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THE BASICS
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The purpose of this booklet is to help you understand how insurance companies
coordinate benefits when you have coverage under more than one group health or
dental plan.
In general, life and health insurance companies follow procedures which are set
out in the Canadian Life and Health Insurance Association's (CLHIA) Coordination
of Benefits Guideline. It establishes which plan pays first and how benefits are
calculated when an individual makes a claim to more than one group plan, either
as the plan member or a dependent. A group health or dental plan is made
available to you and/or your spouse/partner through your employer, a union,
association or other organization.
In families with two working adults, it is common to have access to more than
one health or dental plan – this is in fact the most common type of overlapping
insurance coverage. In other words, though coverage may not be exactly the same
in both plans, they tend to overlap in the types of services they cover.
In order to ensure consistency in how the insurance industry deals with these
situations, the CLHIA Coordination of Benefits Guideline was created for insurance
companies to follow.
This Guideline gives insurance companies a consistent set of rules to follow so
claims are processed in the same way when an individual makes a claim to
more than one plan. The Guideline also describes the order in which benefits are
determined and how to coordinate health care or dental payments from all available
group plans. Essentially it sets out who pays when, and how much.
