Kaiser Hawaii Application Agreement
Sign the application agreement
Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application.
I understand that Kaiser Permanente for Individuals and Families (KPIF) will rely on the information provided in this application. If any information is found to be fraudulent or intentionally misrepresented, then KPIF may choose to terminate coverage back to the coverage effective date.
Arbitration Agreement/Procedure
A. BINDING ARBITRATION
Except as provided below, any and all claims, disputes, or causes of action arising out of or related to this Service Agreement, its performance or alleged breach, or the relationship or conduct of the parties, including but not limited to any and all claims, disputes, or causes of action based on contract, tort, statutory law, or actions in equity, shall be resolved by binding arbitration as set forth in this Service Agreement.
This includes but is not limited to any claim asserted:
a. By or against a Member, a patient, the heirs or the personal representative of the estate of the Member or patient, or any other person entitled to bring an action for damages, arising from or related to harm to the Member or patient as permitted by applicable federal or Hawaii state law existing at the time the claim is filed (“Member Parties”). For purposes of this section 8, all family members of the Member or patient who have derivative claims arising from such harm, shall also be deemed “Member Parties” and bound to these arbitration terms;
b. On account of death, bodily injury, physical ailment, mental disturbance, or economic loss arising out of the rendering or failure to render medical services or the provision or failure to provide benefits under this Service Agreement, premises liability, or arising out of any other claim of any nature, irrespective of the legal theory upon which the claim is asserted; and
c. By or against one or more of the following entities or their employees, officers or directors (“Kaiser Permanente Parties”):
Notwithstanding any provisions to the contrary in this Service Agreement, the following claims shall not be subject to mandatory arbitration:
a. claims for monetary damages within the jurisdictional limit of the Small Claims Division of the District Courts of the State of Hawaii; b. actions for appointment of a legal guardian of a person or property subject to probate laws; c. purely injunctive orders reasonably necessary to protect Kaiser Permanente’s ability to safely render medical services under this Service Agreement (such as temporary restraining orders, and emergency court orders).
B. INITIATING ARBITRATION
A demand for arbitration shall be initiated by sending a registered or certified letter to each named party against whom the claim is made, with a notice of the existence and nature of the claim, the amount claimed and a demand for arbitration. Any Kaiser Permanente Parties shall be served by registered or certified letter, postage prepaid, addressed to the Kaiser Permanente Parties in care of the Health Plan at the address set forth in section VII-J of this Service Agreement. The arbitrators shall have jurisdiction only over persons and entities actually served.
C. ARBITRATION PROCEEDINGS
Within 30 days after the service of the demand for arbitration, the parties shall agree on a panel of arbitrators from which to select arbitrators or shall agree on particular arbitrators who shall serve for the case. If the parties cannot agree on any panel of arbitrators or particular arbitrators within the 30 days, then the panel of arbitrators shall be that of Dispute Prevention and Resolution, Inc. (“DPR”). Unless the parties agree to any other arbitration service and rules, DPR shall administer the arbitration and its arbitration rules shall govern the arbitration (including rules for selection of arbitrators from a panel of arbitrators, if the parties have not already agreed upon particular arbitrators to serve). Kaiser Permanente shall notify DPR (or such other arbitration service as may be chosen by the parties) of the arbitration within 15 days following the expiration of the 30-day period noted above.
Within 30 calendar days after notice to Dispute Prevention and Resolution, Inc., the parties shall select a panel of 3 arbitrators from a list submitted to them by the arbitration service. In all claims seeking a total monetary recovery less than $25,000.00, and in any other case where the parties mutually agree, a panel of 1 arbitrator selected by both parties from a list submitted to them by the arbitration service will be allowed. The arbitrator(s) will arrange to hold a hearing in Honolulu (or such other location as agreed by the parties) within a reasonable time thereafter.
Limited civil discovery shall be permitted only for
a. production of documents that are relevant and material,
b. taking of brief depositions of treating physicians, expert witnesses and parties (a corporate party shall designate the person to be deposed on behalf of the corporation), and a maximum of 3 other critical witnesses for each side (i.e., respondents or claimants), and
c. independent medical evaluations.
The arbitrator(s) will resolve any discovery disputes submitted by any party, including entry of protective orders or other discovery orders as appropriate to protect the parties’ rights under this paragraph.
Any payment for the fees and expenses of the arbitration service and the arbitrator(s) shall be borne one-third by the Member Parties and two-thirds by the Kaiser Permanente Parties.
Each party shall bear their own attorney’s fees, witness fees, and discovery costs.
The arbitrator(s) may decide a request for summary disposition of a claim or particular issue, upon request of one party to the proceeding with notice to all other parties and a reasonable opportunity for the other parties to respond. The standards applicable to such request shall be those applicable to analogous motions for summary judgment or dismissal under the Federal Rules of Civil Procedure.
In claims involving benefits and coverage due under this Service Agreement or disputes involving operation of the Plan, Health Plan’s determinations and interpretations, and its decisions on these matters are subject to de novo review.
The arbitration award shall be final and binding. The Member Parties and Kaiser Permanente Parties waive their rights to jury or court trial.
With respect to any matter not expressly provided for herein, the arbitration will be governed by the Federal Arbitration Act, 9 U.S.C. Chapter 1.
D. GENERAL PROVISIONS
All claims based upon the same incident, transaction, or related circumstances regarding the same Member or same patient shall be arbitrated in one proceeding (for example, all Member Parties asserting claims arising from an injury to the same Health Plan Member, shall be arbitrated in one proceeding).
A claim for arbitration shall be waived and forever barred if on the date notice thereof is received, the claim, if it were then asserted in a civil action, would be barred by the applicable Hawaii statute of limitations. All notices or other papers required to be served or convenient in the conduct of arbitration proceedings following the initial service shall be mailed, postage prepaid, to such address as each party gives for this purpose. If the Federal Arbitration Act or other law applicable to these arbitration terms is deemed to prohibit any term in this Service Agreement in any particular case, then such term(s) shall be severable in that case and the remainder of this Service Agreement shall not be affected thereby. Class actions and consolidation of parties asserting claims regarding multiple Members or patients are prohibited. The arbitration provisions in this Service Agreement shall supercede those in any prior Service Agreement.
Sign the arbitration agreement
Kaiser Foundation Health Plan Arbitration Agreement: Except as provided in the arbitration agreement, excerpted from your Service Agreement on pages 8 and 9 of this enrollment form, any and all claims, disputes, or causes of action arising out of or related to the Service Agreement, its performance or alleged breach, or the relationship or conduct of the parties, including but not limited to any and all claims, disputes, or causes of action based on contract, tort, statutory law, or actions in equity, shall be resolved by binding arbitration. I, on behalf of myself and all family members, hereby (i) acknowledge that I have read and understood the provisions of the arbitration agreement on pages 8 and 9 of this enrollment form, (ii) agree to binding arbitration, and (iii) give up the right to a jury trial.