Health & Wellness

Question about coordination of benefits between insurance companies

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  • Dec 1st, 2020 4:25 pm
Jr. Member
Dec 24, 2018
173 posts
76 upvotes

Question about coordination of benefits between insurance companies

Hi guys,

First of all, my questions aims to recover 100% of my actual costs and nothing else. And frankly, this is the message the insurance companies provide to us and I couldn't care less about the administrative bureaucracy, which always turns out to their favor.
I always read from insurance companies you should first submit under your own plan and then under your spouse's plan and benefit coordination is great and you as a customer always benefit of it LOL....

However, this lead me to a situation where my coverage from both plans is less than 100% and lower when I would have submitted first under my wife's plan and then under my own plan.
The issue is that my wife's plan has a lower customary charge for medical devices than my insurance. Because my insurance already covered 80% and has a higher customary charge, the other insurance only paid the difference between there customary charge and the amount my insurance paid (effectively 10%) and not the remaining 20%.

I always disclose to the insurance there is a second plan and so far I played along by submitting it first under my plan. However, I am wondering if I am truly obliged to submit first under my plan? My intention is not to get more than the actual cost back, just to get the coverage I am supposed to get, the coverage they promise, the coverage we deserve.

This year was already a super bad year #travelinsurance and I do not want to leave that industry more money than they are supposed to have according their obligations.

Thanks for your feedback
5 replies
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Mar 30, 2004
5302 posts
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Durham Region
SirRobin wrote: The issue is that my wife's plan has a lower customary charge for medical devices than my insurance. Because my insurance already covered 80% and has a higher customary charge, the other insurance only paid the difference between there customary charge and the amount my insurance paid (effectively 10%) and not the remaining 20%.
1) Yes, you are obligated to submit to your own plan first
2) Even if you weren't, the second plan would only pay based on their lower customary charge regardless
Deal Fanatic
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Jan 31, 2006
8541 posts
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Toronto
SirRobin wrote: Hi guys,

First of all, my questions aims to recover 100% of my actual costs and nothing else. And frankly, this is the message the insurance companies provide to us and I couldn't care less about the administrative bureaucracy, which always turns out to their favor.
I always read from insurance companies you should first submit under your own plan and then under your spouse's plan and benefit coordination is great and you as a customer always benefit of it LOL....

However, this lead me to a situation where my coverage from both plans is less than 100% and lower when I would have submitted first under my wife's plan and then under my own plan.
The issue is that my wife's plan has a lower customary charge for medical devices than my insurance. Because my insurance already covered 80% and has a higher customary charge, the other insurance only paid the difference between there customary charge and the amount my insurance paid (effectively 10%) and not the remaining 20%.

I always disclose to the insurance there is a second plan and so far I played along by submitting it first under my plan. However, I am wondering if I am truly obliged to submit first under my plan? My intention is not to get more than the actual cost back, just to get the coverage I am supposed to get, the coverage they promise, the coverage we deserve.

This year was already a super bad year #travelinsurance and I do not want to leave that industry more money than they are supposed to have according their obligations.

Thanks for your feedback
So your intention is to cheat?
Jr. Member
Dec 24, 2018
173 posts
76 upvotes
No. I just find it weird that the 2nd insurance might end up paying nothing at all if their customary charge is lower than the 80% what my plan pays. So much to being there for the customer....
Knowing that, I would really have to go over the books if it makes sense for the better half to opt out of her benefits or at least from the family option and switch it to the single option.

I was more pointing out that in any brochure or insurance website when you file a claim they basically say "leave it to us with benefits coordination, we will get you the money back" whereas this is not the case....


Another question; if I use up my bucket from my plan (because they pay 80%), will then the 2nd insurance pay 80% or will they play "we are only the 2nd plan and tops we pay 20%" violin?
Deal Fanatic
Jun 24, 2015
8524 posts
2941 upvotes
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the only exception is if you dont have an actual insurance plan you opted out and only have a HCSA - Health Care Spending Account, then you do your wifes insurance first, then you can use the HCSA to pay any outstanding balacne not covered under hers like deductable or any plan limitts or caps on expenses ,etcc, its pretty easy man
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Oct 13, 2007
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Edmonton
SirRobin wrote: Hi guys,


I always disclose to the insurance there is a second plan and so far I played along by submitting it first under my plan. However, I am wondering if I am truly obliged to submit first under my plan? My intention is not to get more than the actual cost back, just to get the coverage I am supposed to get, the coverage they promise, the coverage we deserve.
The answer to your question is simply whether you want to play by their arbitrary rules. In this day, your best bet is to get what is most beneficial to you. If I have the coverage, do I really care if Insurance Company A pays the bill or Insurance Company B? The technology is there that they can create a database, particularly for employer sponsored plans, to input this information and coordinate it themselves.

Having said that, whatever you decide to do, you will need to keep it consistent.

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