Which plan pays your claim first?
The Canadian insurance industry has created a unique procedural guide to ensure that all insurance companies follow the same principles concerning which plan pays first and how benefits are calculated when making a claim. Settlement to more than one group plan.
If you are insured under both your employer’s and spouse’s, you first submit your claim to your company’s plan and claim any balance from your spouse’s plan.
For example, Elizabeth works at ABC Company while her husband, André, is employed at 123 Company. . Elizabeth is also insured under André’s plan, and André is insured under his spouse’s plan to get the most out of their money and get reimbursed as much as possible after a visit to the dentist, physiotherapist or the optician.
Elizabeth first submits her claim to the ABC Company plan; if her fees are not fully reimbursed, she can submit a claim for the balance to Andrew’s program. Some pharmacies and health care providers will automatically submit your request to both plans, and you will not need to take any further action. In other cases, as soon as your project has paid its portion, you must submit your claim yourself, along with the statement issued by your plan, to the second plan.
Claims for dependent children
Élizabeth and André have two dependent children, who are insured under the plan of both parents. Industry policy is that children are first guaranteed by the parent whose birthday occurs first in the year. Since Elizabeth was born in April and Andrew in August, they would submit their children’s claims first to Elizabeth’s plan and then to Andrew’s plan.
sole custody
If the children live with only one parent and both parents participate in a group plan, the parent’s plan with sole custody of the children pays first.
Shared custody
In shared custody cases where both parents participate in a group plan and whose children are insured under both programs, the plan of the parent whose birthday occurs first in the year pays first.
The procedure also provides which plan will have to pay first in the more complicated cases of reconstituted families. Contact your plan provider for more information.
How do plans calculate benefits?
The plan that pays first treats the request as if there was only one plan for the member. The second scheme considers the reimbursement made by the first scheme and processes the balance. If, for example, the first plan reimburses only 80% of the claim, the second plan could refund the remaining 20%.
You can only receive a maximum of 100% of what you paid — no more — and sometimes the combined reimbursements from the two plans may not cover all you would have paid. For example, the combined cap for coverage for orthodontics or eyeglasses could be less than the number of expenses you would have incurred.
In addition, this reimbursement sequence does not apply in some instances under special rules, for example, in the case of benefits under an automobile insurance plan, payments for health care expenses incurred out of country or province or workers’ compensation benefits. Again, contact your plan provider for more information.
