CHLIC-SG-POL-[2025]
Cigna Health and Life Insurance Company
Small Group
Group Agreement
This Policy is underwritten by Cigna Health and Life Insurance Company
.
Cigna Health and Life Insurance Company
1-860-226-6000
900 Cottage Grove Road
Bloomfield, CT, 06002
12-09-2024
CHLIC-SG-POL-[2025]
GROUP INSURANCE POLICY
This group insurance policy (the “Policy”), is entered into by and between Cigna Health
and Life Insurance Company (the “Insurance Company”) Insurance Company and
«GROUPNAME» (“Group”).
A. APPLICATION
The attached application (the “Application”) is part of this Policy. It serves as the
signature page of this Policy. The terms of the Application will control any conflict
between the terms of the Application and this Policy.
B. CERTIFICATE
The attached Certificate is part of this Policy.
C. DEFINITIONS
Defined terms are capitalized in this Policy:
1.
Agreement
means the contract between the Insurance Company and the
Group.
2.
Aggregate Premium
means the Premium required for all Members.
Aggregate Premiums are shown on all Premium Statements.
3.
Application
means the Employer enrollment form. It serves as the signature
page of this Policy.
4.
Certificate
means the document that contains the eligibility and termination
conditions, as well as the benefits, limitations, and exclusions that apply to the
Member’s coverage under the Policy.
5.
Coverage
means the Medically Necessary covered services paid for,
arranged, or authorized for the Member by the Insurance Company under the
terms and conditions of the Certificate.
6.
Eligible Employee
(use state definition)
7.
Employer
means the sponsor of this group insurance plan or any subsidiary
or affiliate described in this Policy. An employer must employ at least one
CHLIC-SG-POL-[2025]
common-law employee. A business owner and his or her spouse are not
considered common-law employees for this purpose if the entity is considered
to be wholly owned by one individual or one individual and his or her spouse.
8.
Employer Enrollment Form
means the Group’s application for Coverage.
9.
Group
means the legal entity identified as the “Group” on the face page of
the Policy. The Group is the employer and policyholder.
10.
Group Health Plan
means an employee welfare benefit plan (as defined in
section 3(1) of the Employee Retirement Income Security Act of 1974 [29
U.S.C. 1002(1)]) to the extent that the plan provides medical care (as defined
in paragraph (2)) and including items and services paid for as medical care)
to employees or their dependents (as defined under the terms of the plan)
directly or through insurance, reimbursement, or otherwise.
11.
Insurance Company
means Cigna Health and Life Insurance Company or
designated third parties acting on behalf of Cigna Health and Life Insurance
Company.
12.
Member
means the subscriber or a covered dependent who has satisfied the
eligibility conditions, applied for coverage, and for whom required Premiums
have been paid.
13.
Policy
means the document, including the Certificate, together with any
riders, amendments and endorsements, which describe the agreement
between the Insurance Company and the Group. The “Agreement” also
means the Policy.
14.
Policyholder
: Means the legal entity identified as the Policyholder on the
face page of the Policy who establishes, sponsors and endorses an employee
benefit plan for insurance coverage.
15.
Premium
means the amount paid by the Group to the Insurance Company
for Coverage.
16.
Small Employer
(use state definition)
17.
Subscriber
means the eligible individual who elects and signs for the
insurance coverage.
CHLIC-SG-POL-[2025]
18.
Total Estimated Premium Amount
means an estimate of that amount of
money necessary to fund the required Premiums to cover the total number of
Members whom the Group estimates will enroll for Insurance Company
Coverage under the Policy. Payment of the Total Estimated Premium Amount
and execution of the Application is acceptance of this Policy. The Coverage
will not begin until the Insurance Company receives the Total Estimated
Premium Amount.
D. COVERED SERVICES
The Insurance Company provides Coverage to Eligible Employees. The
Coverage is subject to the terms and conditions of this Policy and the
Application. The Group grants the Insurance Company full discretionary authority
to make Coverage decisions. These decisions are pursuant to this Agreement
and include: (1) eligibility; and (2) benefit determinations. These decisions will be
subject to the review standards applicable to ERISA plans, even if the Group’s
group health Insurance Company is not otherwise subject to ERISA.
E. ENROLLMENT AND TERMINATION OF COVERAGE
1.
Enrollment
The Certificate will describe the eligibility requirements for Eligible
Employees (also referred to as Subscribers) and their Dependents. The
Insurance Company relies on the Group to provide accurate information
regarding hours worked or scheduled to work exclusively for the Group.
