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HomeMy WebLinkAboutReso 1976-8174RESOLUTION NO". 8174 RESOLUTION OF THE CITY COUNCIL OF--T1iE`-CITY OF CHULA VISTA, APPROVING AGREEMENT BETWEEN THE CITY OF CHULA VISTA AND KAISER FOUNDATION HEALTH PLAN, INC. AND AUTHORIZING THE MAYOR TO EXECUTE SAID AGREEMENT The City Council of the City of Chula Vista does hereby resolve as follows: NOW, THEREFORE, BE IT RESOLVED that that certain agreement between THE CITY OF CHULA VISTA, a municipal corporation, and KAISER FOUNDATION HEALTH PLAN, INC. dated the 1st day of MaY 19 76 a copy of which is attached hereto and incorporated herein, the same as though fully set forth herein be, and the same is hereby approved. BE IT FURTHER RESOLVED that the Mayor of the City of Chula Vista be, and he is hereby authorized and directed to execute said agreement for and on behalf of the City of Chula Vista. Presented by ,/`' C ~~2~'G~L-cam ~~ ~/L?- -~-~ Gordon K. Grant, Director of 'mow Finance Approved as to form by v ~~ ' v George D. Lindberg, City Attorney ADOPTED AND APPROVED by the CITY COUNCIL of the CITY OF CHULA VISTA, CALIFORNIA, this 25th day of May , 1976 , by AYES: Councilmen Hyde, Hobel, Hamilton NAYES : Councilmen None ABSE ATTE STATE OF CALIFORNIA) COUN~1'Y OF SAN DIEGO) ss . CITY OF CHULA VISTA) I, City Clerk of the City of Chula Vista, California, DO HEREBY CERTIFY that the above is a full, true and correct copy of Resolution No. and that the same has not been amended or repealed. DATED City Clerk KAISER FOUNDATION HEALTH PLAN, INC. A NONPROFIT CORPORATION SOUTHERN CALIFORNIA REGION GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT INTRODUCTION This Group Medical and Hospital Service Agreement has been entered into be- tween Kaiser Foundation Health Plan, Inc. , a California nonprofit corporation, and CITY OF CHULA VISTA (hereafter referred to as "Group") in order to provide eligible Subscribers and their eligible Family Dependents electing to enroll hereunder with medical, sur- gical, hospital and related health care benefits as specified in the attached I3en- efit Schedules. Health Plan, in consideration of the periodic payments to be paid to Health Plan by Group and in consideration of the supplemental charges to be paid by or on behalf of Members, agrees to arrange necessary Medical and Hospital Services and other benefits during the term of this Agreement, subject, however, to all terms and conditions of this Agreement and the attached Benefit Schedules. INTERPRETATION OF AGREEMENT In order to provide the advantages of integrated medical and hospital facilities and of group medical practice, Health Plan operates on adirect-service rather than indemnity basis. The interpretation of this Agreement shall be guided by the direct-service nature of the Health Plan program. 1. DEFINITIONS As used in this Agreement and all schedules or addenda hereto (except as otherwise expressly provided or made necessary by the context): A. "Health Plan" means Kaiser Foundation Health Plan, Inc. , a nonprofit corporation organized for the primary purpose of arranging for Medical and Hospital Services; "Southern California Region" means that division of Health Plan which operates in the Service Area. B. "Group" is identified above. GSA-75 C. "Subscriber means a person who meets all applicable eligibility re- quirement~ of Section 2 and is enrolled hereunder, and for whom the prepay- ment required by Section 4 has been actually received by Health Plan. D. "Family Dependent" means any member of a Subscriber's family who meets all applicable eligibility requirements of Section 2 and is enrolled here- under, and for whom the prepayment required by Section 4 has been actually received by Health Plan. E. "Member" means any Subscriber or Family Dependent; "Medicare Member" means any Member entitled to benefits under both parts of Medicare who has assigned Part B benefits to Health Plan. F. "Medical Group" means any group of medical doctors or medical doc- tor with whom Health Plan has contracted to render the medical and paramed- ical services set forth herein. G. "Physician" means any doctor of medicine associated with or engaged by Medical Group; "Attending Physician" means the Physician primarily respon- sibile for the care of a Member with respect to any particular injury or illness. H. "Hospital" means any hospital in the Southern California Region with which Health Plan maintains contractual arrangements for Hospital Services. A current list of such Hospitals may be obtained from any Health Plan office. J. "Medical Office" means any outpatient treatment facility in the South- ern California Region which is staffed by Medical Group. A current list of Medical Offices may be obtained from any Health Plan office. K. "Medical Services" (except as expressly limited or excluded by this Agreement) means those professional services of physicians and surgeons, and paramedical personnel, including medical, surgical, diagnostic, thera- peutic and preventive services which are (i) generally and customarily pro- vided in the Service Area, and (ii) performed, prescribed, or directed by Physicians. L. "Hospital Services" (except as expressly limited or excluded by this Agreement) means those services for registered bed patients which are (i) generally and customarily provided by acute general hospitals ir_ the Service Area, and (ii)prescribed, directed or authorized by a Physician. M. "Prevailing Rates" means the rates generally prevailing in the Ser- vice Area for hospital, medical and related services . Such rates may be computed on a weighted average or composite basis. N. "Service Area" means that geographical area within Los Angeles, -2- GSA-75 Orange, Riverside, San Bernardino, San Diego and Ventura Counties lying within a radius of thirty miles of any Hospital or Medical Office. O. "House Call Area" means that geographical area surrounding each Hospital and Medical Office within which house calls are rendered under this Agreement. Such areas may be revised without notice from time to time. A current definition of each House Call Area may be obtained at the Health Plan office. P. "Medicare" means the Federal Health Insurance for the Aged and Disabled Act as in effect January 1, 1975. Q. "Spell of Illness" has the same meaning as in Medicare. A Spell of Illness begins when a person enters a hospital or skilled nursing facility and ends when he has not been a patient in either a hospital or skilled nursing Facility For 60 consecutive days. R. "5 killed Nursing Facility" means a licensed institution as defined in Medicare, and approved in writing by Medical Group, which is primarily en- gaged in providing skilled nursing care and related services to inpatients who require medical or nursing care. S. "Extended Care ServiceH" and "Post-Hospital Extended Care Services" have the samd meaning as in Medicare, but apply only to services performed, prescribed or directed by a Physician. T. "Part A Home Health Services" and "Part B Home Health Services" means "Post-Hospital Home Health Services" and "Home Health Services", respectively, as those terms are defined in Medicare, but they apply only to services performed, prescribed or directed by a Physician. U. "Alcoholism Unit" means any alcoholism unit maintained by Medical Group. 