Group insurance

Understanding coordination of benefits

We realize that coordination of insurance benefits can be complex. We’ll explain it all in black and white so you can figure out which plan pays first.

When you’re covered by more than one group insurance plan, you can submit a claim to each of them. This means it’s important to be aware of the steps to ensure you get fully reimbursed, possibly up to 100%. There are rules in place to establish which plan is primary so you know the order to follow to submit a claim.

Identify the scenario that applies best to your situation to know how to proceed, depending on whether the claim is for you, your spouse or your child.

You

You’re covered by your plan and your spouse’s plan

Your plan is always considered to be the primary insurer for your claims.

Submit a claim to:

  1. Your plan
  2. Your spouse’s plan

You have two jobs and participate in both plans

The primary insurer is the plan that has covered you longer.

Scenario

You have two part-time jobs.

  • Job 1: you’ve participated in this plan since May 28, 2017
  • Job 2: you’ve participated in this plan since September 16, 2019

Job 1 is your primary insurer as you’ve been covered under its plan for longer. Submit a claim to your plan at:

  1. Job 1
  2. Job 2

If you’re also covered by your spouse’s plan, you can then submit a claim to this plan.

You’re covered by one plan as a retiree and another plan as an employee

Your primary insurer is always the plan that covers you as an employee, whether you work there full-time or part-time.

Scenario

You’re retired but found a part-time job in a store. You’re covered by your former employer’s insurance plan for retirees and also have coverage with your current employer.

Submit a claim to:

  1. Your current employer’s plan
  2. Your former employer’s plan

Your spouse

Your spouse is covered by their own plan and your plan

The primary insurer is always the plan of the person making the claim. In this case, it’s your spouse’s plan.

Submit a claim to:

  1. Their plan
  2. Your plan

Your child

Your child is covered by your plan and your spouse’s plan (or ex-spouse with shared custody)

The primary insurer is the plan covering the parent whose birthday falls first in the calendar year.

If both parents have the same birthday, the primary insurer is the that of the parent whose first name starts with a letter that appears first in the alphabet.

Scenario 1

The parents’ birthdays are:

  • Parent 1: May 8
  • Parent 2: September 21

Since Parent 1’s birthday falls first in the year, their plan is the primary insurer. Submit a claim to the:

  1. Parent 1’s plan
  2. Parent 2’s plan

Scenario 2

Both parents have a birthday on July 13. Their first names are:

  • Parent 1: Christine
  • Parent 2: Sean

The letter ‘C’ comes before ‘S’ in the alphabet so Parent 1’s plan (Christina) will be the primary insurer. Submit a claim to:

  1. Parent 1’s plan (Christine)
  2. Parent 2’s plan (Sean)

The same rule applies if you’re separated and both of you have a new partner, meaning your child is now covered by four separate plans. You submit first to the plans of the child’s parents and then the new partners after that.

Scenario

The birthdays of the parents and their partners are:

  • Parent 1: May 8
  • Parent 2: September 21
  • Partner of Parent 1: March 14
  • Partner of Parent 2: October 12

Submit a claim to:

  1. Parent 1’s plan
  2. Parent 2’s plan
  3. Partner of Parent 1’s plan
  4. Partner of Parent 2’s plan

You have sole custody of your child: he’s covered by your plan and at least one other plan

Your plan is the primary insurer as your child lives with you.

If you have a new partner and their plan covers your child, their plan becomes the second insurer.

The other parent’s plan, the one without custody, becomes the third insurer.

If the other parent also has a new partner and their plan covers your child, their plan becomes the fourth insurer.

Scenario

Your child lives with you (sole custody) and your new partner.

Submit a claim to:

  1. Your plan
  2. Your new partner’s plan
  3. The other parent’s plan
  4. The plan of the other parent’s partner.

Your child is at university: she’s covered by your plan and has coverage through her university.

The primary insurer is always the plan of the person submitting the claim. In this case, that’s the university plan.

Scenario 1

Your child is at university. She’s covered by the university’s health and/or dental insurance plan, and also your plan.

Submit a claim to:

  1. The university’s plan
  2. Your plan

If your child is also covered by their employer’s plan, the primary insurer is the plan that has covered them for a longer time (university plan or employer plan). Your plan then becomes the third insurer.

Scenario

Your child is covered by a university plan, their employer’s plan and your plan.

  • University: your child has participated in this plan since September 3, 2020
  • Your employer: your child has participated in this plan since January 18, 2019

The employer's plan is the primary insurer as they’ve been covered under that plan for longer. Submit a claim to:

  1. Their employer’s plan
  2. The university’s plan
  3. Your plan

Exception for prescription drug expenses in Quebec: if your child lives in Quebec and the claim is for a prescription drug, the claim must be made to the university’s plan last.

Scenario

Your child lives in Quebec. He’s covered by the university’s plan, his employer’s plan and your plan. He wants to submit a claim for a prescription drug that he was prescribed.

The claim relates to a prescription drug expense so submit a claim to:

  1. Their employer’s plan
  2. Your plan
  3. The university’s plan

Coordination of benefits How does it work?

You now know who the primary insurer is. Follow these steps to properly submit a claim.

  • Submit your claim to the primary insurer

    Your claim will be reimbursed depending on the coverage under your plan.

  • Wait to know what the remaining unpaid balance of your claim will be

    You can’t ask the second insurer to pay the full amount as the primary insurer has already paid a portion. You can only ask for the difference to be reimbursed.

  • Submit your claim to the second insurer

    In your claim, include the total amount you paid as well as the remaining unpaid balance of the initial claim. Based on this updated amount, the claim will be reimbursed according to the coverage under your plan.

  • If you’re covered by more than two plans, repeat steps 2 and 3

    When there is coordination of benefits, the total amount reimbursed by all plans combined can’t exceed the amount that you paid in the first place. Say a care or item costs you $115 and you submitted a claim to three different plans, you can only be reimbursed $115.

    Note that depending on the coverage under the plans, the amount that you initially pay may not be 100% reimbursed.

More questions about coordination of benefits?

Our customer service team is here to help you.

1 888 235-0606
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