05-E TML Health Insurance Cnt - Laserfiche WebLink

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DEFINIT[ONS: The following terms where used in this Agreement, have these meanings: o We, us, or our - The TML Intergovemmental Employee Benefits Pool, known as the Group Benefi[s Administra[or herein, or any subcontractdr which it designates to perform the functions and meet the obligations to which it agrees in this Ageement. o You or your - The Employer named in the Schedule. o The Plan - The employee benefit plan which the Employer named in the Schedule has adopted to provide medical expense benefits to eligible persons, as defined, and which is attached to this Agreement. o Eligible Persons - Employees and dependents who are eligible for benefits under the Plan. You have adopted the Plan and asked us to administer the benefits provided by the Plan. Therefore, in consideration of the mutual promises contained in this Agreement, it is agreed as follows. L OUR DUTIES a. We agree to process all claims presented on behalf of eligible persons for the payment of benefits according to the terms of the Plan. We will administer benefits per your plan document unless authorized by you, in writing, to pay outside the plan guidelines. We will not process any claim which was incurred prior to the Effective Date shown in the Schedule, unless authorized by you in writing prior to determination. b. We agree to provide, at monthly intervals, a listing of all Plan benefits paid. One custom report is provided, at your request, at no cost per plan year. Subsequent custom reports will be billed as shown in the schedule. C. We agree to design, review and print standard forms to explain benefits to employees, standard enrollment cards, standard ID cards and one (1) standard benefit book every two (2) years. d. We agree to provide underwriting services including (i) annual cost projections, (ii) cost projections for Plan modifications; and estimates of reserve amounts required to fund the Plan on a current basis. e. We agree to provide assistance to you in designing your Plan benefits based on coverage adequacy, cost control effectiveness, and medical or economic developments. £ We agree to provide an annual report of tax reportable claim payments to medical care providers. g. We agree to allow you to obtain a third party to conduct an on site claims audit at our offices. Such claims audit will be limited to once per agreement year and the date(s) will be mutually agreed upon. We agree to not unnecessarily delay the claims audit by not mutually agreeing to a date. h. We agree to administer all provisions contained in the Plan bookleUdocument adopted by the Employer. i. We agree to use care and diligence in the exercise of our powers and the performance of our duties as Group Benefits Administrator hereunder but shall not be liable for any mistake orjudgment or other ac[ion taken in good faith or for any loss unless resulting from our gross negligence. j. We agree to process any written requests, issues or comments received from Eligible Persons on appeals of denied benefits and forward the information to the Emp(oyer for review and decision.