Are you or a dependent insured under more than one policy?

August 1, 2017

The Canadian Life and Health Insurance Association (CLHIA) developed The Co-ordination of Benefits Guidelines to ensure consistency within the industry in situations where a person can submit a claim to more than one group insurance plan.

Payment on a particular claim cannot exceed 100 per cent of the eligible expenses. Eligible expenses are determined by reasonable amounts established by the insurer, plan maximums and contractual fee guide limits. When you are insured by more than one plan, the established order of benefits is:

  • You – always submit your claim to your 3sHealth Benefit Plans first, and then submit the remainder under your spouse’s benefit plan.
  • Your spouse – will submit claims to his/her employer’s benefit plan first, and then submit the remainder under the 3sHealth Benefit Plans.
  • Dependent children – submit claims to the plan of the parent with the earlier birth date (month/day) in the calendar year. Then submit the remainder under the other spouse’s benefit plan.
  • If you and your spouse are separated or divorced but share custody of the dependent child, then the date of birth rule still applies.
  • If one parent has sole custody of the child, then their plan will be the first payer. Then submit the remainder under the plan of the parent without custody.
  • If you or your ex-spouse has a new spouse and share custody of the child, the order of benefit is the parent with the earlier date of birth, the parent with the later date of birth, the spouse of the parent with the earlier date of birth, then the spouse of the parent with the later date of birth.

For further information regarding the Canadian Life and Health Insurance Association Inc. (CLHIA) coordination of benefits guidelines, please refer to: https://goo.gl/CLcPIH.

For all the latest information regarding your workplace benefits, please consult the spring 2017 edition of the Members' Annual Statement.

 



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