Personal Finance

Coordination of group insurance benefits

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  • Jan 4th, 2017 12:18 pm
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Deal Addict
Oct 22, 2015
1678 posts
585 upvotes

Coordination of group insurance benefits

I submitted a dental claim for $725 to my work group insurance of which they paid $500.
I am also covered at my wife's group insurance at her work.
I submitted the remaining $225 to be reimbursed by her plan.

They came back and said the eligible expense for the procedure under my wife's plan covers $425 only.
Since my insurance paid $500, they say nothing else will be paid.

Why would nothing be paid? Am I not essentially claiming the remaining $225 not paid by my plan?
Since the eligible coverage under my wife's plan is $425, shouldn't they pay the remaining $225?
What is the use of having two plans then.

Does this make sense to anyone?
How does it work?
7 replies
Deal Fanatic
Dec 12, 2009
6145 posts
3616 upvotes
Toronto
A lot of plans would cover co-payment of $225.
The key is what is in your wife's plan? Get a copy of the benefits booklet and search the entire thing for anything that even remotely sounds like coordination of benefits.

I'd also check with your wife's HR dept or union if applicable.
Banned
Mar 11, 2016
2081 posts
893 upvotes
I also find this confusing and annoying...should be very simple but never is
Member
Nov 29, 2008
216 posts
68 upvotes
Maybe your wife should have made the intial claim and then the remaining under your plan?

I remember in the past that the partner who's birthday occurred first in the calendar year would have to make the claim first.
Sr. Member
Jul 22, 2015
797 posts
464 upvotes
Ontario
tyrantlake wrote: Maybe your wife should have made the intial claim and then the remaining under your plan?

I remember in the past that the partner who's birthday occurred first in the calendar year would have to make the claim first.
I believe you have to submit your own claims to your benefits provider first and then to the spouse's. For your children's claims, they get sent to the parent who is older or with first birthday or something like that.

Hardly makes sense to have benefits with 2 providers in this case!
Deal Addict
Oct 22, 2015
1678 posts
585 upvotes
You are suppose to claim off your own employers plan and then claim the remaining from spouses plan.

I still think this was a mistake but I'm not sure how to ask the insurance company to take a look again.

Any insurance experts out there?
Deal Addict
Jun 20, 2011
2095 posts
1083 upvotes
VANCOUVER
wra45mon wrote: I submitted a dental claim for $725 to my work group insurance of which they paid $500.
I am also covered at my wife's group insurance at her work.
I submitted the remaining $225 to be reimbursed by her plan.

They came back and said the eligible expense for the procedure under my wife's plan covers $425 only.
Since my insurance paid $500, they say nothing else will be paid.

Why would nothing be paid? Am I not essentially claiming the remaining $225 not paid by my plan?
Since the eligible coverage under my wife's plan is $425, shouldn't they pay the remaining $225?
What is the use of having two plans then.

Does this make sense to anyone?
How does it work?
To answer the posts above, generally speaking, claims must be submitted to your primary coverage first. I won't get into custody, first nations, vet affairs, individual products.

Now to answer your question about coordination and what I think happened. Dentists generally follow a fee guide and ins companies will only consider up to that amount. Now lets say you got a crown put in. Price of the crown in the guide is $425. Price charged to you is $725 (lets assume specialist fee) and you got 70% of that covered. So pay out is $500 (rounded). Now since insurance companies only consider the amount up to and including the reasonable amount of $425 and the first plan (primary) paid the full $425 then your secondary will not kick in. Now this is just an example and does not apply to everything.

Another example I'll give you is say you bought some Pantoprazole to treat GERD. Receipt from the pharmacy is $18.00 and your plan kicks in at 70% which pays $12.60. Since drugs don't generally don't have a cap the secondary plan will pay $5.40.
Sr. Member
User avatar
Dec 26, 2010
630 posts
168 upvotes
SW Ontario
Another question
I am currently going through dental treatment. There is still 2-3 more months to complete. I have Sunlife through my employer group benefits (very good benefits). Sunlife was going to cover it per their policies, limitation, etc based on a dental estimate
I am changing companies and will have a new insurance company (Great West Life). I dont have the details on their benefits.
I am concerned that my new insurance company wont cover the ongoing procedure or cover less.

My employer indicates I could keep Sunlife after leaving as long as I pay the premiums, etc of my own pocket.
Is it possible that I could coordinate benefits between Sunlife (then personally paid) and Great West Life (then provided by my new employer)?

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