Transition From Verisk to CareGuard Member Terms & Conditions

A

Placing funds in an interest-bearing Account in a Bank on behalf of Member.

B

Making authorized injury-related payments the Account on Member's behalf in accordance with the MSA Regulations.

C

Keeping accurate records of the disbursements and additions to the Account and report those to Member; including reporting to the Centers for Medicare & Medicaid Services on Member's behalf.

A

To provide CareGuard with Member's W-9 Information and to notify CareGuard of any changes.

B

To provide the MSA or medical settlement funds to CareGuard if they have received them personally, including but not limited to annuity payments. Member agrees that CareGuard has no responsibility or liability for any MSA or medical settlement funds sent directly to Member.

C

To provide CareGuard with any necessary information that CareGuard may need to prepare reports and pay Medicare-covered and injury-related medical bills and for all such Member-provided information to be truthful and and accurate.

Member authorizes CareGuard to disclose Member's personal healthecare information to, and to communicate directly with, healthcare providers providing services to Member, the Centers for Medicare & Medicaid Services and its contractors, Medicare Part C & D providers, Member's health insurers, and CareGuard's third-party partners, in futherance of providing services under this Agreement. More information on CareGuard's privacy policy can be found here. This privacy policy is subject to change, at any time, at Ametros' discretion.

D

To forward any injury-related and covered out of pocket receipts for reimbursement.

E

To report any records discrepancy to CareGuard within sixty (60) days of the transaction date.

F

To provide a copy of the Settlement Agreement to CareGuard, or at a minimum, a copy of those provisions in the Settlement Agreement that impact CareGuard's rights and obligations under this Agreement, with the explicit understanding that CareGuard is in no way is responsible for, or endorsing, the provisions of the Settlement Agreement, including without limitation, terms governing the amount and use of the funds. Moreover, in the event CareGuard is not provided with a copy of the Settlement Agreement, or applicable provisions thereto, which may address termination, Account closure and/or distribution of funds, then CareGuard shall not be responsible or liable to Member or any third parties related to such termination, Account closure and/or distribution of funds.

G

Insurance Coverage. Member is solely responsible for securing insurance coverage, including Medicare Parts A, B, C or D. If Member is a Medicare beneficiary, Member understands that they are responsible for enrolling in an applicable plan, including a Medicare plan, with prescription drug coverage, to ensure Medicare is available to pay for covered items and services should their Account exhaust or deplete. Member agrees that Ametros has no responsibility or liability with respect to Member's potential lack of insurance coverage. Member shall promptly notify Ametros with the name of the Member's insurance company (including the insurer's address, phone number, plan number and policy number) and hereby authorizes Ametros to contact such insurance company on Member's behalf.

A

Member's use of or reliance on any materials, documentation and/or any communications (whether written, oral or in electronic form) from CareGuard to Member under this Agreement or otherwise should not be construed or relied upon as legal, tax or other professional advice. CareGuard assumes no responsibility for tax or other consequences to anyone arising from the establishment, use or administration of the Account.

B

No Third Party or any other entity, signatory or other person acting on Member's behalf (including, but not limited to, Member), shall have any remedy against CareGuard for improper disbursements made by CareGuard from the Account other than as permitted under the MSA Regulations, which limits maximum liability to the repayment of the Account in the amount of the improper

C

Notwithstanding IV(B), maximum total liability to Member for any acts or omissions of CareGuard under this Agreement that are determined to violate this Agreement shall not exceed $1,000.

D

CareGuard is not liable for (i) any of Member's pre-existing payments or mismanagement of the MSA funds that occurred prior to the Effective Date of this Agreement, (ii) any claims submitted by or on behalf of Member to any Third Party without   knowledge, or (iii) any obligations owed by Member to Third Parties under the Settlement Agreement unless specifically acknowledged by the Parties in writing as an obligation of CareGuard. CareGuard is only liable for annual accounting on items with a date of service after the Effective Date of this Agreement.

E

CareGuard does not guarantee any level of discounts, savings or results relative to potential cost savings realized, including but not limited to prescription drugs, medical treatment, items and CareGuard makes no warranties, promises, representations, or guarantees whatsoever about potential cost savings or the level of potential discounts obtained on any service or prescription payment. There are no assurances that prior successes or past results as to cost savings will be applicable to Member. For more information, please refer to at ametros.com and the Frequently Asked Questions section.