If the Group offers Insurance Company one or more other group health
benefit plans for like benefits, to eligible Persons and their eligible
Dependents, the Group must permit them to enroll in this Policy. The
Group: (1) will make equitable contributions to this Policy and any other
plans; and (2) will not promote any other Insurance Company over this
Policy. The Group will not directly or indirectly encourage, discourage or
otherwise attempt to influence eligible Persons or Dependents to enroll in
the Coverage under this Policy based upon: (1) health status; or (2)
anticipated utilization of Covered Services.
a. The Group shall allow and eligible Persons can enroll for Coverage for
themselves and their eligible Dependents during: (1) the initial
enrollment period; (2) an annual Open Enrollment Period; or (3) upon a
Qualifying Event. The Parties may agree to an additional Open
Enrollment Period.
CHLIC-SG-POL-[2025]
b. The eligible Persons must complete and submit an Enrollment Form to
the group administrator for transmittal to the Insurance Company.
c. When the Group provides enrollment data and that data does not
match the Insurance Company’s data, the Insurance Company’s data
will be used to determine the premium. The Insurance Company will
work with the Group to resolve the discrepancy. If no agreement can be
reached, the Insurance Company’s records will control. Until the
dispute is resolved, the Group must pay the premium indicated, based
on the Insurance Company’s records.
d. The Group’s enrollment data shall not contain ineligible Persons and/or
Dependents.
2.
Enrollment Program Data
The Group must follow the Insurance Company’s guidelines for the
transmittal of Member enrollment or termination data, which shall be
facilitated through the use of Microsoft Excel spreadsheets in an “.xls” file
format, or such other format as may be determined by Insurance Company
in its sole discretion.
a. Insurance Company’s Duties and Responsibilities:
i. The Insurance Company will work with the Group to facilitate
secure transmittal of Member enrollment and eligibility data.
ii. The Insurance Company will assist the Group in correcting errors,
as identified through the editing process administered by the
Insurance Company. The Insurance Company may need to
contact the Group to resolve such issues.
iii. Member enrollment and eligibility data will be uploaded into the
Insurance Company’s system within
10
calendar days of its
receipt by the Insurance Company.
iv. Exception errors will be worked by the Insurance Company within
10
calendar days of upload of file transmission.
b. Group’s Duties and Responsibilities:
i. The Group will specify which persons have authority to transmit
Member spreadsheet enrollment and eligibility data to the Insurance
Company on behalf of the Group.
CHLIC-SG-POL-[2025]
ii. The Group must transmit Member spreadsheet enrollment and
eligibility data through Insurance Company-approved medium.
The parties shall agree on the medium the Group will use before
the program starts.
iii. The Group will submit its ETD data in one of the following
formats:
a) The Insurance’s Company’s standard Microsoft Excel
“.xls” spreadsheet format (supplied to the Group), or such
other format as may be required by the Insurance
Company in its sole discretion.
b) Custom format, subject to prior approval by the Insurance
Company.
iv. The Group is responsible for assuring all Member spreadsheet
enrollment and eligibility data is accurate/valid.
v. The Group shall indemnify the Insurance Company to the extent
permitted by applicable law in the state of GA, including the GA
Governmental Tort Liability Act for damages or injuries to the
Insurance Company caused by the Insurance Company’s
reliance on Member spreadsheet enrollment and eligibility data
from the Group.
3.
Notification of Termination of Coverage
The Group will notify the Insurance Company of the termination of a
Member’s Coverage not more than 15 days after the Member is no longer
eligible for Coverage.
CHLIC-SG-POL-[2025]
F. DISTRIBUTION OF MATERIALS
Group shall handle and distribute enrollment materials in a timely manner and
promptly provide to Insurance Company the information necessary to administer
this Policy. Group’s failure to provide information in a timely manner may
substantially delay and/or jeopardize the enrollment of eligible Members.
1.
Group shall distribute notices to Members that Group and/or Insurance
Company are legally required to provide (e.g., summary of benefits and
coverage documents) in a timely manner and in accordance with all
applicable laws. Group shall indemnify Insurance Company and hold
Insurance Company harmless from any damages, loss, action, claim or
suit (including court costs and attorney’s fees) arising from or related to its
failure to provide such notices.
2.
If Insurance Company provides its enrollment and/or change forms
(“Forms”) and/or any summary Insurance Company descriptions, benefit
summaries, summary of benefits and coverage, and/or comparison sheets
(“Documents”) in an electronic medium, and Group delivers Documents
electronically to Members or includes Documents on the Group’s internal
intranet or by similar means or for similar purposes, Group agrees that:
a) electronic access shall be limited to the Group’s enrolling employees
and covered employees and be restricted to a “read- only” or similar
basis;
b) they will replace any hard-copy Forms that have been modified by
Insurance Company;
c) the hard-copy documents on file with Insurance Company including the
Policy (which includes the Application and the Certificate) shall control
in the event of any discrepancy; and
d) the Group remains solely responsible for the content of the documents
and all other legal requirements pertaining to them (e.g., distribution).
