AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Determination concerns an admission, availability of care, continued stay, or health care item or
service for which you received emergency services, but have not been discharged from a facility.
Immediately upon receipt of the request for expedited External Review, Aetna will determine whether the
request meets the reviewability requirements set forth above for standard External Review. Aetna must
immediately send you a notice of its eligibility determination.
REFERRAL OF EXPEDITED REVIEW TO ERO
Upon a determination that a request is eligible for External Review following preliminary review, Aetna will
assign an ERO. The ERO shall render a decision as expeditiously as your medical condition or
circumstances require, but in no event more than 72 hours after the ERO receives the request for an
expedited External Review. If the notice is not in writing, within 48 hours after the date of providing that
notice, the assigned ERO must provide written confirmation of the decision to you, Aetna and the Plan.
LEGAL ACTION
No legal action can be brought to recover any benefit under the Plan after three years from the date you
have exhausted the Plan’s review procedure.
SUBROGATION AND RIGHT OF REIMBURSEMENT
1) Subrogation. The Plan does not cover expenses for which another party may be responsible as a
result of having caused or contributed to an Injury, Illness or other loss. This means that, to the extent
the Plan provides or pays benefits or expenses for Covered Services, you automatically assign to the
Plan and the Plan assumes your (and your heirs’, estate’s or legal representative’s) legal rights to
recover the amount of those benefits or expenses from any person, entity, organization or insurer,
including, but not limited to, your own insurer and any under insured or uninsured coverage, that may
be legally obligated to pay for those benefits or expenses. This process is referred to as subrogation.
The amount of the Plan’s subrogation rights shall equal the full amount you are entitled to receive up
to the total amount paid by the Plan for the benefits or expenses for Covered Services.
The Plan’s right of subrogation applies on a first-dollar basis and shall have priority over your or
anyone else’s rights until the Plan recovers the total amount the Plan paid for Covered Services. The
Plan’s right of subrogation for the total amount the Plan paid for Covered Services is absolute and
applies whether or not you receive, or are entitled to receive, a full or partial recovery or whether or
not you are “made whole” by reason of any recovery from any other person or entity, and applies to
funds paid for any reason, including non-medical or dental charges, attorney fees, or other costs and
expenses. This provision is intended to and does reject and supersede the “make-whole” rule, which
rule might otherwise require that you be “made whole” before the Plan may be entitled to assert its
right of subrogation.
The Plan’s right of subrogation allows the Plan to pursue any claim, right or cause of action that you (and
your heirs, estate or legal representative) may have, whether or not you (or your heirs, estate or legal
representative) chooses to pursue that claim. You must cooperate with the Plan Administrator and
Employer in any respect necessary or advisable to make, perfect or prosecute such claim, right or
cause of action, and shall enter into a subrogation agreement with the Plan upon the request of the
Plan Administrator or Employer. By this assignment, the Plan’s right to recover from insurers includes,
without limitation, such recovery rights against no-fault auto insurance carriers in a situation where no
third party may be liable.
2) Reimbursement. The Plan also reserves the right of reimbursement. This means that, to the extent
the Plan provides or pays benefits or expenses for Covered Services, you must repay the Plan from,
and the Plan has the right to reimbursement from, any amounts recovered by suit, claim, settlement
or otherwise, from any person, entity, organization or insurer, including your own insurer and any
under insured or uninsured motorist coverage, for those benefits or expenses (even if the amounts
recovered are not designated as payments of medical expenses). The amount of the Plan’s
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