Coordination of benefits

If your family has access to more than one health and/or dental plan you can use what is called coordination of benefits to have more of your expenses covered.  All insurance companies follow the same procedures, which are set out in the Canadian Life and health Insurance Association’s (CLHIA) Coordination of Benefits Guidelines.

The plan that pays first pays as though there is no other coverage.

The plan that pays second pays the lesser of:

  1. The amount they would have covered if they were the first plan, or
  2. The full amount of eligible expenses minus the amount paid by the first plan

You go for an eye exam that costs $100, and submit the claim to your plan which covers $75. The remainder ($25) is submitted to your spouse’s plan and would be paid.

The Rules:

The plan which covers you as a member pays before the plan which covers you as a dependent.

If you have coverage as a member with your employer and as a dependent with your spouse’s plan:

  • Your plan pays your claim first
  • Your spouse’s plan pays the claim second

When children are covered as dependents on 2 plans, the plan of the parent with the earlier birth date in the calendar year pays first.

  • Mom’s birthday – April 17
  • Dad’s birthday – February 2

Dad’s plan pays first as his birthday is earlier in the year.

If Mom and Dad’s birthday are on the same date, the parent with a given name earlier in the alphabet pays first.

  • Mom’s given name is Julie
  • Dad’s given name is Tom

Mom’s plan pays first – the name Julie comes first alphabetically.

If one parent has custody of the child(ren), the plan of the parent where the child lives pays first.

  • Child lives with their father and his new spouse
  1.      Father’s plan pays first
  2.      Father’s spouse’s plan pays second
  3.      Mother’s plan pays third
  4.      Mother’s spouse’s play pays fourth.

Your insurance carrier or broker will be able to help you to determine where claims should be sent.

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