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FMCP Subrogation Letter - NECA IBEW Healthcare


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									               NECA/IBEW FAMILY MEDICAL CARE PLAN
                                       CompuSys, Inc.
                                      5837 Highway 41 North
                                     Ringgold, GA 30736

Phone (706) 937-9600            Fax (706) 937-9601                 Toll Free (877) 937-9602


        RE:    NECA/IBEW Family Medical Care Plan Subrogation Reimbursement
               Date of Potential Accident?:
               Date of Service:
               Provider Name:
               Provider address:

Dear Participant:

       This letter regards a medical claim filed by your provider on behalf of you or your
dependant under the NECA/IBEW Family Medical Care Plan (Plan). It was flagged by
our computer system indicating the medical service provided may have been necessary
because of accidental injury. Presently, we are only reviewing the circumstances of the
claim. You should not construe this letter to indicate any legal suit at this time. This is
merely an information gathering tool.

       We request you fill out and return the enclosed questionnaire concerning the
above accident or injury. If you were not injured in any sort of accident, including, but
not limited to, car accidents, work related accidents, falls, or assaults, note that on the
questionnaire and inform us of the circumstances leading to the medical services sought.

        You are required to comply with our request for information on your claims. The
Subrogation Section, on pages 77-78 of the NECA/IBEW Family Medical Care Plan
Summary Plan Description Booklet (SPD), available on the plan’s website at
       “[I]n the event of any failure or refusal by the participant or dependants to execute
       any document requested by the Fund or to take other action requested by the Fund
       to protect the interests of the Fund, the Fund may withhold payment of benefits or
       deduct amount of any payments from future claims of the participants or

Your failure to respond could result in the suspension of payments of medical claims on
your behalf until you comply.

If you have already provided the information requested, notify us of this as soon as
possible. Pay close attention to the specifics of the claim we are currently asking about.
If you do not recognize the named service provider, complete the form based on the date
the service was provided. Often service providers use a name strictly for billing purposes
and thus not recognized by you. If no service was sought on the date noted, it is vitally
important that you inform us of this.

Please compete and return the form to us as soon as possible.

Please comply within 30 days of receipt of this letter. Do not disregard this letter if
you have received a similar request in the past as it may relate to another date,
occurrence or service provider.

Very truly yours,

NECA/IBEW Family Medical Care Plan


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