CALIFORNIA - Pacificare Health Systems

PART B
202
Section 9 – Organization Determination,
Appeals and Grievance Procedures
complaint with the QIO in your local area.
(The name, address and telephone number of
your local QIO are referenced in the “Quality
Improvement Review” portion of Section 9.)
Binding Arbitration
Any and all disputes of any kind whatsoever,
including claims relating to the delivery of
services under the plan and claims of medical
malpractice (that is as to whether any medical
services rendered under the health plan
were unnecessary or unauthorized or were
improperly, negligently, or incompetently
rendered), except for claims subject to
ERISA, between Member (including any
heirs or assigns) and PacifiCare of [state,
Inc.], or any of its parents, subsidiaries or
affiliates (collectively, “PacifiCare”), shall
be submitted to binding arbitration. Any
such dispute will not be resolved by a
lawsuit or resort to court process, except
as the Federal Arbitration Act provides for
judicial review of arbitration proceedings.
Member and PacifiCare are giving up their
constitutional rights to have any such
dispute decided in a court of law before a
jury, and are instead accepting the use of
binding arbitration by a single arbitrator in
accordance with the Comprehensive Rules of
JAMS, and administration of the arbitration
shall be performed by JAMS or such other
arbitration service as the parties may agree
in writing. The parties will endeavor to
mutually agree to the appointment of the
arbitrator, but if such agreement cannot be
reached within thirty (30) days following
the date demand for arbitration is made, the
arbitrator appointment procedures in the
Comprehensive Rules will be utilized.
Arbitration hearings shall be held in the
county in which the Member lives or at such
other location as the parties may agree in
writing. Civil discovery may be taken in such
arbitration. The arbitrator selected shall have
the power to control the timing, scope and
manner of the taking of discovery and shall
further have the same powers to enforce
the parties’ respective duties concerning
discovery as would a Superior Court of
California including, but not limited to,
the imposition of sanctions. The arbitrator
shall have the power to grant all remedies
provided by federal and state law. The parties
shall divide equally the expenses of JAMS and
the arbitrator. In cases of extreme hardship,
PacifiCare may assume all or part of the
Member’s share of the fees and expenses of
JAMS and the arbitrator, provided the Member
submits a hardship application to JAMS. The
approval or denial of the hardship application
will be determined solely by JAMS.
The arbitrator shall prepare in writing an
award that includes the legal and factual
reasons for the decision. The requirement of
binding arbitration shall not preclude a party
from seeking a temporary restraining order
or preliminary injunction or other provisional
remedies from a court with jurisdiction;
however, any and all other claims or causes
of action including, but not limited to, those
seeking damages, shall be subject to binding
arbitration as provided herein. The Federal
Arbitration Act, 9 U.S.C. ¤¤ 1-16, shall also
apply to the arbitration.
BY ENROLLING IN PACIFICARE BOTH
MEMBER (INCLUDING ANY HEIRS OR
ASSIGNS) AND PACIFICARE AGREE
TO WAIVE THE CONSTITUTIONAL
RIGHT TO A JURY TRIAL AND INSTEAD
VOLUNTARILY AGREE TO THE USE OF
BINDING ARBITRATION AS DESCRIBED IN
THIS EVIDENCE OF COVERAGE.
Nothing within this Arbitration provision
alters a Secure Horizons Group Retiree
Medicare Advantage Plan Member’s right
to use the Medicare Appeals process. The
binding arbitration provision will be used to
resolve any matters that are not fully resolved
through the Medicare Appeals process or are
not subject to the Medicare Appeals process.
Arbitration does not apply to claims and
service disputes that are subject to the
Medicare reconsideration and Appeals
process.