CHLIC-SG-POL-[2025]
3.
Insurance Company shall create the Summary of Benefits and
Coverage (“SBC”) and provide to Group or its legal representative for Group,
for distribution to Members within required timeframes. Group shall distribute
SBC to Members in manner, method and timeframes required under
applicable law. The information in the SBC and other Forms provided by
Insurance Company is based only on those services provided by Insurance e
Company. Group’s distribution of the Forms, SBC, or other materials indicates
that Group has reviewed and approved the content of such materials. In no
circumstance will Members be charged for access to, or creation of the SBC.
G. PREMIUMS
1. Amount
The initial Premium Amounts payable for Coverage under this Policy are set
out in the Application. To begin Coverage, the Group must pay the Total
Estimated Premium Amount to the Insurance Company. The Total Estimated
Premium Amount is an estimate of that amount of money necessary to fund
the required Premiums to cover the total number of Members whom the
Group estimates will enroll for Insurance Company Coverage under the
Policy. Payment of the Total Estimated Premium Amount and execution of the
Application is acceptance of this Policy. The Coverage will not begin until the
Insurance Company receives the Total Estimated Premium Amount.
The Aggregate Premium is the Premium required for all Members. Aggregate
Premiums are shown on all Premium Statements.
The Insurance Company may change the Premium amounts upon 60 days
written notice to the Group at renewal based on various factors, including: (1)
the Group’s claim experience; and (2) the demographics of the Members
Covered by the Insurance Company, including their age, geographic area,
family composition, tobacco use, or number of Members. The Insurance
Company may also change the Premiums on a quarterly basis, based on
scheduled trend increases or additional rate changes allowed by the state
regulatory authority. In the event of termination or addition of a subsidiary,
operation or class of Subscribers Covered by the Insurance Company, the
Insurance Company may change the Premium amounts as noted above
CHLIC-SG-POL-[2025]
The Group may reject any revised Premium by terminating this Policy as of
the date that the revised Premiums would become effective. To do so, the
Group must provide written notice of termination not less than 30 days prior to
the date that revised Premium would first become payable pursuant to this
Policy.
2. Premium Statement
The Insurance Company will prepare and submit a monthly Premium
statement (“Statement”) to the Group, listing: (1) Subscribers shown on its
records; (2) type of Coverage selected by each Subscriber (e.g., individual,
family, etc.); and (3) the Aggregate Premium payable to the Insurance
Company for providing Coverage for all Members for the next billing period.
The Insurance Company will prepare this statement not less than 15 days
prior to the end of each billing period this Policy remains in effect.
The Group must pay the Aggregate Premium for anyone Covered or added
during the billing period.
3. Subscribers Listed on Premium Statement and Terminations
a. A Subscriber and his or her Covered Dependents will not have
Coverage if the Subscriber is not listed on the Premium statement. Any
such Subscriber and his or her Covered Dependents may still have
coverage if:
i. The Insurance Company receives the Enrollment Form from the
Group within 30-60 days after:
a) the date the Enrollment Form was executed; or
b) the end of the Open Enrollment Period during which the
Member is eligible to enroll in Coverage
ii. And if:
a) the Group promptly submits the Enrollment Form to the
Insurance Company; and
b) the Group pays the applicable Premium to the Insurance
Company from the date that error occurred upon
discovery of that error and a request for such payment
from the Insurance Company.
b. The Group may terminate a Member’s Coverage by submitting a
termination request to the Insurance Company. The Group will not
request retroactive termination of a Member’s coverage for any time
period during which the applicable premium was paid.
CHLIC-SG-POL-[2025]
The Insurance Company will retroactively terminate a Member’s
Coverage to the extent allowed by law, if:
i. the Group notifies the Insurance Company of a Member’s
termination from Coverage within 90 days after the Member's
termination. The Insurance Company will refund any remitted
Premium.
ii. the Group does not notify the Insurance Company of a
Member’s termination from Coverage within 90 days after the
date of Member’s termination. The Insurance Company will only
retroactively terminate the Member's Coverage for 90 days from
the date of notice to the Insurance Company. The Insurance
Company will not refund more than 3 months of Premium
payments to the Group if it fails to notify the Insurance Company
of the termination of the Member’s Coverage in a timely
manner.
c. If after notification, the Insurance Company fails to terminate that
Member’s Coverage; then, upon the Group’s discovery of the
Insurance Company’s failure to delete the Member, the Insurance
Company will:
i. terminate the Member’s Coverage retroactively; and
ii. credit the Group for Premiums paid during such time period
when Coverage was retroactively terminated.
