How Does Coordination of Benefits Work?

Coordination of benefits is when two insurance companies work together to pay claims for one person. It’s a fairly simple process, but can seem complicated if you don’t know where to start. Coordination of claims is a question frequently asked by our customers, so this article will explain how you and your family can make the most out of your combined benefits coverage. 

As a single person without dependants, it will be pretty clear where you submit your insurance claims to. However, if you have a spouse who also has employee benefits and/or children or other dependants, you may have questions as to where your claims should go, and which insurance provider the claims ought to be submitted to. 

Terminology

1. Primary insurer – your own insurance provider
2. Secondary insurer – your spouse’s insurance
3. Dependant – the party listed under your insurance plan as your dependant

All claim submissions

Some rules apply to all coordination of benefits claims. Whether you are submitting a claim for yourself or your dependent, remember to  take into consideration the following when submitting this type of claim:

1. Include a copy of your receipt, plus an explanation of benefits from your primary insurance when submitting a claim to your secondary insurance provider. 
2. A claim must be submitted to your primary insurance first, even if your claim is not covered by your primary insurance or if the maximum claim amount has been already reached.
3. Your combined insurance coverage can cover no more than 100% of your total claim amount.

Submitting your own claim 

When submitting a claim on your own behalf, always first submit your claim to your primary insurance the way you normally would. Whatever your insurance doesn’t pay, you can then submit to your secondary insurance. 

Submitting a claim on behalf of a child 

When submitting a claim on behalf of a child, priority of payment is determined by which group plan member’s birthday (month, date) falls first on a calendar year. For example, if your birthday falls on April 12th and your spouse’s birthday falls on October 8th, then your dependant’s claims should be first submitted through your insurance plan. The year on which your respective birthdays fall is not taken into consideration in this case, only birth date. 

In the unlikely event that your and your spouse’s birth dates fall on the same day, then priority goes to the person who was born in the earlier year. 

For a comprehensive coordination of benefits guide, please see the Canadian Life and Health Insurance Association’s coordination of benefits guidelines here.