Service Employees 32BJ North Health Fund

Tri-State Preferred North Summary Plan Description (SPD) >> Fraud

The Board reserves the right to cancel or rescind Fund coverage for any participant or enrolled dependent who willfully and knowingly engages in an activity intended to defraud the Fund. If a claim has been submitted for payment or paid by the Fund as a result of fraudulent representations, such as enrolling a dependent who is not eligible for coverage, the Fund will seek reimbursement and may elect to pursue the matter by pressing criminal charges.

The Fund regularly evaluates claims to detect fraud or false statements. The Fund must be advised of any discounts or price adjustments made to you by any provider. A provider who waives or refunds co-payments is entering into a discount arrangement with you. The Fund calculates the benefit payment based on the amount actually charged, less any discounts, rebates, waivers, or refunds of co-payments or deductibles you receive. Failure to notify the Fund of such price adjustments may result in an overpayment of benefits and constitutes a serious violation of the provisions of the Plan.