2. ELIGIBILITY, ENROLLMENT AND COVERAGE A. Eligibility of Individuals. Individuals are accepted for enrollment hereunder only upon meeting all applicable requirements set forth below: (1) Subscribers. To be eligible as a Subscriber a person must be either (a) an actual and bona fide member of Group, or (b) entitled under the trust agreement, employment contract or other established standard of Group, on his own behalf and not by virtue of dependency status, to participate in medical and hospital care benefits arranged by Group. Subscribers must meet the Following additional requirements: must be permanent ~i~- 'ro active employees of Group. -3- GSA-75 (2) Family Dependents. To be eligible as a Family Dependent a person must be either (a) the spouse of the Subscriber or (b) a dependent unmar- ried child under age 19 of either the Subscriber or his spouse. Foster children under age 19 entirely supported by and residing in the household of the Subscriber and his spouse are included. Newborn children are Fam- ily Dependents from birth if promptly enrolled by a parent. Coverage of a child who attains the age of 19 may be continued while he is incapable of self-sustaining employment by reason of mental retardation or physical handicap incurred prior to age 19 and chiefly dependent upon the Subscriber or his spouse for support and maintenance; proof of such incapacity and dependency must be furnished annually if required by Health Plan. (3) Membership Previously Terminated. No person is eligible to enroll hereunder who has had Health Plan coverage terminated for cause under this or any other Health Plan Medical and Hospital Service Agreement. (4) Change of Group Eligibility Rules. The composition of Group and requirements determining eligibility for membership in Group and For par- ticipation in medical and hospital care benefits arranged by Group are con- siderations material to the execution of this Agreement by Health Plan; during the term of this Agreement no change in Group's eligibility or par- ticipation requirements shall be permitted to affect eligibility or enroll- ment under this Agreement in any manner deemed adverse by Health Plan unless such change is effected by mutual agreement with Health Plan. (5) Right to Examine Records. Health Plan has the right, at reasonable times, to examine Group's records, including payroll records of employ- ers having employees covered through Group, with respect to eligibility and monthly payments under this Agreement. B. Enrollment. Subscriber and Family Dependents eligible under Section 2-A may enroll hereunder only at the following times: as of May 1, 1976; within ninety (90) days of first meeting the requirements of Section - to e e ective the first of the following month; or subsequently as of May 1 eac year. Newly acquired Family Dependents may be enrolled within thirty days of ac- quisition. If Health Plan at its discretion, determines that it is necessary to limit enrollment of additional Members in order to maintain a suitable level of Medical or Hospital Services to Members, Health Plan may limit enrollment in such fashion as it deems appropriate notwithstanding the eligibility and en- rollment provisions of this section and Section 2-A or any other provision of this Agreement. -4- GSA-75 C. Coverage. Coverage of Members enrolled hereunder is determined as set forth below: (1) Members Not Entitled to Any Medicare Benefits. Subscribers who are not entitled to any Medicare Benefits have "A" coverage and Family Dependents who are not entitled to any Medicare Benefits have "A" coverage. (2) Members Entitled to Medicare Benefits. All sums payable to or on behalf of Members pursuant to Medicare for services provided pursuant to this Agreement are payable to and retained by either Health Plan or the pro- vider of services entitled thereto, and each Member entitled to any Medicare benefits shall complete and submit to Health Plan all documents reasonably requested by Health Plan in order to obtain or assure such payment. The monetary amounts referred to in Sections J and L of the applicable Benefit Schedules are available only to satisfy those costs not covered under Medi- care and do not duplicate any benefit to which a Member is entitled under Medicare. (a) Entitled to Benefits Under Both Parts of Medicare. Members who are entitled to benefits under Parts A and B of Medicare wdzn have assigned Part B benefits to Health Plan have "M" coverage. (b) Entitled to Benefits Under Only One Part of Medicare. Members who are entitled to benefits under one Part of Medicare but not the other Part have the same coverage as Members who are not entitled to any Medicare benefits. 3. RELATIONS AMONG PARTIES AFFECTED BY AGREEMENT The relationship between Health Plan and Medical Group and between Health Plan and Hospitals is an independent contractor relationship; Physicians and Hos- pitals are not agents or employees of Health Plan, nor is Health Plan, or any em- ployee of Health Plan, an employee or agent of Hospitals or Medical Group. Physicians maintain the physician-patient relationship with Members and are solely responsible to Members for all Medical Services. Hospitals maintain the hospital-patient relationship with Members and are solely responsible to Members For all Hospital Services. Information from medical records of Members and information received by Physicians or Hospitals incident to the physician-patient or hospital-patient relationship is kept confidential, and, except for use incident to bona fide medi- cal research and education or reasonably necessary in connection with the admin- istration of this Agreement, including Medicare requirements, is not disclosed without the consent of the Member. Neither Group nor any Member is the agent or representative of Health Plan, and neither is liable for any acts or omissions of Health Plan, its agents or em- ployees, or of Medical Group, any Physician, or Hospital, or any other person -5- GSA-75 or organization with which Health Plan has made or hereafter makes arrangements for the performance of services under this Agreement. Certain Members may, for reasons personal to themselves, refuse to accept procedures or courses of treatment recommended by Physicians. Physicians may regard such refusal to accept their recommendations as incompatible with the con- tinuance of the physician-patient relationship. Physicians shall use their best ef- forts to render all necessary and appropriate professional services in a manner compatible with Member's wishes, insofar as this can be done consistently with Physician's judgment as to the requirements of proper medical practice. If a Mem- ber refuses to follow a recommended treatment or procedure, and the Physician believes that no professionally acceptable alternative exists, such Member shall be so advised and if upon being so advised the Member still refuses to follow the rec- ommended treatment or procedure then the Member shall be given no further treat- ment and neither Physicians, Hospitals nor Health Plan shall have any further re- sponsibility to provide care for the condition under treatment. 