A member who has, or may have, a right to receive compensation or damages from a third party for expenses as a result of accident or injury must inform Health Partners as soon as they know or suspect that such a right exists, keep us informed of the progress and determination/settlement of the claim, plus copies of all related settlement documentation and/or associated medical information in relation to the claim for compensation and damages.
Benefits are not payable for expenses incurred in relation to an accident or injury where the member has received, or may be entitled to receive, compensation in respect of that injury. Where a member appears to have a right to make a claim for compensation but that right has not been established, Health Partners may withhold payment of benefits in respect of expenses incurred in relation to that injury.
Where a claim for compensation in respect of an accident or injury is in the process of being made, or has been made and remains unfinalised, Health Partners may in its absolute discretion make a provisional payment of benefits in respect of expenses incurred in relation to the injury. A provisional payment is conditional upon the member signing a legally binding undertaking and authority that the member will disclose to us all matters pertaining to the progress of the claim and details of any determination made or any settlement reached in respect of the claim, in addition to repaying to the Health Partners the full amount of the provisional payment immediately upon the determination or settlement of the claim, whether or not the terms of such a settlement specify that the sum of money paid under the settlement relates to expenses past or future for which Health Partners benefits are otherwise payable.
Where benefits have already been paid by Health Partners and the member has later received compensation in respect of an accident or injury, the member must repay the full amount that Health Partners paid for expenses in relation to the injury, upon the determination or settlement of the claim for compensation. Health Partners has the right in its absolute discretion take any action permitted by law to pursue the member for repayment of all benefits paid in relation to the injury.
For the avoidance of doubt, a member is not entitled to benefits for as much of the expenses as the member is entitled to recover under another insurance policy or would have been entitled but for this insurance. The member must first claim under that insurance policy. This applies whether the other insurance policy provides full or partial coverage.