# Coordination of benefits, maximum = sum of coverage?



## joncnca (Jul 12, 2009)

i'm having trouble searching..er...the internet for some direction about this, and i'm hoping for some source other than the actual insurance company involved.

if a person and their spouse both have benefits through work (whether paid by employer or paid by oneself), does the maximum benefit for a particular service equal the sum of both maximums, or the higher of the two?

let's say i get $300 per year for eyeglasses, and my wife gets $400 per year for eyeglasses, and we are both listed as each other's dependent. does that mean each of us can get covered for a maximum of $700?

i would think that this makes sense considering that each of us (my employer pays my premiums, her premiums are deducted from her own wages) through our employer or ourselves is paying for the benefit.

is this true? or is the maximum coverage only equal to higher of the two maximums (i.e. $400). 

anyone have experience or a reference regarding this matter? thanks!



(i put this in Frugality because i'm getting shafted by an optical, and already used my own allotment and wondering if i can also access the allotment through my wife's benefits cause i don't want to pay any more to fix the problem)


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## Guban (Jul 5, 2011)

That's what happens in our family. The excess gets picked up by the other's plan. May be a problem if you both work for the same company though.


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## Addy (Mar 12, 2010)

You should have received a booklet or a link to a website that explains this as every plan is different, but generally, from past experience with both my husband and I having benefits, you claim on your own benefits first, then the remainder of the claim (if any) you submit to your spouses plan.

If you both work for the same employer, I believe (but could be wrong as I'm going by memory and my memory isn't great) the person with the birthday first in the year you claim against them first.


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## Toronto.gal (Jan 8, 2010)

joncnca said:


> let's say i get $300 per year for eyeglasses, and my wife gets $400 per year for eyeglasses, and we are both listed as each other's dependent. does that mean each of us can get covered for a maximum of $700?


For consistency purposes, the COB rules for health & dental claims are pretty much standard, as insurers follow the CLHIA guidelines.
http://www.clhia.ca/domino/html/clhia/clhia_lp4w_lnd_webstation.nsf/resources/Consumer+Brochures/$file/Brochure_Guide_To_CoOrdinationBenefits_ENG.pdf 

What you need to keep in mind, is that though you could think of it as double coverage, the purpose of COB, is not to over-insure, but to only cover as much of your out-of-pocket expenses within that plan's eligibility & policy limits, so the combined payment from all plans [and there can be more than 2], can never exceed 100% of the eligible expenses. 

For example, if your claim was $400 and your eligible plan payment was $300 as per your example, your spouse's plan would pay up to $100 & leaving you with $0 out-of-pocket expenses. If your plan paid 100% of the claim, then there would be no COB.

However, note that not all times will your out of pocket expenses be reimbursed 100%. For example, if your plan paid 100% with $25 deductible, but your spouse's plan paid 80% with $25 deductible, you would not receive your $25 out-of-pocket amount [$25 out of pocket expense x 80% - $25 = $0]

**********

- 1st payer of your eligible claims = your plan, and this is regardless whether you both work for same employer or not.
- 2nd payer = your spouse's plan
- payer of children's claims = the spouse with the earliest b'date in the year [month/day].


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## joncnca (Jul 12, 2009)

thanks for the replies, everyone.

my wife and I do not work for the same organization, so that's not a consideration. and i've successfully filed coordination claims like this kind:

For example, if your claim was $400 and your eligible plan payment was $300 as per your example, your spouse's plan would pay up to $100 & leaving you with $0 out-of-pocket expenses. If your plan paid 100% of the claim, then there would be no COB.

i'm wonder though, as per my first post:

let's say i get $300 per year for eyeglasses, and my wife gets $400 per year for eyeglasses, and we are both listed as each other's dependent. does that mean each of us can get covered for a maximum of $700?

if i buy a pair of eyeglasses for 400, my benefits will cover the first 300, and her benefits will cover the remaining 100 so there's nothing out of pocket. however, this still leaves another 300 remaining out of the 700 (total of my 300 and her 400 in eligible coverage).

if i had originally bought a pair of $700 glasses, i think the coordination would pick it all up. however, if i buy one pair for $400 and coordinate the 300+100, can I then buy another pair of glasses (prescription) up to 300 to get to the total of $700?

shouldn't i get to do this?, because if you look at our paystubs, there are deductions from both of our paychecks to pay for extended health benefits. it seems that the insurance company is getting their money, why shouldn't i get the use all of the eligible amount?

btw, i'm talking about a second legitimate pair of prescription glasses.

thanks!