4. RATES AND PAYMENT Payment for coverage hereunder is made as follows: A. Periodic Payment Schedule. Group shall remit to Health Plan on behalf of each Subscriber and his Family Dependents for each month on or before the last day of the preceding month the following amounts: SUBSCRIBER ONLY SUBSCRIBER and ONE FAMILY DEPENDENT SUBSCRIBER and TWO or more FAMILY DEPENDENTS In addition: $ 28. $ 57.50 $ R~ ~~ ADD $ q_67 For each Member age 65 or older (a) not entitled to ben- efits under Part B of Medicare, or (b) entitled to benefits un- der Part B of Medicare but who has not assigned such benefits to Health Plan. SUBTRACT $ 17.15 For each Subscriber with "M" coverage. SUBTRACT $ 17.15 For each Family Dependent with "M" coverage. -6- GSA-75 The amounts set forth above are called the "Base Payment. " If a state or any other taxing authority imposes upon Health Plan a tax or license Fee which is levied upon or measured by the Base Payment or by Health Plan's gross receipts or any portion of either, then commencing upon the effective date of such tax or license fee, Group shall remit to Health Plan with the appropriate Base Payment an amount sufficient to cover all such taxes or license fees rounded to the nearest cent. Only Members for whom the stipulated payment is actually received by Health Plan are entitled to Medical and Hospital Services hereunder and then only for the period For which such payment is received. If any payment required is not timely paid by or on behalf of any Member, all rights of such Member hereunder shall terminate and may be reinstated only by renewed application and re-enrollment in accordance with all require- ments of this Agreement. B. Supplemental Charges. In addition, Members shall pay or arrange for payment of applicable supplemental charges as provided in the accompany- ing Benefit Schedules, and in case of failure to do so the rights of the Member and of all other Members in the same family unit may be terminated on fifteen (15) days' notice and may be reinstated only by renewed application and re- enrollment in accordance with all requirements of this Agreement. C. Economic Stabilization Rules. No amount otherwise payable under this Agreement shall be payable to the extent that it is not payable by virtue of the Economic Stabilization Act of 1970, or any extension or amendment thereof, or any other law of similar or related. purpose or import, or any rule, regulation, order or decision issued thereunder. Any such amount actually paid to Health Plan shall be refunded or credited. 5. SERVICES AND BENEFITS Medical and Hospital Services furnished hereunder are furnished respec- tively, only by Physicians and Hospitals, and only at Hospitals, Skilled Nurs- ing Facilities or Medical Offices, or at the Member's residence as herein- after provided for house calls and Part A Home Health Services and Part B Home Health Services. The locations of such facilities shall be Furnished by Health Plan upon request. Except for reimbursement as provided under Sections J or L of the appli- cable Benefit Schedules, Health Plan will not reimburse Members For the cost of services received from doctors or hospitals or other agencies or Facilities other than those with whom Health Plan has contracted or that Medical Group has approved in writing. -7- GSA-75 6. EXCL~JSIONS AND LIMITATIONS A. Exclusions. All services for conditions within any of the following classifications are excluded from the coverage of this Agreement: (1) Psychiatric Conditions. Psychiatric care, including any treatment for insanity, mental illness or disorders. (2) Drug Addiction. Drug addiction; drug induced mental conditions caused by a drug or drugs for which the patient does not have a prescription. (3) Employer or Governmental Responsibility. Illness, injuries or condi- tions covered by services, indemnification or reimbursement available either: (a) Pursuant to any federal, state, county or municipal workmen's compen- sation or employer's liability law or other legislation of similar purpose or import; or (b) From any federal, state, county, municipal or other governmental agency, including, in the case of service-connected disabilities, the Veterans' Admin- istration. If there is reasonable doubt whether or not a Member should receive benefits under this Agreement or from any such source, if the Member seeks diligently to establish his rights to benefits from such other source, benefits will be furn- ished under this Agreement; provided, however, that the value of such services, at Prevailing Rates, shall be recoverable by Health Plan or its nominee from such other source, or from the Member, if and to the extent it is determined that monetary benefits should have been provided by such other source. (4) Custodial, Domiciliary, or Convalescent Care. Custodial care, domi- ciliary care, or convalescent care for which, in the judgment of the Attending Physician, the facilities and service of an acute general hospital or a Skilled Nursing Facility are not medically required. (5) Rehabilitation. Neuromuscular rehabilitation, except for that associated with the treatment of poliomyelitis which First manifests itself after the effective date of membership. (6) Cosmetic Surgery. Conditions for which plastic surgery is indicated primarily for cosmetic purposes. (7) Dental Care and Dental X-rays. (8) Rental of Durable Equipment. Durable medical equipment, including iron lungs, oxygen tents, hospital beds, and wheelchairs used in the Member's home (including an institution used as his home). -8- r_c~_~c B. Li!nitations. The rights of Members and obligations of Health Plan, Hospitals and Medical Group hereunder are subject to the following limitations: (1) Major Disaster or Epidemic. In the event of any major disaster or epidemic, Physicians and Hospitals shall render Medical and Hospital Services (and arrange Extended Care Services and Part A Home Health Services and Part B Home Health Services for Members entitled thereto) insofar as practical, according to their best judgment, within the limitation of such facilities and personnel as are then available, but neither Health Plan, Hospitals nor Medical Group has any liability or obligation for delay or Failure to provide or arrange any such services due to lack of available facilities or personnel if such lack is the result of such disaster or epidemic. (2) Circumstances Beyond Health Plan's Control. If due to circumstances not reasonably within the control of Health Plan, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, disability of a significant part of Hospital or Medical Group personnel, or similar causes, the rendition of Medical Services, Hospital Services, Extended Care Services, Part A Home Health Services or Part B Home Health Services hereunder is delayed or rendered impractial, neither Health Plan, Hospitals, Medical Group nor any Physician shall have any liability or obligation on account of such delay or such failure to provide services. (3) Corrective Appliances and Artificial Aids. Artificial aids and corrective appliances, such as braces, prosthetic devices, hearing aids, corrective lenses and eyeglasses, are not provided under this Agreement, but Health Plan will attempt to make arrangements whereby such aids and appliances may be obtained at reasonable rates; services necessary to determine the need therefor are pro- vided. (4) Injuries Caused by 'Third Parties. In case of injuries caused by any act or omission of a third party, and complications incident thereto, services and other benefits requested hereunder are furnished but are charged at Pre- vailing Rates. However, the Member is not required to pay any amount in excess of the total amount collected on account of the injury. This limitation is not applicable to Medicare Members. (5) Chronic Hemodialysis and Kidney Transplants. Hemodialysis for chronic conditions and kidney transplants are provided only in accordance with Section J of the applicable Benefit Schedule. (6) Alcoholism. Treatment for alcoholism is provided only in accordance with Section O of the applicable Benefit Schedule. Detoxification is not covered. This limitation (6) does not apply to Medicare Members. -9- GSA-7.ri 7. CONVERSION AND TRANSFER A. Conversion to Individual Enrollment. If any person who has been a bona fide Member under this Agreement ceases to be qualified to continue as a Member for any reason other than: 1. Nonpayment of applicable charges; or 2. Termination of Membership rights pursuant to Section 8-B or 11-D; then said person may, within thirty (30) days after termination of rights under this