Common use of Suspension of Coverage Clause in Contracts

Suspension of Coverage. a) Entitlement to Medi-cal If a Subscriber becomes entitled to Medi- Cal, the benefits of this Agreement will be suspended for up to 24 months. The Subscriber must make a request for suspension of coverage within 90 days of Medi-Cal entitlement. Blue Shield shall return to the Subscriber the amount of prepaid dues for the period after the date of suspension, if any, minus any monies paid by Blue Shield for claims during that period. If the Subscriber loses entitlement to Medi-Cal, the benefits of this Agreement will be automatically reinstated as of the date of the loss of entitlement, provided the Subscriber gives notice to Blue Shield within 90 days of that date and pays any dues amount attributable to the retroactive period. b) Total Disability While Covered Under Group Health Plan Blue Shield shall suspend the benefits and dues of this Agreement for a Subscriber when that Subscriber: i) is Totally Disabled as defined herein and entitled to Medicare Benefits by reason of that disability; ii) is covered under a group health plan as defined in section 42 U.S.C. 1395y(b)(1)(A)(v); and iii) submits a request to Blue Shield for such suspension. After all of the above criteria have been satisfied, benefits and dues of this Agreement for the Subscriber will be suspended for any period that may be provided by federal law. For Subscribers who have suspended their benefits under this Agreement as specified above, and who subsequently lose coverage under their group health plan, the benefits and dues of this Agreement will be reinstated only when: i) the Subscriber notifies Blue Shield within 90 days of the date of the loss of group coverage; and ii) the Subscriber pays any dues attributable to the retroactive period, effective as of the date of loss of group coverage. The effective date of the reinstatement will be the date of the loss of group coverage. Blue Shield shall: i) provide coverage substantially equivalent to coverage in effect before the date of suspension; ii) provide dues classification terms no less favorable than those which would have been applied had coverage not been suspended; and iii) not impose any waiting period with respect to treatment of preexisting conditions.