Your Right to Privacy

Personal information of any kind, including information about your medical care or health status, is protected by Anthem blue cross’ confidentially policies and procedures. While we need such information to process your claims, we do not release information that identifies you, your diagnosis or medical condition without your consent.

Grievances

All complaints and disputes relating to your coverage must be resolved in accordance with Anthem blue cross’ grievance procedure. Grievances may be made by the telephone or in writing to the phone number or address located on the back of your Anthem blue cross Identification Card. All grievances received by Anthem blue cross that cannot be resolved by phone (when appropriate) to the mutual satisfaction of the Member and Anthem blue cross will be acknowledged in writing, together with a description of how Anthem blue cross proposes to resolve the grievance. We will not respond in writing following a regular telephone inquiry unless specifically requested to do so by the Member. Grievances that cannot be resolved by these procedures shall be resolved as indicated under Arbitration.

Department of Corporations

The California Department of Corporations is responsible for regulating health care services plans. The department’s Health Plan Division has a toll-free telephone number (1-800-400-0815) to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service’s toll-free telephone numbers (1-800-735-2929 (TTY) or 1-888-877-5378 (TTY)) to contact the department. The department’s Internet web site (http://www.CORP.CA.GOV) has complaint forms and instructions online.

If you have a grievance against us, you should telephone us and use our grievance process before contacting the Health Plan Division. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your plan, or a grievance that has remained unresolved for more than 30 days, you may call the Health Plan Division for assistance. The plan’s grievance process and the Health Plan Division’s complaint review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

Binding Arbitration

Any dispute between the employer and/or covered persons and Anthem blue cross must be resolved by binding arbitration (not by lawsuit or trial by jury or other court process, except as California law provides for judicial review of arbitration proceedings), if the amount in dispute exceeds the jurisdictional limit of the Small Claims Court. Under this coverage, both you and Anthem blue cross are giving up the right to participate in class arbitration or have any dispute decided in the court of law before a jury.

Medicare

Under TEFRA/DEFRA, Medicare is the primary coverage for groups of less than 20 employees. Anthem blue cross is considered primary coverage for groups of less than 20 employees. Anthem blue cross is considered primary coverage for groups of 20 or more employees. This Anthem blue cross coverage is NOT a supplement to Medicare, but provides benefits according to Non-Duplication of Medicare Claims.
This means that when Medicare is the primary health coverage, benefits will be provided in accordance with the benefits of the plan less any amount paid by Medicare. If the member is Medicare eligible, even if the member did not enroll or claim Medicare benefits, the Anthem blue cross plan would pay only in accordance with the benefits of the plan less any amount that would have been payable by Medicare. If Medicare is the member’s primary coverage, it is important that the member enroll in both Medicare Parts A and B. NOTE: Medicare-eligible employees/dependents enrolled in plans where Medicare is primary may obtain an Individual Anthem blue cross of California Medicare Supplement with preexisting conditions waved.

Coordination of Benefits

The benefits of a member’s plan may be reduced if the member has other group health, dental, drug or vision coverage, so that benefits and services the member receives from all group coverage's do not exceed 100 percent of the Covered Expense.

Third Party Liability

If a member is injured, the responsible party may be legally obligated to pay for medical expenses related to that injury. Anthem blue cross may recover benefits paid for medical expenses if the member recovers damages from a legally liable third party. Examples of third party liability include car accidents and work-related injuries.

Voiding Coverage for False and Misleading Information

False or missing information or failure to submit any required enrollment material may form the basis for voiding coverage from the date a plan was issued or retroactively adjusting premium to what it would have been had the correct information been furnished. No benefits will be paid for any claim submitted if coverage is void. Premiums already paid for the time period for which coverage was rescinded will be refunded, minus claims paid.

Loss Ratio

As required by law, we are advising you that Anthem blue cross of California’s incurred loss ratio for 1998 was 79.4 percent. This loss ratio was calculated after provider discounts were applied.

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