Agreement, convert his membership effective as of the date of such term- ination of rights to the conversion coverage in effect at the time of his appli- cation for conversion. B. Transfer of Residence. Members who transfer their residence from the Southern California Region to any geographical area not served by Health Plan may, if they so desire, continue their Health Plan coverage by paying applicable charges. However, the only benefits provided outside of Health Plan service areas are those specified in Section L of the applicable Benefit Schedule. Members who transfer their residence to another Health Plan Region must promptly apply to a Health Plan office in such Region to transfer their member- ship. Acceptance of transfer applications is discretionary with the Region to which transfer is sought; ordinarily, a person who has been a bona fide member in one Region for at least one year will be accepted for transfer. No right to service benefits under Section K of the applicable Benefit Sched- ule exists in another Health Plan Region after a Member has lived in the vicin- ity of such Region more than ninety (90) days, unless the Member, by prior ap- plication to Health Plan, demonstrates special circumstances under which a longer period is "temporary" and the Member's continuing status of temporary residence is confirmed in writing by Health Plan. 8. TERM AND TERMINATION This Agreement shall continue in effect from the effective date hereof to January 1, 1977 and from year to year thereafter, subject to: A. Termination on Notice. Either party may terminate this Agreement by giving written notice to the other party at least thirty (30) days prior to any anniversary date (the month and day referred to above of any year). All rights to services terminate as of the effective date of such termination. -10- GSA-75 B. Individual Termination for Cause. If Hospitals or Medical Group, after reasonable efforts to establish and maintain a satisfactory hospital-patient or physician-patient relationship with any Member, is unable to do so, then the rights of such Member and other Members of his family under this Agreement may be terminated on not less than fifteen (15) days' written notice to Subscriber. At the effective date of such termination, prepayments received on account of such terminated Member or Members applicable to periods after the effective date of termination shall be refunded, and Health Plan shall have no further liability or responsibility under this Agreement. C. Discontinuance of Health Plan Operations. If, due to circumstances beyond Health Plan's control, it becomes impractical, in the judgment of Health Plan's Board of Directors, to continue the operation of Health Plan within the Service Area, then Health Plan may terminate this Agreement at any time on thirty (30) days' written notice to Group, and neither Health Plan, Hospitals nor Medical Group shall have any further liability or responsibility by reason of or pursuant to this Agreement after the effective date of such termination. 9. AMENDMENT This Agreement, including the attached Benefit Schedules, may be amended at any time by Health Plan in any respect provided written notice of such amend- ment is mailed to Group at least thirty (30)days prior to the effective date of such amendment. The agreement of Group and Subscribers to such amendment shall be established by making payments to Health Plan pursuant to Section 4-A hereof or the acceptance of benefits hereunder after the effective date of such amendment. 10. ARBITRATION OF CLAIMS A. Initiating a Claim. Any claim arising from the alleged violation of a legal duty incident to this Agreement shall be submitted to binding arbitration if the claim is asserted: (1) By a Member, or by a Member's heirs or personal represen- tative ("Claimant"), (2) On account of death or bodily injury arising out of the rendition or failure to render services under this Agreement, irrespective of the legal theory upon which the claim is asserted, (3) For monetary damages exceeding the jurisdictional limit of the Small Claims Court, -11- GSA-75 (~) Against one or more of the following ("Respondent"): a. Health Plan, b. Hospitals, c. Medical Group, d. Southern Permanente Services, Inc. , or e. Any employee or partner of the foregoing. Claimant shall initiate the claim by serving at least one Respondent with a notice of the existence and nature of the claim and of a demand for arbitra- tion. Claimant shall serve all Respondents reasonably servable, and the ar- bitrators shall have jurisdiction only over Respondents actually served. The notice and demand must be served in the following manner: Natural persons must be served as in a California civil action, and any other Respondent must be served by registered letter, postage prepaid, addressed to the Respondent in care of Health Plan at the address provided in Section 11. B. Initiating Arbitration Proceedings. Within thirty (30) calendar days after initial service on a Respondent, Claimant and Respondent each shall des- ignate an arbitrator and give written notice of such designation to the other, and each shall deposit $150. 00 in a special account maintained by Bank of America National Trust and Savings Association, Wilshire-Robertson Branch, 8760 Wilshire Boulevard, Los Angeles, California 90211, to provide the initial funds to pay the fees of the neutral arbitrator and expenses of arbitration as approved by him, which fees and expenses shall be borne equally by the parties. Said account shall be replenished from time to time as directed by the neutral arbitrator. Within thirty (30) calendar days after these notices have been given and payments made,' the two arbitrators so selected shall select a neutral ar- bitrator and give notice of the selection to Claimant and all Respondents served, and the three arbitrators shall hold a hearing within a reasonable time there- after. Except where otherwise agreed to by the parties, arbitration shall be held at a time and place designated by the neutral arbitrator in a county where an alleged act of negligence occurred. C. General Provisions. All claims based upon the same incident, trans- action or related circumstances shall be arbitrated in one proceeding and all Respondents duly served in connection therewith shall be parties. A claim shall be waived and forever barred if (1) on the date notice thereof is received the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the Claimant fails to pursue the arbitra- tion claim in accordance with the procedures prescribed herein with reason- able diligence. In addition, a claim arising hereunder may not be submitted to arbitration or the arbitration concluded unless and until the procedures pre- scribed herein have been fully complied with. All notices or other papers re- quired to be served or convenient in the conduct of arbitration proceedings following the initial service shall be served by mailing the same postage pre- -12- GSA-75 paid to such address as each party gives the other for that purpose. With re- spect to any matter not herein expressly provided for, the arbitration shall be governed by the California Code of Civil Procedure provisions relating to arbi- tration. 