F

CareGuard is not responsible for the creation or determination of the underlying Medicare Set-Aside or Future Medical Member acknowledges that CareGuard responsible or liable for the methodology utilized to allocate the Medicare Set-Aside or Future Medical Allocation or for its adequacy or sufficiency. Moreover, the Member agrees that CareGuard is in no way responsible or liable for submission or non-submission of the Medicare-Set Aside or Future Medical Allocation to the Centers for Medicare & Medicaid Services.

A

• Termination by Member. If there is no restriction in the Settlement Agreement, or as noted above, Member may terminate this Agreement at any time upon sixty (60) days prior written notice to CareGuard.
• Termination by Careguard. CareGuard shall have the right to terminate this Agreement upon thirty (30) days prior written notice to Member if CareGuard determines in good faith that Member is in breach of this Agreement, in violation of the terms of the Settlement Agreement, or in violation of the MSA Regulations, and such breach is not cured by Member within this thirty (30) day period.
• Termination by Careguard for Member Action. CareGuard shall have the right to terminate this Agreement immediately if Member engages in harassing behavior against CareGuard or any employee of  CareGuard. "Harrassing behavios" includes, but is not limited to, threatening or hostile language, threatening violence, or making racist or discriminatory statements, communicated by Member in any form or medium, including in writing, via electronic mail or text, verbally, via photographs, in-person and/or other means.
• Effect of Termination. Upon termination of this Agreement for any reason, CareGuard shall have no further duties, obligations or liabilities with respect to the Account or the administration of the MSA. No termination for any reason shall affect  right to debit the Account for charges made by Member for authorized services under this Agreement prior to the effective date of termination.

B

Member's Death. Upon receipt of notice of Member's death, CareGuard will continue to maintain the Account after Member's death for the period set forth under the MSA Regulations. This period is twelve (12) months from the date of Member's death. Following this period, CareGuard shall proceed to close the Account and distribute the remaining balance of the Account to the Designated Beneficiary(ies) in accordance with Section V(C) of this Agreement.

C

Account Closure & Designated Beneficiary(ies). To proceed with closure of the Account, CareGuard shall deduct any medical payments for any final transactions made prior to    charge backs and any other Account fees and As soon as practical after closure of the Account, CareGuard shall pay any balance remaining in the Account to ( 1 ) the designee(s) identified in the Settlement Agreement or any addendum thereto (to the extent provided to CareGuard), or (2) if no designee is named in the Settlement Agreement, or if the CareGuard Beneficiary Designation Form has not been provided to CareGuard, then to  estate; provided, that the funds shall remain in the Account until such time as the executor/administrator/or other similarly recognized or appointed individual under the  probate  laws  of  state of domicile contacts CareGuard with the legally required documentation and demand for the release of the funds. In the event that no designee is named in the Settlement Agreement (if provided), Member may request a CareGuard Beneficiary Designation Form, directing CareGuard to disburse the funds in accordance with the beneficiary information provided on the form rather than proceeding with providing funds to Member's estate. However, at no time does the CareGuard Beneficiary Designation form supersede any beneficiary information specifically outlined in the Settlement Agreement or any state law governing the disposition of assets upon death. Moreover, this provision herein is only applicable in regard to funds remaining in the Account, and is not applicable with respect to beneficiaries designated in relation to any other financial accounts, such a structured settlement or annuity contracts. In the event that Member or any other Third Party notifies CareGuard in writing that there is a conflict between the Settlement Agreement and Member's estate planning documents or applicable law with respect to the distribution of the funds in the Account, CareGuard shall distribute the funds remaining in the Account in accordance with and only upon receipt of a final non-appealable judgment issued by a court of competent jurisdiction. Member acknowledges and agrees that CareGuard has no obligation to resolve any conflict related to beneficiary(ies) or any other Third Party.

D

Insufficient Balance. Member acknowledges that CareGuard shall not be responsible for payment or reimbursement of any claim if the funds in the Account are insufficient to cover the payment. CareGuard shall notify Member if there are insufficient funds in the Account to cover a claim, and Member may present the claim to other health insurance payor(s) or pay it directly.

E

Amendments. CareGuard may amend this Agreement at any time for changes required by law or required by the MSA Regulations. CareGuard shall provide Member with written notice of any such amendments. These may come in the form of electronic notices to be accepted in  portal.