4. Determining Premium
On approximately the fifteenth day of each month, the Insurance Company
will determine the number of Members Covered under the Policy, and this will
be the basis for the Premium charged by the Insurance Company for the
following billing period. The Group will submit monthly a listing of Members for
the Insurance Company to reconcile Members covered under the Group’s
Coverage. The following describes how the Insurance Company will bill for
adding and terminating Members:
a. Additions
If a Subscriber or Dependent becomes eligible under the Group's
Coverage during the billing period, the Subscriber or Dependent is
added on the first day of the next billing period following the date he or
she becomes eligible for Coverage. Subscribers are not added during
the billing period, unless they become eligible for Coverage due to a
Qualifying Event.
b. Subscriber Terminations
CHLIC-SG-POL-[2025]
If a Subscriber’s or Dependent’s Coverage terminates during a billing
period, and the Premium would be affected by this change, the
Premium charged for that Subscriber’s Coverage for the last billing
period does not reduce.
c. Qualifying Event
If a Member has been added or terminated as a result of a Qualifying
Event, the addition or termination will be handled according to the
statutory requirement for the Qualifying Event. Premiums will be
determined in accordance with the provision outlined in Section E.4.a
and E.4.b above.
5. Payment of Premium
The Aggregate Premium is due in full at the Insurance Company’s office on or
before the first day of each billing period.
After payment of the Total Estimated Premium Amount, subsequent
payments have a grace period of 31 days following the Premium due date
(the “Grace Period”).
The Aggregate Premium may be paid to the Insurance Company during that
Grace Period without causing termination of the Policy. If the Aggregate
Premium is paid after the Grace Period, the Insurance Company’s
acceptance or depositing of such funds shall not be construed to mean or
equate to a guarantee of or acquiescence to reinstate the Policy, continue
Coverage, or waive termination of of the Policy by the Insurance Company.
If the Group pays the premium electronically, the Group will transfer the
amount specified in the statement into an account or the Insurance
Company’s designated account so that such funds will be available through
the ACH (Automated Clearing House) by the first day of each billing period.
There will be a charge for any checks for payment of premiums that are
returned to the Insurance Company for insufficient funds, closed accounts,
or any other reason.
6. Failure to Pay Premiums
If the Aggregate Premium is not paid by the end of the Grace Period, the
Insurance Company, in its sole discretion, may: (1) notify the Group of such
non-payment and termination date of the Policy and all Coverage thereunder
and terminate the Policy Coverage back to the last Premium due date; or (2)
work with the Group to arrange payment of the Aggregate Premium, for a
period of up to 90 days. If the Group fails to pay the Premium when required,
the Insurance Company will be entitled to recover Insurance Company
Expenses. Insurance Company Expenses include: (1) the total outstanding
CHLIC-SG-POL-[2025]
Aggregate Premium; (2) the finance charge set forth below; and (3) a fee for
any checks for payment of Premiums that are returned to Insurance Company
for insufficient funds, closed accounts, or any other reason; and (4) any
expenses reasonably incurred in recovering the amount owed to the
Insurance Company including attorney’s fees.
If the Insurance Company terminates the Policy back to the last Premium due
date, the Insurance Company may recoup benefit payments from Members
and/or Providers.
The Group is still obligated to reimburse the Insurance Company for any
claims or charges which the Insurance Company has to pay, as required by:
(1) state or federal law; (2) pharmacy benefit management agreement; or (3)
provider agreement, plus a reasonable administrative fee.
7. Termination for Non-Payment of Premium
If the payment received does not pay the Aggregate Premium, plus any other
due charges in full, the Insurance Company has the discretionary authority to
terminate the Policy, or place an administrative hold on the payment of Policy
benefits. A payment of less than the full amount due will be deemed non-
payment. If the Group has access to pharmacy benefits through the
Insurance Company’s pharmacy benefit manager, and its Members incur
claims after the termination date of Coverage, the Group must reimburse the
Insurance Company for the cost of these services.
8. Reinstatement
If this Policy is terminated and the Group requests reinstatement, the Group
must remit: (1) the total outstanding Aggregate Premium; (2) the applicable
finance charge or fee; and (3) the Aggregate Premium for the current billing
period. The Group must do so within fifteen (15) calendar days following the
termination date. The Policy may be reinstated by the Insurance Company as
though it had remained continuously in effect. The Insurance Company
reserves the right to decline to reinstate this Policy, however, upon refunding
the Aggregate Premium for the current billing period to the Group.
9. Finance Charge
The Insurance Company may impose a finance charge of five percent (5%)
per month. This applies to the amount of any Aggregate Premiums not
remitted to the Insurance Company on or before the first day of any billing
period after the expiration of the Grace Period. This applies through the
duration of this Policy.