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## Toronto.gal (Jan 8, 2010)

joncnca said:


> 1. my wife and I do not work for the same organization
> 2. if i buy *one pair* for $400 and coordinate the 300+100, *can I then buy another pair of glasses* (prescription) up to 300 to get to the total of $700?
> 3. if you look at our paystubs, there are deductions from both of our paychecks to pay for extended health benefits.


*1.* Even if you worked for the same employer, why would that be an issue?

*2.* You're thinking strictly in $ amounts, however, you need to check both booklets for other coverage limitation [or call your HR or CS dpts if you don't have them/don't understand them]. IE: is the benefit maximum per year/per 2 consecutive benefit years? Is there another limit, ie: *1 pair* eyeglasses per year/2 years, etc.? 

*3.* It doesn't mean that you can double up; that's not what COB is for.

Btw, wanting to collect maximum coverage [if that's why you want a 2nd pair of glasses], is not exactly what I would call frugal.


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## Xoron (Jun 22, 2010)

joncnca said:


> let's say i get $300 per year for eyeglasses, and my wife gets $400 per year for eyeglasses, and we are both listed as each other's dependent. does that mean each of us can get covered for a maximum of $700?


It depends on the plan. Some offer a max per insured person (so 700 for each covered family member) others only offer it per family (700 to share amongst the whole family). Only way to know for sure is to check the employee handbook, talk to your admin person at your office or call the insurance company directly.


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## the-royal-mail (Dec 11, 2009)

It makes no sense to me that two people should be entitled to $700 per year for each person. That would mean a doubled benefit of $1400 a year for the couple, when they were only eligible for $700 as singles.

The only way to find out for sure is simply to call the provider and ask. I don't understand why you are opposed to doing that. All any of us here can do is speculate.


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## crazyjackcsa (Aug 8, 2010)

He doesn't want to call the provider because he doesn't want to tip them off to the "fast one" he's interested in pulling.


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## Xoron (Jun 22, 2010)

crazyjackcsa said:


> He doesn't want to call the provider because he doesn't want to tip them off to the "fast one" he's interested in pulling.



Coordination of benefits is completely above board. In fact there is a section in my employee handbook that addresses that question and how to go about it.


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## joncnca (Jul 12, 2009)

i said i was looking around at other sources of information. i did not at any point say that i was refusing to contact the insurance companies, because ultimately i will need to clear it with them. surely, crazyjackcsa isn't so obtuse or naive that he cannot see that the insurance company has an incentive to withhold clear information from me, in that they would rather i use less than the amount for which i am eligible. perhaps i'm giving him too much credit.

that's why i asked if anyone had any personal experience with this, not only to speculate, but to please share first hand experience about a similar situation. i would then be able to compare that account with my own first hand experience. if i was only relying on calling the insurance companies, why would i even bother posting on a message board? why would anyone even bother posting on message boards?

i don't believe i'm asking any sort of questions to 'pull a fast one.' i've asked a perfectly logical question.

if my wife pays, for example, $50 in premiums every month for $400 of coverage every 2 years, and i pay, for example, $50 in premiums every month for $300 coverage every 2 years, and we are paying these premiums for family coverage (i.e. if we were single with no dependents, each person would only pay let's say $30 in premiums), why shouldn't we be eligible for the total of $700 every 2 years? that only makes sense. otherwise, the insurance companies collect $50 per month from me, $50 per month from my wife, and each of us only receives only $300 or $400 coverage. seems more like the insurance companies are trying to pull a "fast one" on me!

when we changed our benefits coverage from single to family, each of us had to pay more in premiums. i presume that is because the benefits then needed to cover more than just the one person.

someone please tell me you know what i'm talking about here. if there's some flaw in my logic or someone knows something i don't, please share. but as i see it, if our premiums are higher, why wouldn't our eligible claim amount be higher as well?