F

Communications. Member consents to (1) receiving marketing communications from CareGuard, and (2) CareGuard sharing Member's contact information with Third Parties for marketing purposes subject to Member's rights to opt out of marketing communications.

G

CareGuard has no liability or responsibility arising out of Member's breach of Member's obligations under this Agreement or the Settlement Agreement, or violation of the MSA Regualtions.

H

No Third-Party Beneficiary. This Agreement is for the exclusive benefit and convenience of the Member and CareGuard. Nothing contained herein shall be construed as granting, vesting, creating, or conferring any right of action or any other right or benefit upon any other Third Party, including without limitation, any payor of funds. This provision is not intended to limit or impair the rights which any person may have under applicable state or Federal laws, rules or regulations, including MSA Regulations.

I

Miscellaneous. This Agreement embodies the entire agreement between the Parties and supersedes all prior agreements. If any provision of this Agreement is determined to be invalid or unenforceable, the validity and enforceability of the remaining provisions will not be This Agreement will be governed by the laws of the Commonwealth of Massachusetts without regard to its conflicts of laws provisions.

J

Mediation. If any disputes or claims arise under or are related in any way to this Agreement or with Ametros, and if they cannot be settled through negotiation between the Parties; the Parties agree that they shall engage in mediation administered by the American Arbitration Association under its Commercial Mediation Procedures. Mediation will occur exclusively on an individual basis only, and not in any form of class, group, collective or on behalf of the general public or other Ametros Members. Mediation under this Agreement is a condition precedent to seeking arbitration.

K

Arbitration & Class Action Waiver. If mediation is not successful, then any claim, dispute or controversy arising under or in any way related to this Agreement or with Ametros shall be resolved exclusively through binding arbitration in accordance with the applicable commercial arbitration rules of the American Arbitration Association. Any and all such disputes or claims will be resolved exclusively through arbitration on an individual basis only, and not in any form of class, group, collective or on behalf of the general public or other Ametros Members. The Member expressly waives all rights to assert any claims against Ametros in any venue, arbitration forum or court as a representative or member in any class, representative action or on behalf of the general public or other Ametros Members. The Member expressly disclaims any right to recover  fees or costs associated with pursuing a class, representative, or collective action.

In no event may arbitration be initiated more than one year following the date the dispute arose. The arbitrator(s) shall have no authority to award extra-contractual damages of any kind, including punitive or exemplary damages, and shall be bound by controlling law. The arbitrator(s) will have the discretion  and authority, however, to order the losing party to pay the reasonable attorney' fees of the prevailing party. Judgment upon an arbitration award may be entered in any court of competent jurisdiction. To the extent consistent with applicable law, the arbitration shall take place in Boston, Massachusetts.

Account

A FDIC insured, interest-bearing bank account in a federally regulated bank.

MSA Regulations

The Medicare Secondary Payer Act (42, U.S.C. §1395) and related rules, regulations, and policies.

Professional MSA Administration MSA Requirements

The requirements that apply to the professional administration of Medicare Set Asides and/or Future Medical Allocations Accounts under the MSA Regulations.

Settlement Agreement

The settlement agreement between Member and a payor of funds, including all accompanying Exhibits and Addenda.

Third Parties

Healthcare providers, pharmacists, mental health professionals, attorneys, funding sources, health insurers, or any other person that provides services to Member in connection with the MSA or Settlement Agreement in any capacity, other than CareGuard, or any other person or entity that is not Member or CareGuard.

Effective Date

The date this Agreement is in effect and shall not commence until it is executed by the Member and an authorized agent of CareGuard, and the applicable Account funded.

CareGuard Beneficiary Designation Form

Form provided by CareGuard in which the Member identifies individual(s) designated by Member to whom available funds in the Account will be distributed to upon Member's death, following the applicable waiting period and pursuant to provisions in V(B). However, as indicated in V(A), any provisions in the Settlement Agreement, or any addendum thereto, will supersede and supplant any CareGuard Designation Form.

The Taxpayer Identification number shown is my correct taxpayer identification number.

I am NOT subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest of dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

I agree I will notify Ametros if I have been notified by IRS that you are currently subject to backup withholding because you failed to report all interest and dividends on your tax return.

I am a U.S. Citizen or resident alien.

I agree I will notify Ametros if I am an Exempt recipient under the Internal Revenue Service Regulations or if I am neither a citizen nor a resident of the United States (Non-Resident Aliens).