CHLIC-SG-POL-[2025]
H. TERM
The initial term of this Policy is set forth in the Application. The Policy will
automatically renew for an additional 12 month period unless terminated by the
Group upon not less than 30 days advance written notice prior to the end of the
Renewal Date. The Insurance Company shall give the Group not less than 60
days written notice of any: (1) change in the Premium for providing Coverage to
Members; (2) material changes in the Covered Services; or (3) other material
changes in the provisions of this Policy; that will become effective on a Renewal
Date. Payment of the applicable Aggregate Premium on or after that date shall
constitute acceptance of those changes by the Group, individually and on behalf
of all Members.
I. TERMINATION POLICY
1. For Cause
a. If the Insurance Company does not receive payment of any
Aggregate Premium, when due, the Insurance Company may
terminate this Policy in accordance with section D of this
Agreement.
b. The Insurance Company may terminate this Policy, upon not less
than 30 days prior written notice, if the Group fails to comply with a
material Insurance Company provision relating to the Group’s
contribution or group participation rules.
c. Upon written notice, the Insurance Company may terminate or
rescind the Policy for fraud or intentional misrepresentation of a
material fact concerning the coverage.
d. Upon written notice, the Insurance Company may terminate a
Subscriber’s or Member’s Coverage under this Policy for fraud or
intentional misrepresentation by the Group or the Member of a
material fact concerning the Subscriber or Member. Termination of
a Subscriber’s Coverage automatically terminates Coverage for all
of his or her Dependents.
CHLIC-SG-POL-[2025]
2. For No Cause
The Group may terminate this Policy upon providing 30 days’ notice in
advance of the requested termination date.
3. Effect upon Incurred Obligations
The termination of this Policy shall not relieve either party from any
obligations incurred prior to the date of termination. The termination will
not constitute an election of remedies by the terminating party. Any
CHLIC-SG-POL-[2025]
remedies available upon the termination of this Policy will be
cumulative.
If the Insurance Company terminates the Policy back to the last date
through which the Group’s Premium has been paid, the Insurance
Company may recoup benefit payments from Members and/or
Providers.
The Group is still obligated to reimburse the Insurance Company for
any claims or charges which the Insurance Company has to pay, as
required by: (1) state or federal law; (2) pharmacy benefit management
agreement; or (3) provider agreement, plus a reasonable
administrative fee.
If the Group has access to pharmacy benefits through the Insurance
Company’s pharmacy benefit manager, and its Members incur claims
after the termination date of Coverage, the Group must reimburse the
Insurance Company for the cost of these services.
4. Post Termination Premium Balances
Within 120 days from the date the Insurance Company is notified of the
Group’s Coverage termination, the Insurance Company will conduct a
final accounting. The final accounting will take into account all
payments, funds transfers, etc., necessary to fulfill both parties’
obligations under this Policy. If any outstanding payments, funds,
transfers, etc. due to the Insurance Company or the Group total less
than $25 when the Group’s Coverage terminates: (1) the amount shall
be forgiven; and (2) the parties agree that any financial obligation to
the other party shall end.
5. Post Termination Reports
Upon termination of this Policy, the Group must pay charges for the
cost of producing any report in advance of receiving the requested
report. Among other things, this applies to post- termination audits,
requests from replacement insurers or administrators, and requests
from the Group itself.
J. CONTINUATION OF COVERAGE AND CONVERSION
1. Continuation of Coverage
If a Member’s Coverage terminates as the result of an event which permits
that Member to elect to continue his or her Coverage in accordance with
CHLIC-SG-POL-[2025]
applicable Federal or State laws (a “Qualifying Event”), (“Continuation
Coverage”), that Member will be entitled to remain Covered under this Policy.
The Member must comply with the requirements of the laws and pay the
applicable Premium for the Coverage. Federal and state laws determine how
long the Group is required to continue to provide Coverage to that Member.
The EOC describes the terms and conditions of such Continuation Coverage
in greater detail.
NOTICE TO MEMBERS OF OPPORTUNITY TO ELECT CONTINUITY OF
CARE ON POLICY TERMINATION. The Policyholder must provide written
notice to members, who are continuing care patients as defined in §2799A-
3(b)(1) of the PHS Act, of the opportunity to elect continuity of care coverage
when this Policy is terminated, either by the Policyholder or by the Insurance
Company. The Policyholder will provide promptly to the Insurance Company
proof of that mailing and the date thereof.
The Group will notify Members of their right to obtain Continuation Coverage
following a Qualifying Event. The Group will collect and remit the Premium for
the Coverage to the Insurance Company. If Members do not enroll and pay
the Premium for Continuation Coverage, on or before the date their
Continuation Coverage would become effective, the Insurance Company will
terminate their Coverage. They may be reinstated if they subsequently enroll
and pay the applicable Premiums within the enrollment period for
Continuation Coverage specified by law. If the Group fails to notify a Member
of his or her right to enroll for Continuation Coverage in accordance with
applicable laws, the Insurance Company will not extend the enrollment period
beyond that required by law had the Group informed the Member of that right
in a timely manner. The Insurance Company may consent, in writing, to
extend the enrollment period for Continuation Coverage for that Member.