and i spent several hundred dollars on a prescription and a set of glasses that simply are not working. neither the optometrist nor optical store have stepped up to fix the issue. it's not as if i damaged the glasses and i'm trying to cheat the system, or that I simply want another pair for the sake of vanity. if i'm legitimately eligible for enough to replace the lenses so that i will have ONE working pair of glasses, i'll be happy. i'm trying to find a legitimate way to dig myself out of a situation for which no one else has taken responsibility. put yourself in my shoes, if you're not an optometrist or optician yourself, don't you have a reasonable expectation that (in the absence of having the skills needed to prescribe/manufacture yourself the right pair of glasses) the money your paying should get you a pair of eyeglasses that will work? is this a foreign concept or what?


edit: useful point below, thanks for this, i will take a closer look at the benefits booklet to see if it actually identifies the limit as 1 pair, or if it's just the dollar amount. i know the time frame is every 24 months
From Toronto.Gal.

2. You're thinking strictly in $ amounts, however, you need to check both booklets for other coverage limitation [or call your HR or CS dpts if you don't have them/don't understand them]. IE: is the benefit maximum per year/per 2 consecutive benefit years? Is there another limit, ie: 1 pair eyeglasses per year/2 years, etc.?


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## Xoron (Jun 22, 2010)

Mine has always been a $ amount (Per Calendar year or per 12 months, can't remember).

Basically, claim up to the max amount on your own, then submit the uninsured amount to your spouse's plan. Simple as that.

So if you both have $400, claim the $400 on your own, and the balance to your spouse's plan (once yours has gone through)


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## joncnca (Jul 12, 2009)

Xoron said:


> Mine has always been a $ amount (Per Calendar year or per 12 months, can't remember).
> 
> Basically, claim up to the max amount on your own, then submit the uninsured amount to your spouse's plan. Simple as that.
> 
> So if you both have $400, claim the $400 on your own, and the balance to your spouse's plan (once yours has gone through)


thanks, xoron. i appreciate your continued help.


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## cedebe (Feb 1, 2012)

I haven't coordinated benefits with a spouse's plan, but I have coordinated benefits from work with benefits from school. Be careful if the insurance companies are the same for both benefits providers... Pacific Blue Cross (PBC), for example, doesn't care how many plans you may have with them... they'll only cover up to their 'reasonable and customary limits.' For paramedical services, for example, you can have two plans that seem to cover a total of $130 per massage, but since PBC's reasonable and customary limit for a massage is $105, they will only reimburse up to this amount. Hope this makes sense...


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## Cal (Jun 17, 2009)

joncnca said:


> if my wife pays, for example, $50 in premiums every month for $400 of coverage every 2 years, and i pay, for example, $50 in premiums every month for $300 coverage every 2 years, and we are paying these premiums for family coverage (i.e. if we were single with no dependents, each person would only pay let's say $30 in premiums), why shouldn't we be eligible for the total of $700 every 2 years? that only makes sense. otherwise, the insurance companies collect $50 per month from me, $50 per month from my wife, and each of us only receives only $300 or $400 coverage. seems more like the insurance companies are trying to pull a "fast one" on me!
> 
> when we changed our benefits coverage from single to family, each of us had to pay more in premiums. i presume that is because the benefits then needed to cover more than just the one person.
> 
> ...


Yes, you have the math correct, but my guess is they have a clause in the booklet stating something along the lines of 1 pair of glasses every x number of months. Remember the insurance company is trying to make a profit, regardless of your health care needs.

It is in your best interests to read and understand your coverage, otherwise you are financially responsible for anything not covered. If you need clarification, give them a call, after being on hold, someone will eventually clarify your coverage details for you.

Also note, that regardless of how long you have had coverage, if you do not use your insurance, the coverage does not carry forward.


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## the-royal-mail (Dec 11, 2009)

Hi Jon,

I think you're probably getting some useful feedback in the thread but the reason I suggested you contact the provider directly is because every plan has different rules. Many of us have experience with this in some form or other but it may have been at a different provider at a different time. The experience I have which is most relevant to your situation is in speaking with the provider. I have called them a few times through the years with questions like this and contrary to your statement that "the insurance company has an incentive to withhold clear information from me, in that they would rather i use less than the amount for which i am eligible", the people who answer the phone are almost always very helpful. I have never once had my calls answered by someone attempting to withhold this type of information from me. All have been forthright, clear and extremely helpful with the info. And because your questions seem to be so specific, at the risk of frustrating you (which is not my intention at all) that is why I feel they are the best ones you help you sort this out. I hope you can connect with them soon.


