount paid by Medicare. If the member is Medicare
eligible, even if the member did not enroll or claim Medicare
benefits, the Blue Cross plan would pay only in accordance with
the benefits of the plan less any amount that would have been
payable by Medicare. If Medicare is the member’s primary
coverage, it is important that the member enroll in both Medicare
Parts A and B. NOTE: Medicare-eligible employees/dependents enrolled
in plans where Medicare is primary may obtain an Individual Blue
Cross of California Medicare Supplement with preexisting conditions
waved.
Coordination of Benefits
The benefits of a member’s plan may be reduced
if the member has other group health, dental, drug or vision coverage,
so that benefits and services the member receives from all group
coverage's do not exceed 100 percent of the Covered Expense.
Third Party Liability
If a member is injured, the responsible party
may be legally obligated to pay for medical expenses related to
that injury. Blue Cross may recover benefits paid for medical
expenses if the member recovers damages from a legally liable
third party. Examples of third party liability include car accidents
and work-related injuries.
Voiding Coverage for
False and Misleading Information
False or missing information or failure to submit
any required enrollment material may form the basis for voiding
coverage from the date a plan was issued or retroactively adjusting
premium to what it would have been had the correct information
been furnished. No benefits will be paid for any claim submitted
if coverage is void. Premiums already paid for the time period
for which coverage was rescinded will be refunded, minus claims
paid.
Loss Ratio
As required by law, we are advising you that
Blue Cross of California’s incurred loss ratio for 1998 was
79.4 percent. This loss ratio was calculated after provider discounts
were applied.
Enrollment guidelines
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