2. Conversion Coverage
If Members are eligible to purchase individual conversion coverage from the
Insurance Company upon the termination of his or her Coverage under this
Agreement, the Insurance Company will offer those individuals the right to
purchase the conversion coverage as outlined in the Certificate.
K. RELATIONSHIPS WITH OTHER PARTIES
1. Between Network Providers and the Insurance Company
The Insurance Company may enter into agreements with health care
providers, insurers, and any other individuals or entities, as it deems
CHLIC-SG-POL-[2025]
necessary to fulfill its obligations under this Agreement. Such parties are
independent contractors. Network Providers are independent contractors who
are solely responsible for any services rendered to their Member patients.
The Insurance Company makes no express or implied warranties or
representations concerning the continued participation of any Network
Provider. The Group acknowledges for itself and on behalf of Members that
the Insurance Company has established various arrangements to encourage
Network Providers to render Covered Services in an appropriate and cost
effective manner. Such arrangements include provider penalties.
2. Between the Group and the Insurance Company
The relationship between the Insurance Company and the Group is a
contractual relationship between independent contractors. Neither party is a
partner, joint venturer, agent or employee of the other when performing its
obligations pursuant to this Agreement.
Nothing in this Agreement shall be construed to make the Insurance
Company a sponsor, administrator or fiduciary of the Group’s Employee
benefit under ERISA. The Insurance Company is not and shall not be
deemed to be a fiduciary of the Group’s plan, except as necessary to exercise
the discretionary authority granted to it by the Group in making authorization,
eligibility and coverage determinations and construe the terms of Members’
Coverage pursuant to this Policy.
L. GROUP ADMINISTRATION ASSIGNMENT TO BROKER OR OTHER THIRD
PARTY AND HOLD HARMLESS ARRANGEMENT
If the Group has assigned some or all of those functions, as indicated below, to a
third party and if the Group has appointed such third party to act on its behalf for
those functions, the Group understands and agrees that the third party is the
contractor and/or agent of the Group and not the Insurance Company. This
Group is responsible and shall hold the Insurance Company harmless as a result
of any actions resulting from such delegation and appointment. The Group
affirms that it has properly executed a Business Associate Agreement (as
defined in 45 CFR Part 160) with such third party.
1. Third Party to Provide Enrollment Information
If the Group has contracted with a third party to provide enrollment
information to the Insurance Company on the Group’s Members, the third
party shall submit such enrollment information to the Insurance Company in
either paper or electronic form. The third party must submit the enrollment
CHLIC-SG-POL-[2025]
information using the Insurance Company’s approved forms or electronic
guidelines. In the event the Group and the third party submit duplicate or
conflicting information, the Insurance Company will rely on the latest
information provided.
If the third party submits such enrollment information to the Insurance
Company in electronic format (including but not limited to on-line enrollment
via the web or other electronic media), then the Insurance Company may
provide a password for use by the third party in accessing the electronic
system to provide enrollment information. If granted, this password is for the
exclusive use of the third party and will expire, at the latest, when the Group’s
relationship with the third party expires. A separate and distinct password will
be supplied to the Group. All access and activity to the electronic system will
be monitored by the Insurance Company. Such access may be limited or
confined to certain information according to the agreement between the
Group and the third party. The Insurance Company reserves the right to block
access to information contained in the electronic system.
The Group authorizes the Insurance Company to accept such enrollment
information. The Group shall be responsible for the validity and accuracy of
the information provided to the Insurance Company and shall indemnify and
hold the Insurance Company harmless from any and all liability, loss,
damages, claims and expenses, including attorney’s fees, as a result of the
actions or inactions of the third party, including without limitation, any
incorrect information provided.
2. Third Party to Receive Premium Statement and/or Make Premium
Remittance
If the Group has contracted with a third party to receive the Premium
Statement and/or make premium remittances to the Insurance Company, the
Group understands that this does not relieve the Group from remittance of the
amount due by the due date. The Group will be held responsible for the
premium remittance. The Group will be responsible for any late fees or
finance charges imposed for late payment. Any payment delinquency notices
or coverage termination notices for non- payment of premium will be sent to
the third party for notice and delivery to Group Members.
The Group authorizes the Insurance Company to send such Premium
Statements to and receive and accept such premium remittances from the
third party. The Group shall be responsible for the validity and accuracy of the
CHLIC-SG-POL-[2025]
information provided to the Insurance Company and shall indemnify and
hold the Insurance Company harmless from any and all liability, loss,
damages, claims and expenses, including attorney’s fees, as a result of the
actions or inactions of the third party, including without limitation, any
incorrect information provided.