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## Toronto.gal (Jan 8, 2010)

joncnca said:


> 1. i spent several hundred dollars on a prescription and a set of *glasses that simply are not working.*
> 2. the *insurance company has an incentive to withhold clear information* from me
> 3. when we changed our benefits coverage from single to family, each of us had to pay more in premiums. *i presume that is because the benefits then needed to cover more than just the one person*.
> 4. if my wife/i pay for example, $50 in premiums every month for $400 of coverage every 2 years, *why shouldn't we be eligible for the total of $700 every 2 years? *
> ...


*1.* I can understand your frustration now, but your anger should not be directed at the insurance company, nor should they be penalized, ie: submit a 2nd claim, and just because of alleged errors by the optometrist/optical store. If they gave you glasses that are not working, you should demand that they give you a replacement or reimburse your expenses.

*2.* No, this isn't true, if you call them, they will answer your questions; in this case, a simple one about the limitations of your visioncare benefits, not a more complex out-of-country claim. 

*3.* You don't seem to fully understand how COB's are calculated; it was explained in the link I posted upthread, pg.8. 

*4.* You pay a single [one] family health premium that covers many services, such as drugs, paramedical, vision, OOC, etc.; surely you would not pay $1,200 premiums just yourself [$50x24 months] for just glasses, and only to receive a benefit maximum of $300/$700 per 24 months. :rolleyes2: 

Insurance is there to use it when you need it, not to use it just because there are unused amounts. Do you take sick days when you're not sick? Do you go to the dentist when you don't need to just because you may have an unused $2K? Would you volunteer for a root canal or two, to use that max.? :biggrin: Do you go to the doctor when you're not sick? Also, doesn't your employer contribute to your premiums as well? 

*5.* Yes, that's what you need to do, check all the inside limitations, exclusions, etc. You might also want to look into what type of replacement coverage you have [if any], for damaged glasses [you say it's nothing you did, but are you sure?]. If both plans cover just 1 pair in that 24 month period, then a 2nd one would not be eligible, even when you did not use the full amount with the 1st pair. If there are no such limitations, the claim will be paid as described on pg.8 of the link I posted.

That max. of $300 & $400, is typically to allow 1 pair of glasses for the 12/24 month period, and the reason for that is to avoid abuse/fraud; if you had a $1,000 maximum, you might be buying 2 or 3 pairs; one for the car, office, etc. You're not abusing here, but are punishing the insurance company for someone else's error.


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## Toronto.gal (Jan 8, 2010)

cedebe said:


> Be careful if the insurance companies are the same for both benefits providers......


Careful? So what should he do? :biggrin:


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## Four Pillars (Apr 5, 2009)

I would suggest just putting the claims in and see what happens.


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## cedebe (Feb 1, 2012)

Toronto.gal said:


> Careful? So what should he do? :biggrin:


I'm not getting your humour... I've only been up for 20 minutes so maybe that's the reason.  I mean careful in the sense that he'd best check in advance that both companies will coordinate smoothly so as not to be stuck out of pocket for expenses he thought would be shared between the two plans. 

FWIW, I currently have extended health insurance with two different insurance providers. Neither limits eyewear by 'pair,' but by dollar amount. If someone has $500 worth of coverage and his/her glasses only cost $250, I see nothing wrong with applying the balance to another pair. Different activities have different needs...


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## Toronto.gal (Jan 8, 2010)

cedebe said:


> 1. I'm not getting your humour...
> 2. Neither limits eyewear by 'pair,' but by dollar amount. If someone has $500 worth of coverage....


*1.* Few do cedebe, so no worries. I understood what you meant & was just teasing.

*2.* That's just it though, the $ limit is typically low [or shall we say that glasses are expensive to begin with], so if the max. is $300/$400, that max. is pretty much limiting it to 1 pair for someone that has no COB, even without including any glass limit.


