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The Settlement provides that payments will be based, in part, on premiums paid for BCBS health insurance or administrative services plans during the relevant periods between February 2008 and October 2020 for fully insured plans, and between September 2015 and October 2020 for administrative services plans.
The Settlement further provides default formulas for the Claims Administrator to use when determining what percentage of the premium was paid by an employer/entity and what percentage was contributed by its employees/members.
If you accept the
, you are NOT required to provide any additional data or evidence in support of your claim at this time. If another claimant’s filing affects your claim, you will be provided with an opportunity to respond at a later date.
If you proceed with the
, you must also provide data or evidence to support the alternative contribution percentages you provide. If you select this option, for any time period for which supporting data or evidence is not provided, the Default Option will be applied.
If you want to use the DEFAULT OPTION,
FILL OUT THIS SECTION. Instead, click
Please state the percentage contribution you believe you contributed for each year that you were enrolled in a BCBS health insurance or administrative services plan.
If you choose to apply for an alternative contribution percentage you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not submit supporting documentation the Default contribution rates will be applied to your claim.
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If you choose to apply for an alternative contribution percentage, you must supply documentation with this claim form supporting the percentage you claim to have contributed. If you do not provide additional documentation, the Default Option will be applied to your claim.
Selection of the Alternative Option does not ensure a contribution percentage higher than or equal to the Default Option. Your percentage will be dependent on a process that includes a review of all materials submitted pertaining to your premium.
Are you sure you want to apply for an alternative contribution percentage?
Please let us know how you would like to receive your settlement payment if your claim is deemed valid.
Final determinations of claim amounts will not be made until after processing by the Claims Administrator is complete. Claims will not be paid if the value is equal to or less than $5.00.
Claimants who submit valid, approved claims shall receive a pro-rata percentage of the Net Settlement Fund allocated to their type of coverage (fully-insured or self-funded) based upon their estimated proportion of the cumulative total of premiums and/or administrative fees paid by all claimants.
Your claim form has been submitted successfully. Please keep the Claim Number below for your records.