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Workers' Compensation

The MPI Health Plan does not cover expenses incurred as a result of, or in connection with, any of the following:
  1. Injuries sustained while performing any act pertaining to any occupation or employment for remuneration or profit, or
  2. Sickness, disease or injuries covered under any Workers' Compensation or Occupational Disease Act or Law.
Under the California Workers' Compensation Act, and the laws of other states, medical treatment for injury or illness either caused or aggravated by your work activities is the responsibility of your Employer.

You must notify your Employer as soon as you are aware of any medical problem that you think has been caused or aggravated by your work by filing a "Workers' Compensation Claim Form (DWC 1)" for Workers' Compensation Benefits in California, and comparable forms in other states.

If the MPI Health Plan determines that the injury or illness is work-related, no benefits will be payable. Therefore, if your Employer denies liability for your work-related injury or illness, you may wish to protect your rights by filing a Workers' Compensation Claim as soon as possible.

If you file a Workers' Compensation claim, the MPI Health Plan will be able to advance you payment for covered medical services rendered. The Plan would then file a lien claim on its own behalf before the Workers' Compensation Appeals Board for reimbursement by your Employer if it is determined that your condition was caused or aggravated by your work.

If you file a claim for Workers' Compensation Benefits, please notify the MPI Health Plan of the case number and the name of your attorney, if you have one.

In the event that you settle a Workers' Compensation claim, you should attempt to have your Employer agree to pay expenses for future medical treatment of the \ alleged work-related condition. If the Workers' Compensation settlement does not contain such an agreement, the MPI Health Plan will make its own determination whether future medical expenses related to your work-related condition are excluded from coverage under "1" or "2" (previously described).

Benefits from the MPI Health Plan are not intended to duplicate any benefits which are available under Workers' Compensation Law, whether or not you or your Employer has actually purchased Workers' Compensation insurance.

Participants and dependents are obligated to complete and submit the necessary claim forms, consents, releases, assignments and other documents requested so the MPI Health Plan may pursue its lien rights. Any Participant or dependent who fails to submit such documents or cooperate with the Plan in processing the lien will not be entitled to benefits under this provision of the MPI Health Plan until the documents are received by the Plan or the Participant or dependent cooperates in the Plan's efforts.

Additionally, any failure on the part of a Participant or eligible dependent to cooperate with the MPI Health Plan in pursuing its lien rights that results in a loss to the Plan may result in the Plan deducting the amount of the loss from all future benefit payments for the Participant or eligible dependents until the amount of the loss is recovered. A loss to the MPI Health Plan means any action or inaction on the part of the Participant or eligible dependent that prevents the Health Plan from obtaining reimbursement for health expenses that we otherwise would be entitled to.

A failure to cooperate could include, but is not limited to, any of the following acts:

A Participant or eligible dependent fails to:
  • Notify the MPI Health Plan of the filing of a Workers' Compensation claim;
  • Provide the MPI Health Plan with a copy of the Workers' Compensation Claim Form or Application;
  • Complete and return a Questionnaire Form;
  • Notify the MPI Health Plan of the approval of a Workers' Compensation Award;
  • Provide the MPI Health Plan with a copy of a Workers' Compensation Award;
  • Notify the MPI Health Plan of the approval of a Workers' Compensation Compromise and Release;
  • Provide the MPI Health Plan with a copy of a Workers' Compensation Compromise and Release, Stipulation with Request for Award, and Findings and Award;
  • Cooperate with the MPI Health Plan in litigating its lien rights before the Workers' Compensation Appeals Board; or
  • Provide accurate information on the Questionnaire Form.