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## cedebe (Feb 1, 2012)

Toronto.gal said:


> *1.* Few do cedebe, so no worries. I understood what you meant & was just teasing.
> 
> *2.* That's just it though, the $ limit is typically low [or shall we say that glasses are expensive to begin with], so if the max. is $300/$400, that max. is pretty much limiting it to 1 pair for someone that has no COB, even without including any glass limit.


I agree, it is low, especially for those needing progressive lenses and such. Earlier in the thread, I think, people were making references to more than one pair which is why I made the comment I made. 

On a related note, dental insurance is the real travesty, IMO. People need decent/full coverage for high-priced procedures like root canals and implants, not run-of-the-mill treatments like check-ups and scalings. Make everyone with insurance pay for the small things so the big things are better covered... /rant


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## Toronto.gal (Jan 8, 2010)

cedebe said:


> 1. people were making references to more than one pair...
> 2. People need decent/full coverage for high-priced procedures like root canals and implants, not run-of-the-mill treatments like check-ups and scalings.
> 3. Make everyone with insurance pay for the small things so the big things are better covered... /rant


*1.* I made such reference also, because some plans do indicate the wording '1 pair' per person per X period. The thing is that one should read/understand the policy details in full, & not assume anything; just ask when in doubt, as there are inside limits, exclusions & not just $ limits with certain benefits; and the reason of course, has to do with over-utilization, and yes, this can happen with dental benefits as well, ie: some may like cleaning every 3 months, especially those allergic to flossing, but not to prophylaxis. 

*2.* Most people don't routinely need such services; I have had 1 root canal in my life, and the rest have been cleaning/fillings covered at 100%, as these fall under basic. Even root canal falls under basic services under some plans.

*3.* Don't think that most people would like to pay for those ''run-of-the-mill treatments", especially those with children. A family of 4 would easily pay $1.5K for 2 cleanings per year; double for a single filling.

Preventive care, ie: basic dental care, is important, though there is no escaping wear & tear, which eventually would take you to the major restorative services.

But I agree that dentists are expensive.


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## joncnca (Jul 12, 2009)

thanks, everyone, for your kind responses =)

i'll work it out with the insurance company. 

my intention is not to take out my frustration with the optometrist/optician on the insurance company, rather to accurately determine exactly what it is i'm eligible for, and to use it.

Toronto.gal: i know i didn't 'damage' the glasses because it's the prescription that's wrong. it's not physical damage, the prescription was too strong, so the curvature of the lens was made in such as way that did not accurately correct my myopia. i don't have a knife sharp enough to botch up changing the prescription myself

also, my example with the $50 in premiums was just my estimate of what i'd pay for glasses, which is $50x24=1200. in fact it was just a random number that i took out of the air for illustration purposes. in fact, my wife and i both pay something like $350 per month for extended health (including glasses ever 24 months), so that's like $4200 per person for insurance coverage that's deducted from pay....i know that we don't spend each spend $4200 on claims...i know the idea of insurance is that most people won't use all their eligible amount, but someone give me a break here =) 

i'm just trying to get ONE pair of glasses that i can use out of this whole thing here, someone can relate to my feelings here, right?


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## Toronto.gal (Jan 8, 2010)

joncnca said:


> 1. my intention is not to take out my frustration with the optometrist/optician.......
> 2. didn't 'damage' the glasses...
> 3. my wife and i both pay something like $350 per month for extended health (including glasses ever 24 months), so that's like $4200 per person ...


*1.* And why not Joncnca? They got paid, didn't they? And what did you get in return? I would not give up that easily, that's for sure, but thankfully I have a wonderful optometrist.

*2.* I didn't know the specific problem before, so I thought I would mention it just in case you would be eligible for replacement coverage.

*3.* Does extended health include dental benefits as well? Even so, those premiums are quite high. 

I would suggest you review your situation, and since you both work & have benefits, determine whether you both require family coverage. 

For example, if it's just you and your wife, and one of you has good coverage, maybe just one should select family coverage, or maybe both single, if the coverage is good & savings would be substantial enough. Review your coverage in full, and know what you're paying for, because you're paying a lot!

Good luck.


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## the-royal-mail (Dec 11, 2009)

Glad to hear you'll be talking to the ins co. However, if you are not satisfied with your glasses you should def tell either the opto or the optician. Also, if you're not using as much of the ins money as you are paying in premiums, why pay it? Where's the value?


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