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How To Coordinate Your Personal and Group Health Benefit Claims

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If you have individual health insurance and are covered by a group plan, figuring out how to submit a claim to maximize your health benefits can be confusing. Understanding how to co-ordinate the plans is important. Luckily, the Canadian Life and Health Insurance Association (CLHIA) created guidelines for insurance companies that set out who pays when, and how much. The guidelines ensure that regardless of which insurer you are with, how your benefits are coordinated is handled the same way.Follow these steps to coordinate your personal and group health and dental benefit claims.

Step 1: Determine if You Have Group Health Insurance Benefits

An insurance policy that provides coverage for many people under one contract is called “group insurance.” The group is typically made up of employees of the same company or members of the same is organization (e.g., a union or trade association) who have a relationship beyond the desire for insurance. Each individual covered under the ‘group’ is called a Plan Member.

Your group insurance will be provided by your employer or your spouse’s employer, or you may have ‘association’ group health benefits through your affiliations. 

The money you receive based on a claim is called your Group Benefits. They are also known as Employee Benefits. A claim can be submitted on behalf of either a plan member or a dependent of the plan member.

Step 2: Determine if you have personal health insurance benefits

Personal insurance is an insurance policy that provides coverage for an individual and their dependents. You have this type of plan if you have purchased and paid for the policy personally and it is issued and owned in your name. Personal Insurance is also known as Individual Insurance.

Step 3: Who do you submit a claim to first?

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Coordination of benefits determines which insurance plan pays first and how much each insurance plan pays. If you have both individual and group health or dental coverage, the Group Plan will typically pay first.

The Coordination of Benefits Provision limits the total benefit amount you can claim, up to a combined maximum of 100 percent of the cost of the eligible expenses incurred. This means that any overlapping coverage you have on a specific claim will not result in you receiving total payments greater than the actual cost of the claim you submitted.

Your group insurer (who is typically ‘first payer’) will first determine the amount of the expense you incurred that is eligible under the plan, and pay the claim as though you have no other coverage.

So the first step is to submit your claim to your group insurer and keep copies of all original receipts.

Step 4: Submit any unpaid portion to the ‘second payer’

The second payer is typically your personal insurance company. When you submit your claim to your individual insurer, be certain to attach all copies of your original receipts along with the explanation of benefits (EOB) you received with your payment from the group plan. The EOB summarizes the charges submitted, the dollar amount allowed by the insurer for each service, the amount paid, and the balance owing  by you (the Insured) if any. If any services were not paid, reasons are given for the benefit reduction or denial of coverage.

This “second payer” insurer will calculate the amount of the eligible expenses it must pay, which is the lesser of

  • The amount the insurer would have paid had it been first payer
  • One hundred (100) percent of the eligible expenses reduced by the benefit amount paid by the first payer.

The combined payment from both (or all) plans cannot exceed 100% of the eligible medical or dental expenses. Sometimes the combined payment may be less than what you had to pay out of pocket.

Step 5: Dealing with plan maximums

Your two plans are almost always going to have different types of coverage, maximum visits per year, and deductibles. Some health insurance plans­ limit the number of visits per year to a health or dental practitioner – for example once every 9 months – and some plans have an annual dollar maximum. 

It is important to understand that when a plan (first or second payer) pays out any benefit for a visit, it will count as a visit towards the maximum under both plans.

If your dental claim is because of an accident, your health insurance plan with accidental dental coverage will be the first payer.

Step 6: Special Rules

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There are a few special circumstances where the rules for submitting a claim to your first or second payer do not apply:

  • Auto insurance
    Provincial legislation determines if coverage available under automobile insurance is first or second payer, or whether it will be coordinated with your health and dental insurance.
  • Out-of-Country/Province Health Care Expenses
    Other rules have been developed to coordinate benefits when more than one plan covers these emergencies.
  • Workers Compensation
    This comes into effect if you are making a claim regarding a work-related injury or accident.

In Summary: Why it’s Great to Co-ordinate Benefits

If you have group benefits but don’t have personal health insurance already, it makes sense to carefully review your group plan. Is it meeting your needs and your family’s needs?

Personal health insurance coverage can serve as a financial cushion if

  • you would like additional or even 100% drug coverage or an “emergency back-up fund” for when prescription drug costs get out of hand because of a chronic issue
  • you’re concerned about high healthcare costs that may result from an accident or illness medical crisis and want a “safety net” in place
  • your work is in transition, you are thinking of becoming self-employed or retiring – having your own personal insurance in place ensures you won’t have “gaps” between those times you have group insurance and those times that you don’t.

Talk to us today

If you ever have any questions about managing your health insurance claim, our team is available to help. And if it’s time for you to put your personal health insurance plan in place, we can give you guidance and support on finding the perfect plan to meet your needs and budget.

2 Responses

  1. Out-of-Country/Province Health Care Expenses
    Other rules have been developed to coordinate benefits when more than one plan covers these emergencies.

    Please explain this. What do I do when I get 2 cheques both paying 100% of my medical out-of-country expenses. I was very clear to give full coordination of benefits information to both my work policy and my private policy.

    1. Thank you for your question. My suggestion is that you advise both insurance companies about the mistake. Individuals should never profit off of a travel claim. Coordination of benefits is that both insurance companies speak to each other about the claim and work together to make sure it is paid in full. On the application there is an area to indicate that you have other travel insurance, if they have overlooked that then that may be the issue. Thank you for your question

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