If the Group assigns other functions to the third party, this Agreement shall
control the performance of those functions.
The Insurance Company is not a party to the agreement between the Group
and the third party. The Insurance Company may refuse to accept information
from the third party.
The Insurance Company shall make reasonable accommodation to assist the
Group in the administration of its assigned duties and responsibilities.
With regard to Electronic Protected Health Information (as defined in 45 CFR
Parts 160 and 162 (“Security Standards”)), the Group shall:
a. implement administrative, physical, and technical safeguards that
reasonably and appropriately protect the confidentiality, integrity and
availability of Electronic Protected Health Information that the Group
creates, receives, maintains or transmits as required by the Security
Standards;
b. ensure that any agent, including third party or any subcontractor to
whom the Group provides such information agrees to implement
reasonable and appropriate safeguards to protect it;
c. report to the Insurance Company any Security Incident (as defined in
the Security Standards) involving the Group’s data of which the Group
becomes aware within seven (7) days of the Security Incident.
3. This section will take effect on the effective date of the Agreement and will
end on the earlier of:
a. The date the Group’s Insurance Company terminates.
b. The date the Group notifies the Insurance Company in writing 31 days
of the termination of such agreement that is has terminated the
relationship with the third party.
c. The information provided is consistently unusable by the Insurance
Company in the administration of the Group’s Insurance Company.
d. The information provided is not in the format required by the Insurance
Company.
CHLIC-SG-POL-[2025]
e. The inability of the third party to perform obligation(s) of the agreement
between it and the Group.
f. Any password provided to the third party will be blocked when this
arrangement terminates. Any notice required to be sent to either the
Insurance Company or the Group may be sent to the address of that
party as shown in this Agreement or it attachments.
M. DISPUTE RESOLUTION
The Group may agree that any dispute related to this Policy must be submitted to
non-binding arbitration. Unless the parties otherwise agree, such arbitration shall
be conducted in accordance with applicable rules of the American Arbitration
Association (“AAA”) and the GA Uniform Arbitration Act.
The arbitrator shall be required to issue a reasoned opinion explaining the basis
of the decision and the manner of calculating any award. The arbitrator may not
award punitive or exemplary damages and must base the decision on the terms
of this Agreement and applicable law. Once the parties agree to accept the
arbitrator’s decision, it may be entered and enforced in any state or federal court.
Once it has been agreed to by the parties, that decision may only be vacated,
modified or corrected for the reasons set forth in the GA Uniform Arbitration Act, if
the award contains material errors of law or is arbitrary and capricious.
Upon completion of arbitration, the parties may pursue other available legal
remedies.
N. INSURANCE COMPANY’S RIGHT TO AUDIT
The Insurance Company has the right to randomly audit for compliance with
participation and eligibility requirements. This audit will take place no more than
twice a year.
The Insurance Company has the right to randomly audit if intentional
misrepresentation of material fact or fraud is suspected.
The Group shall have the right to review the Insurance Company’s audit for
participation and eligibility requirements to verify that it has conducted the audit
according to the Insurance Company’s guidelines.
O. MISCELLANEOUS
1. Information Request from Insurance Company
Group shall promptly provide Insurance Company with any and all information
requested by Insurance Company for the purposes of Insurance Company’s
compliance with any state or federal law or regulation, including, but not
CHLIC-SG-POL-[2025]
limited to Group’s Premium Contribution Rate and amount.
GROUP MUST
IMMEDIATELY NOTIFY INSURANCE COMPANY OF ANY AND ALL
CHANGES IN GROUP’S PREMIUM CONTRIBUTION RATE AND CONFIRM
THE CONTRIBUTION RATE AT RENEWAL
.
2. Premium Rebates
If Insurance Company is required by law to provide a premium rebate to
Group’s Members and former Subscribers, Insurance Company, in its sole
discretion, will as allowed by law:
a. Group will provide Insurance Company with any information that is
necessary for Insurance Company to pay the rebates to Members in
accordance with applicable law, including, but not limited to information
relating to premium contribution amounts and contact information.
b. If Group fails to provide Insurance Company with premium contribution
information that is necessary to calculate a rebate to Members on a
pro rata basis based on the percentage of premium paid, Insurance
Company will distribute 100% of the rebate for Group’s coverage to
Members, without regard to the pro-rata share of the premium
contribution made by Group and Group waives any claim it has to a
share of the rebate.
3. Entire Agreement
This Policy, including the Application, Certificate, any Riders, and any
Amendments, Attachments or Exhibits, constitute the entire agreement
between the parties. It supersedes all prior oral or written understanding or
agreements between the parties.
