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Coordination of Benefits

Coordination of benefits (COB) is the process used by insurance companies to determine the order in which multiple plans will pay for the same claim when a person is covered under more than one policy. The goal is to ensure that combined reimbursements do not exceed 100 percent of the eligible expense, while allowing the insured to receive the maximum possible coverage across all plans.

This process commonly applies when both spouses have separate health or dental insurance, or when a child is covered under plans from both parents. The primary insurer pays first, according to its coverage rules, and the secondary insurer reimburses any remaining eligible amount up to the limit of its own plan. Insurance companies follow standardized coordination rules set by the Canadian Life and Health Insurance Association (CLHIA) to ensure consistency.

Example:

If your dental cleaning costs $200 and your plan covers 80 percent, your insurer reimburses $160. You can then submit the remaining $40 to your spouse’s plan for secondary coverage, which may cover all or part of the balance, depending on its terms.

What to Watch For

Always submit claims to the primary plan first. For adults, the primary plan is the one under which they are the policyholder. For dependent children, the primary plan is determined by the “birthday rule,” meaning the parent whose birthday falls earlier in the calendar year pays first. Keep receipts and explanation of benefits (EOB) statements from the first insurer, as they must be submitted with the secondary claim.

Related Terms

Calendar Year

The calendar year defines a benefit period that runs from January 1 to December 31. Many annual maximums, deductibles, and claim resets follow this schedule. It provides a consistent framework across most insurers and simplifies tax reporting for medical expenses.

Certificate of Insurance

A certificate of insurance is an official document issued by an insurance company that summarizes the key details of your coverage. It serves as proof that you are insured and outlines the essential terms of your policy, including the type of coverage, effective dates, benefit limits, exclusions, and any dependents or beneficiaries listed under the plan.

Claim

A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.

Claim Submission Deadline

The claim submission deadline is the final date by which an insured person must submit a claim to their insurance company for reimbursement of eligible expenses. After this date, the insurer is not obligated to pay the claim, even if the expense itself would have been covered. This deadline ensures timely processing, accurate recordkeeping, and proper financial reporting for both the insurer and the policyholder.

Claimant

A claimant is the person who submits a request for reimbursement or payment under an insurance policy. In health and dental insurance, the claimant is usually the insured individual who received the service, such as a medical treatment, prescription, or dental procedure. However, a claimant can also be a parent, spouse, or legal guardian submitting a claim on behalf of a covered dependent.

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