11. MISCELLANEOUS PROVISIONS A. Acceptance of Agreement. Group may accept this Agreement either by execution of the acceptance provided below or by making payment to Health Plan pursuant to Section 4-A hereof, and such acceptance renders all terms and provisions hereof binding on Health Plan and Group. B. Agreement Binding on Members. By this Agreement, Group makes Health Plan coverage available to persons who are eligible under Section 2; however, this Agreement is subject to amendment, modification or t~rmina- tion in accordance with any provision hereof or by mutual agreement between Health Plan and Group without the consent or concurrence of the Members. By electing medical and hospital coverage pursuant to this Agreement, or accepting benefits hereunder, all Members legally capable of contracting, and the legal representatives of all Members incapable of contracting, agree to all terms, conditions and provisions hereof. C. Applications, Statements, Etc. Members or applicants for member- ship shall complete and submit to Health Plan such applications, medical re- view questionnaires, or other forms or statements as Health Plan may reason- ably request; Members warrant that all information contained in such applica- tions, questionnaires, forms or statements submitted to Health Plan incident to enrollment under this Agreement or the administration hereof is true, cor- rect and complete. Each Member entitled to Medicare benefits shall complete and submit to Health Plan such consents, releases, assignments and other doc- uments as Health Plan may reasonably request in connection with Medicare; any Member who fails to do so must pay for services received at Prevailing Rates. D. Identification Cards. Cards issued by Health Plan to Members pursuant to this Agreement are for identification only. Possession of a Health Plan ident- ification card confers no rights to services or other benefits under this Agree- ment. To be entitled to such services or benefits the holder of the card must, in fact, be a Member on whose behalf all applicable charges under this Agree- ment have actually been paid. Any person receiving services or other benefits to which he is not then entitled pursuant to the provisions of this Agreement shall be charged therefor at Prevailing Rates. If any Member permits the use of his Health Plan identification card by any other person, such card may be retained by Health Plan, and all rights of such Member and any other Member of his family unit pursuant to this Agreement shall be immediately terminable at the will of Health Plan. -13- ncn_vG E. Notices. Any notice under this Agreement may be given by United States Mail, postage prepaid, addressed as follows: IF TO HEALTH PLAN: KAISER FOUNDATION HEALTH PLAN, INC, 1515 North Vermont Los Angeles, California 90027 IF TO A MEMBER: To the latest address provided for the Member on enrollment or change of address forms actually delivered to Health Plan. IF TO GROUP: CITY OF CHULA VISTA 276 Fourth Avenue Chula Vista, California 92010 Executed at Los Angeles, California, May 12 19 76 to take effect as of May 1 19 76 KAISER FOUND,,ATION HE~L~'H PLAN, INC, By Aut orize Representative, Southern California Region Accepted May 25 ~ 19 76 CITY OF CHULA VISTA -14- GSA-75 Mayor of the City of Chula Vista KAISER FOUNDATION HEALTH PLAN, INC. A Nonprofit Corporation Southern California Region BENEFIT SCHEDULE "A" COVERAGE Subject to all terms, conditions and definitions in the foregoing Medical and Hospital Service Agreement, Members with "A" coverage are entitled to receive the Medical and Hospital Services and other benefits set forth in this Benefit Schedule, upon payment of specified supplemental charges. These services and benefits are available only if and to the extent that they are (1) provided, prescribed or directed by a Physician, (2) requested and, (3) except for house calls pursuant to Section C and special benefits under Sections J, K and L, received at a Hospital or Medical Office, as defined in Section 1 of the Agreement. The benefits under this Agreement for Members entitled to benefits under one Part of Medicare but not the other Part, do not duplicate any bene- fit to which they are entitled under Medicare; and the monetary amounts re- ferred to in Sections J, K and L of this Benefit Schedule are available only to satisfy those costs not covered under Medicare and not to duplicate any bene- fits to which a Member is entitled under Medicare. A. MEDICAL CARE IN HOSPITAL, SKILLED NURSING FACILITY AND OFFICE 1. Care While Hospitalized. All services of Physicians as requested or directed by the Attending Physician, including operations, other surgical procedures, anesthesia and consultation with and treatment by specialists, are provided without charge while the Member is admitted to a Hospital as a registered bed patient. 2. Care in Medical Offices or Emergency Departments. All services of Physicians and paramedical personnel provided, requested or directed by the Attending Physician, including surgical procedures and consultation with and treatment by specialists, are provided at Medical Offices and Hos- pital emergency departments without charge. 3. Care in Skilled Nursing Facility. All services of Physicians as re- quested or directed by the Attending Physician (to the extent practicable within the limitations of the equipment and staff of the Skilled Nursing Facil- ity) are provided without charge during the 100 days of Extended Care Ser- vices specified in Section N of this Benefit Schedule. A-75 B. HOSPITAL CARE During each calendar year, 365 days of prescribed hospital care are pro- vided without charge. Hospital care includes room and board and general nurs- ing care while the patient is admitted to the Hospital as a registered bed patient, and the following additional facilities, services and supplies as prescribed; use of operating room, private room,intensive care room and related hospital ser- vices; special diet, special duty nursing, medications as specified in Section F, and supplies. Prescribed blood transfusions are provided without charge if blood is replaced at a blood bank designated by Medical Group. Prevailing Rates are charged if blood is not replaced. No charge is made for blood covered under Medicare. A blood transfusion program is available to Members who make per- iodic blood contributions. C. HOUSE CALLS FOR EMERGENCIES OR ACUTE CONDITIONS All necessary house calls by Physicians far emergencies or acute condi- tions, and by visiting nurses when prescribed by a Physician, shall be provided within House Call Areas. A charge of $5. 00 is made for Physicians' house calls. An additional charge of $2. 00 is made for each additional Member who requires attention at the same household. No charge is made for prescribed calls by visit- ing nurses. D. X-RAY AND LABORATORY All prescribed x-ray and laboratory tests and services, including diagnos- tic and therapeutic x-rays, certain clinical isotope services and materials, and orthoptics are provided without charge. E. PHYSICAL THERAPY Prescribed physical therapy is provided without charge. Physical therapy provided hereunder is limited to conditions which, in the judgment of the Attend- ing Physician, are subject to significant improvement through relatively short- term therapy. F. PRESCRIBED MEDICATIONS A reasonable charge is made for medications, injectables, allergy treat- ment materials, and supplies furnished to outpatients at Medical Offices, at emergency departments, or on house calls. Dressings and casts are provided without charge. A moderate charge may be made for administration of medi- cations supplied by the patient. All prescribed medications, injectables, allergy materials, supplies, dress- ings and casts are provided without charge during the period of hospitalization specified in Section B of this Benefit Schedule to be provided without charge. Thereafter, a reasonable charge is made for such items. -2- A-75 G. EMERGENCY AMBULANCE SERVICE Necessary ambulance service is provided without charge within the Ser- vice Area if such service is ordered or approved by a Physician. H. OBSTETRICAL CARE Full obstetrical care, after pregnancy is confirmed, including all appli- cable benefits set forth above, is provided upon payment of $150. 