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SPECIFIC STOP LOSS: <br />A. Claims eligible for coverage under this Contract are those specified on Exhibit <br />A. <br />B. Each month throughout the Contract Period the Claims Administrator shall <br />provide Medical Mutual of Ohio with a listing or a report of monthly Paid <br />Claims for Covered Persons that reach or exceed fifty percent (50%) of the <br />Specific Stop Loss Threshold. Medical Mutual of Ohio will instruct the Claims <br />Administrator to issue a credit to the Plan Sponsor for claims in excess of the <br />Stop Loss Threshold. The Claims Administrator will credit the invoices to the <br />Plan Sponsor for these amounts as they are reached and as they continue to <br />accumulate throughout the remainder of the Contract Period, such payments <br />not to exceed the Specific Stop Loss Annual Maximum per Covered Person <br />shown on Exhibit A. <br />C. In order to confirm that all Paid Claims exceeding the Specific Stop Loss <br />Threshold have been identified and credited to the Plan Sponsor, Medical <br />Mutual of Ohio shall make a final review and Specific Stop Loss settlement <br />within four (4) months after the end of the Contract Period and the Claims <br />Administrator will issue a final credit to the Plan Sponsor, if necessary. <br />3. LIMITATIONS OF COVERAGE <br />Medical Mutual of Ohio is not responsible or liable under this Contract for <br />payments to any Covered Person or Provider for any Covered Service for which <br />the Plan Sponsor provides coverage under the terms of the Plan. <br />This Con#ract is solely for the benefit of the Plan Sponsor. There is no intended <br />third party beneficiary to this Contract. It is agreed that this Contract shall not <br />create any right or legal relationship between Medical Mutual of Ohio and any <br />Covered Person or Provider. <br />4. EXCLUSIONS <br />The following expenses and Paid Claims are excluded from coverage under this <br />Stop Loss Contract: <br />A. Expenses which are not covered under the terms and provisions of the Plan, <br />including claims paid by the Plan that are not medically necessary as <br />determined by Medical Mutual of Ohio. <br />B. Expenses which can be recovered from, or attributed to, any other plan or <br />group coverage, or recovered by applying the coordination of benefits <br />provisions (COB) of the Plan. <br />C. Claims paid by the Plan for charges in excess of reasonable and customary <br />fees. <br />CCX0202 Page 3 090102 <br />03 eCityofNorthOlmsted SL <br />