4. Effective Date of This Policy
This Policy will be effective as of the date indicated after the Insurance
Company accepts the Application and accepts the Total Estimated Premium
Amount. The Group’s execution of the Application and payment of the Total
Estimated Premium Amount will be its acceptance of this Policy. The
Application is the signature page of this Policy.
5. Renewals
The parties may agree to extend the term of this Policy. The Group will
indicate its acceptance of any change in terms of the Agreement by the
payment of the next due Aggregate Premium.
6. Amendments
CHLIC-SG-POL-[2025]
This Policy may be amended, in writing, by an authorized representative of
both parties. The Insurance Company may also amend the Policy, upon
notice to the Group, as necessary to comply with: (1) applicable laws; (2)
regulations; or (3) lawful orders of governmental agencies. Only an officer of
the Insurance Company has the authority to: (1) modify this Policy; (2) waive
any of its provisions; or (3) extend the time for taking any action required by
this Policy.
7. Claim Adjudication
The Insurance Company adjudicates claims in accordance with its internal
administrative guidelines. Any rebates or refunds on Member’s Covered
Services are credited against the Group’s experience for rating purposes.
8. Clerical Errors
Clerical errors will not change the rights or obligations of either party under
this Policy. They also will not grant additional benefits to Members. The
parties shall cooperate, in good faith, to promptly correct such errors.
9. Waiver
The terms or conditions of this Policy may only be waived by express written
consent of the party from whom such a waiver is requested. Any waiver of a
breach of any provision shall not constitute a waiver of any subsequent
breach of the same or any other provision of this Policy.
10. Assignability
No rights or duties under this Policy are assignable by the Group to any other
party unless the Insurance Company consents to such assignment in writing.
11. Notices
Any notice required or permitted under this Policy shall be in writing. Such
notice will be deemed to have been given on the date when delivered to the
other party’s most recent address: (1) in person; or (2) by certified or
overnight mail, return receipt requested. Notice from the Insurance Company
to the Group will be deemed to be notice to all Members.
12. Third Parties
This Policy does not confer any rights or obligations on third parties except as
specifically provided herein.
13. Construction
CHLIC-SG-POL-[2025]
This Policy will be construed without regard to the party that drafted it. Any
ambiguity will not be interpreted against either party but will, instead, be
resolved in accordance with other applicable rules concerning the
interpretation of contracts.
14. Governing Law and Severability
This Policy is executed and is to be performed in accordance with applicable
federal and GA laws. If any provision of this Policy is deemed to be invalid or
illegal by a court or regulatory agency having jurisdiction over such matters,
the surviving provisions of this Policy shall remain in effect unless the
severance of that provision shall deprive a party of the material benefits of this
Policy
15. Legal Action
No action at law or in equity shall be brought to recover on this Policy until 60
days after written proof of loss has been furnished as required by this Policy.
No such action shall be brought beyond 3 years after the time written proof of
loss is required to be furnished.
16. Confidentiality
The parties acknowledge that this Policy and information provided to the other
party that is identified as confidential information, including, but not limited to,
reimbursement information, group membership lists, marketing information
and information obtained from and/or about the Insurance Company
("Confidential Information"); shall be treated as confidential, proprietary or
trade secret information. A party may release Confidential Information to
providers or its affiliates, or their respective directors, partners, officers,
employees, advisors and other representatives ("Representatives") who: have
a need to know such Confidential Information, for purposes of their
participation in or oversight of matters within the scope of this Policy; and are
under a duty or obligation of confidentiality at least as restrictive as those set
forth in this Policy. Each party shall advise its Representatives of their
obligation to maintain the confidentiality of such information. Each party is
responsible if its Representative breaches this Section. Neither party shall
otherwise release nor disclose such Confidential Information to third parties
without the other party's prior written consent, except as required by law. This
paragraph shall survive the termination of this Policy.
Notwithstanding anything herein to the contrary, the following shall not
constitute Confidential Information for the purposes of this Policy:
CHLIC-SG-POL-[2025]
a. Confidential Information that is or becomes generally available to the
public other than as a result of a disclosure by a party or its
Representatives;
b. Confidential Information that was available to the parties on a non-
confidential basis prior to its disclosure by a party or its
Representatives; or
c. Confidential Information that becomes available to the parties on a
non- confidential basis from a third party, provided that third party is
not known to be subject to any prohibition against transmitting that
information.
17. Other Acceptable Forms of this Document and its Attachments
The following shall have the same legal effect as an original: facsimile copy,
imaged copy, scanned copy, and/or an electronic version, including a digital
or electronic signature.
18. Additional Programs
The Insurance Company may, from time to time, offer or arrange for various
entities to offer discounts, benefits or other consideration to Employees for
the purpose of promoting their general health and well being. Contact the
Insurance Company for details of these programs.