00 if con- finement is due after ten months' continuous membership, or upon payment of $350. 00 if confinement is due before ten months' continuous membership. Obstetrical care includes the following services for the mother before and during confinement and during the post partum period: Hospital care, including use of delivery room; all services of Physicians including oper- ations and special procedures such as Caesarean sections if necessary: anesthesia; medications, including injectables; x-ray and laboratory services as required for conditions relating to pregnancy. Outpatient medications, including injectables, are subject to a reasonable charge. Care for the newborn child is provided during the mother's confinement. Interrupted Pregnancy. If care is required for interrupted pregnancy, Prevailing Rates are charged for all services rendered, but payment required hereunder shall not exceed two-thirds of the payment specified above, for full obstetrical care. J. CHRONIC HEMODIALYSIS AND KIDNEY TRANSPLANTS Subject to the limitiations set forth in this section, Health Plan will pay for hemodialysis for chronic conditions and for kidney transplants up to $10, 000. 00 each calendar year per Member for the aggregate of these services, reduced by payments to the Member or on his behalf under corresponding pro- visions of other Health Plan Service Agreements. Covered services include equipment, training, and medical supplies required for home dialysis, and a kidney donor's reasonable expenses directly related to a kidney donation to a Member. Unless the recipient directs otherwise in writing, his expenses will be paid before any of the donor's expenses are paid. Covered services are provided at the Kaiser Foundation Hemodialysis Center in Los Angeles, if the Attending Physician and the Medical Group Regional Renal Conference are of the opinion that the Member meets the criteria of the Hemodialysis Center; or upon written referral by the Medical Group Regional Renal Conference at hemodialysis facilities or at community transplant facilities within the Service Area that are approved by Medical Group. Referrals to hemodialysis facilities or to community transplant facilities are made only if the Medical Group Regional Conference determines that a service referred to in this section represents the preferred method of treatment. If, after the start of treatment at the Kaiser Foundation Hemo- dialysis Center, or after referral to another facility, either the Medical Group or the medical staff of the hemodialysis facility determines that the Member does not satisfy its criteria for the service involved, Health Plan's -3- A-75 obligation is limited to paying for covered services provided prior to such determination. Neither Health Plan, Medical Group nor Physicians under- takes to furnish a kidney donor nor to assure the availability or capacity of referral facilities approved by Medical Group. Hemodialysis for acute conditions is provided subject to the provisions of this Benefit Schedule, excluding this Section J. Whether a Member is suffer- ing from an acute or chronic condition will be determined by Medical Group. K. SERVICE BENEFITS IN OTHER HEALTH PLAN SERVICE AREAS Health Plan, either directly or through an affiliated corporation, conducts direct-service hospital and medical care programs in the San Francisco Bay and Sacramento areas in California, in the Cleveland area in Ohio, in the Denver area in Colorado, on the Islands of Oahu and Maui, Hawaii, and in Portland, Oregon, and vicinity. Members regularly residing in the Southern California Region, while temporarily in another Health Plan service area, may receive hospital and medical services. To obtain such services Members must apply to a hospital or medical office, within such service area, which is covered by a contractual arrangement maintained by Health Plan For hospital or medical services and must pay applicable supplemental charges. Services and supplemental charges are those prevailing in such service area for the Health Plan coverage generally provided within the service area which is most nearly comparable to the Member's coverage in the Southern California Region. A description of such other service areas and a list of contracting hospitals and medical office facilities located therein may be obtained at the Health Plan office. L. OUT OF AREA BENEFITS 1. Emergency Illness or Injury. If a Member becomes ill or is injured and receives emergency medical, hospital or ambulance services while tempo- rarily more than thirty (30) air miles from both (a) his regular place of resi- dence and (b) the nearest Hospital or Medical Office, Health Plan shall pay up to $3, 000. 00 for all customary and reasonable charges actually incurred for such services, plus 80% of such charges between $3, 000..00 and $50, 000. 00. Obstetrical Cases. Payment as outlined above is made on account of emer- gency hospitalization required as a result of complications of pregnancy but not for normal delivery. Any unpaid portion of the supplemental charge speci- fied in Section H of this Benefit Schedule will be offset against amounts other- wise payable hereunder. -4- A-75 2, Continuing or Follow-Up Treatment. Monetary payment on account of emergency illness or injury is limited to emergency care required before the Member can, without medically harmful or injurious consequences, return to the Southern California Service Area or a Hospital or Medical Office in the nearest Service Area. Benefits for continuing or follow-up treatment are pro- vided only at an appropriate Hospital or Medical Office in the nearest Service Area. If the Member obtains prior approval from Health Plan or a Physician in the nearest Service Area, a portion of the allowance described in Section L-1 may be applied toward the cost of necessary ambulance service or other special transportation arrangements medically required to transport the Member to such Service Area for continuing or follow-up treatment. 3. Notification and Claims. Any Member having an emergency within the scope of Section L shall notify the Health Plan office within forty-eight (48) hours after care is commenced. No claim pursuant to Section L is allowed unless a complete application for payment, on forms provided by Health Plan, is filed with the Health Plan office within sixty (60) days after the date of the first service for which payment is requested. N. EXTENDED CARE SERVICES During each calendar year, 100 days of Extended Care Services prescribed by a Physician are provided or arranged without charge at Skilled Nursing Facil- ities. Extended Care Services include supplies and equipment ordinarily furn- ished by the Skilled Nursing Facility, and all prescribed drugs and biologicals. O. TREATMENT FOR ALCOHOLISM Subject to the exclusions and limitations set forth in this section, the out- patient services referred to in this Benefit Schedule are provided for alcohol- ism, plus the added Alcoholism Unit services of individual therapy (upon pay- ment of the registration charge, if any, required under Section A-2), and group therapy (upon payment of one-half of the individual therapy registration charge). The following services are not provided: (1) Inpatient care for acute alcoholism or detoxification. (2) Alcoholism care for the patient who, in the professional judgment of the attending therapist, would not be responsive to therapeutic management. (8) House Calls. -5- A-75 KAISER FOUNDATION HEALTH PLAN, INC. A Nonprofit Corporation Southern California Region BENEFIT SCHEDULE "M"COVERAGE This Health Plan/Medicare Integrated Coverage is available only to Members who are entitled to benefits under Parts A and B of Medicare. The benefits under this Agreement do not duplicate any benefits under Medicare, and the monetary amounts referred to in Sections J, K and L of this Benefit Schedule are available only to satisfy those costs not covered under Medicare and not to duplicate any benefits to which the Member is entitled under Medicare. Subject to all terms, conditions and definitions in the foregoing Medical and Hospital Service Agreement, Members with "M" coverage are entitled to receive the Medical and Hospital Services and other benefits set forth in this Benefit Schedule, upon payment of specified supplemental charges. These services and benefits are available only if and to the extent that they are (1) provided, prescribed or directed by a Physician, (2) requested and (3) except for services of Physicians in a Skilled Nursing Facility under Section A, house calls pursuant to Section C, Post-Hospital Extended Care Services pursuant to Section M, Part A and Part B Home Health Services pursuant to Section N, and special benefits under Sections J, K and L, received at a Hospital or Medical Office, as defined in Section 1 of the Agreement. A. MEDICAL CARE IN HOSPITAL, SKILLED NURSING FACILITY AND OFFICE 1. Care While Hospitalized. All services of Physicians as requested or directed by the Attending Physician, including operations, other surgical pro- cedures, anesthesia, and consultation with and treatment by specialists, are provided without charge while the Member is admitted to a Hospital as a regis- tered bed patient. 2. Care in Medical Offices or Emergency Departments. All services of Physicians as requested or directed by the Attending Physician, including surgical procedures and consultation with and treatment by specialists, are provided at Medical Offices and Hospital emergency departments without charge. M-75 3. Care in Skilled Nursing Facility. All services of Physicians, as requested or directed by the Attending Physician (to the extent practicable within the limitations of the equipment and staff of the Skilled Nursing Facil- ity), are provided without charge during the 100 days of Post-Hospital Ex- tended Care Services specified in Section M of this Benefit Schedule. B. HOSPITAL CARE During each calendar year, 365 days of prescribed hospital care are pro- vided without charge. Hospital care includes room and board and general nurs- ing care while the patient is admitted to the Hospital as a registered bed patient, and the following additional Facilities, services and supplies as prescribed: use of operating room, private room, intensive care x•oom and related hospital serv- ices; special diet, special duty nursing, medications as specified in Section F, and supplies. Prescribed blood transfusions are provided without charge if blood is replaced at a blood bank designated by Medical Group. Prevailing Rates are charged if blood is not replaced. No charge is made for blood covered under Medicare. A blood transfusion program is available to Members who make periodic blood contributions. C. HOUSE CALLS FOR EMERGENCIES OR ACUTE CONDITIONS All necessary house calls by Physicians for emergencies or acute conditions, and by visiting nurses when prescribed by a Physician, are provided within House Call Areas. For Physicians' house calls, payment in accordance with the following schedule is required: Calls requested or made between 8 A. M. and 10 P. M. $2. 50 per call Calls requested and made between 10 P. M. and 8 A. M. $3. 50 per call An additional charge of $1. 00 is made for each additional "M" Member who requires attention at the same household. No charge is made for pre- scribed calls by visiting nurses. D. X-RAY AND LABORATORY All prescribed x-ray and laboratory tests and services, including diagnostic and therapeutic x-rays, certain clinical isotope services and materials, and orthoptics are provided without charge. -2- E. PHYSICAL THERAPY Prescribed physical therapy is provided without charge in Hospitals and Medical Offices. Physical therapy provided hereunder is limited to conditions which, in the judgment of the Attending Physician, are subject to significant improvement through relatively short-term therapy. F. PRESCRIBED MEDICATIONS No charge is made for injectables, for allergy test and treatment mate- rials, or for dressings furnished to outpatients at Medical Offices, at Hospital emergency departments, or on house calls. A reasonable charge is made for medications and supplies furnished to outpatients at Medical Offices, at Hos- pital emergency departments, or on house calls. All prescribed medications, injectables, allergy materials, supplies and dressings are provided without charge during the period of hospitalization specified in Section B of this Benefit Schedule to be provided without charge. Thereafter, a reasonable charge is-made for such items. Immunizations for the following diseases are provided without charge: cholera, diphtheria, DPT (diphtheria, pertussis and tetanus), influenza, measles, mumps, polio, smallpox, tetanus, typhoid, and typhus. G. EMERGENCY AMBULANCE SERVICE Necessary ambulance service is provided without charge within the Service Area if ordered or approved by a Physician. H. OBSTETRICAL CARE Full obstetrical care, after pregnancy is confirmed, including all appli- cable benefits set forth above, is provided without charge. Obstetrical care includes the following services for the mother before and during confinement and during the post-partum periods Hospital care, including use of delivery room; all services of Physicians including operations and special procedures such as Caesarean sections if necessary; anesthesia; medications, including injectables; x-ray and laboratory services as required for conditions relating to pregnancy. Outpatient medications, including injectables, are subject to a reasonable charge. Care for the newborn child is provided during the mother's confinement. Interrupted Pregnancy. Care required for interrupted pregnancy is pro- vided without charge. -3- M-75 I. CASTS AND SPLINTS Casts and non-reusable splints are provided without charge. Reusable splints and other devices used for reduction of fractures and dislocations are provided without charge during the period of hospitalization specified in Section B of this Benefit Schedule to be provided without charge and the 100 days of Post-Hospital Extended Care Services specified in Section M of this Benefit Schedule. At all other times, such reusable splints and other devices are provided at a charge of 20% of reasonable rates. J. CHRONIC HEMODIALYSIS AND KIDNEY TRANSPLANTS All services for hemodialysis for chronic conditions and for kidney trans- plants which are paid for in whole or in part under Medicare are provided without charge. Covered services include equipment, training, and medical supplies required for home dialysis, and a kidney donor's reasonable expenses directly related to a kidney donation to a Member. Covered services are provided at the Kaiser Foundation Hemodialysis Center in Los Angeles, if the Attending Physician and the Medical Group Regional Renal Conference are of the opinion that the Member meets the criteria of the Hemodialysis Center; or upon written referral by the Medical Group Regional Renal Conference at hemodialysis facilities or at community transplant facilities within the Service Area that are approved by Medical Group and are approved for participation in the Medicare program. Referrals are made only if the Medical Group Regional Renal Conference determines that a service referred to in this section represents the preferred method of treatment. Neither Health Plan, Medical Group nor Physicians undertakes to furnish a kidney donor nor to assure the availability or capacity of referral facilities approved by Medical Group. Hemodialysis for acute conditions is provided subject to the provisions of this Benefit Schedule, excluding this Section J. Whether a Member is suffering from an acute or chronic condition will be determined by Medical Group. K. SERVICE BENEFITS IN OTHER HEALTH PLAN SERVICE AREAS Health Plan, either directly or through an affiliated corporation, conducts direct-service hospital and medical care programs in the San Francisco Bay and Sacramento areas in California, in the Cleveland area in Ohio, in the Denver area in Colorado, on the Islands of Oahu and Maui, Hawaii, and in Portland, Oregon, and vicinity. Members regularly residing in the Southern California Region, while temporarily in another Health Plan service area, may receive hospital and medical services. To obtain such services Members must apply to a hospital or medical office, within such service area, which is covered by a contractual arrangement maintained by Health Plan for hospital or medical services and must pay applicable supplemental charges. -4- Services and supplemental charges are those prevailing in such service area for the Health Plan coverage generally provided within the service area which is most nearly comparable to the Member's coverage in the Southern California Region. A description of such other service areas and a list of contracting hospitals and medical office facilities located therein may be obtained at the Health Plan office. L, OUT OF AREA BENEFITS 1. Emergency Illness or Injury. If a Member becomes ill or is injured and receives emergency medical, hospital or ambulance services while temporarily more than thirty (30) air miles from both (a) his regular place of residence and (b) the nearest Hospital or Medical Office, Health Plan shall pay up to $8, 000. 00 for all customary and reasonable charges actually incurred for such services, plus 80% of such charges between $8, 000. 00 and $50, 000. 00. Obstetrical Cases. Payment as outlined above is made on account of emer- gency hospitalization required as a result of complications of pregnancy but not for normal delivery. Any unpaid portion of the supplemental charge specified in Section H of this Benefit Schedule will be offset against amounts otherwise payable hereunder. 2. Continuing or Follow-up Treatment. Monetary payment on account of emergency illness or injury is limited to emergency care required before the Member can, without medically harmful or injurious consequences, return to the Southern California Service Area or a Hospital or Medical Office in the nearest Service Area. Benefits for continuing or follow-up treatment shall be provided only at an appropriate Hospital or Medical Office in the nearest Service Area. If the Member obtains prior approval from Health Plan or a Physician in the nearest Service Area, a portion of the allowance described in Section L-1 may be applied toward the cost of necessary ambulance service or other special transportation arrangements medically required to transport the Member to such Service Area for continuing or Follow-up treatment. 3. Notification and Claims. Any Member having an emergency within the scope of Section L shall notify the Health Plan office within forty-eight (48) hours after care is commenced. No claim pursuant to Section L is allowed unless a complete application for payment, on forms provided by Health Plan, is filed with the Health Plan office within sixty (60) days after the date of the first service for which payment is requested. -5- M. POST-HOSPITAL EXTENDED CARE SERVICES Subject to the limitations set forth in this Section, during each Spell of Illness 100 days of prescribed Post-Hospital Extended Care Services are pro- vided or arranged without charge at approved Skilled Nursing Facilities except that the number of days of care is reduced and offset by all days of Post-Hospital Extended Care Services covered in whole or in part by Medicare that the Member receives during the Spell of Illness from facilities not approved in writing by Medical Group. Post-Hospital Extended Care Services include all drugs, bio- logicals, supplies, appliances and equipment provided, furnished or arranged by the Skilled Nursing Facility. N. PART A HOME HEALTH SERVICES AND PART B HOME HEALTH SERVICES Subject to the limitations set forth in this Section, Part A Home Health Ser- vices are provided without charge for up to 100 visits (during the applicable one- year period) after the beginning of one Spell of Illness and before the beginning of the next; and Part B Home Health Services are provided without charge for up to 100 visits during a calendar year; provided, that the number of Part A Home Health Services visits and the number of Part B Home Health Services visits available to the Member under this Section each are reduced and offset by all such visits covered in whole or in part by Medicare that the Member receives during the applicable yearly period which are not performed, prescribed or directed by a Physician. If after receiving all the visits to which he is entitled under this Section a Member requires additional visits and because of the start of a new calendar year (in the case of Part B Home Health Services) or the start of a new applicable yearly period (in the case of Part A Home Health Ser- vices) has any right to additional visits under Medicare, then such visits are provided in accordance with the terms of the preceding sentence. The benefits referred to in this Section are available to Members living outside the House Call Area only when a Physician determines that he can feasibly maintain effective supervision and control of the Members care. Health Plan makes a reasonable effort to provide or arrange for Part A Home Health Services and Part B Home Health Services referred to in this Section, and Physicians help arrange these Services in appropriate cases, but neither Health Plan nor Physicians undertake to assure their availability. -6- TR_o^ - .::; KAISER FOUND ATICN HEALTH PLAN, INC. Southern Caii=ornia Region 'AMENDMENT • to _ GROUP h1EDICAL AND HOSPITAL SERVICE 'AGREEMENT Your Medical and Hospital Service Agreement with Kaiser . Foundation Health Plan, Inc, is amended in the following respects: Section 6-A (3) is amended to read as follows: a (3) Employer or Goverrmer.tal Responsibility. Illness, injuries Or COndltlOnS CCVered b_T SerV1Ce5, Ind 2IP,?•i1f lCatlOn or reimburs~m~nr a~~a. ;_ i agile ~; r:.o,-. (d) Pursuant t0 any ~ C,"Yerc.l, Stat°_, CO L'n t:T Or -~:iniClDai workmen's co:pensation cr employer's liahiiity lava cr c`h~r 1 P_O 1. S.lar10^. nt c_..__ar ='•_ .. ,_ Cr ~. mot. ... ~l.i) li Wlt ai1V LcGe_'dl, Statev lC'XCeDL :•",edl-Cal beref lt_) r COllnty, munlClpal Or Utl":er gOvernmCntal agE.itC,', 1nClUding, in the case of service-connected disabilities, the Veterans' Administration. If there is reasonable doubt whether or not a Member should receive beP.efit5 llnd2r this Agreement Cr frCm anV SllCh SO L:r C°, if the aember s=eks diligc-ntly to establish his rights to b=_::- efits from <uCi? Otf'ier SGllrCF?, p~_^.~'1t5 Wlll •L"~' fUrn15_':2;: L': ~'~r this Agreement; provided, ho;•:aver, that the value o° suc;: ser- V1CC5, dt _°rEValliP.g F.a teS, SI'lall I]~ rECOVerablP~ V ~°31-h ?/lr'; Or 1tS nOm1I'iee -rOP.'i SllC Otner SOllrCe, Or :rC,^i t:?e ."•3.^.:.;i ~~r, _f and to the e;titer.t it is determined t.,at monetary benefits shoul_ have been provided by such other source." G-MGIISA-76