What is Coordination of Benefits?

Coordination of Benefits means that Manulife Financial will take into account coverage under a spousal benefits plan when determining the amount of expenses payable under the ELCIC Group Benefits Plan. This process allows for reimbursement of insured medical and dental expenses from all plans up to a total of 100% of the actual expense incurred.

The “Primary Carrier” is responsible for making the initial payment towards the eligible expense and the “Secondary Carrier” is responsible for making the payment to cover the remaining eligible expense. The Primary Carrier makes the payment for their own member first, then the any remaining balance must be submitted to the Secondary Carrier. Where both Spouses have a plan, the Primary Carrier for their Dependent Children is the Spouse with the first birthday in a calendar year.

Submitting a Claim

When submitting claims where Coordination of Benefits applies, please refer to these guidelines:

  • determine which Plan is the Primary Carrier and the Secondary Carrier;
  • submit all necessary claim forms and original receipts to the Primary Carrier;
  • keep a photocopy of each receipt or ask the Primary Carrier to return the original receipts to you once your claim has been settled;
  • once the Primary Carrier has settled your claim, you will receive a statement outlining how your claim has been handled. Submit this statement along with all necessary claim forms and receipts to the Secondary Carrier for further consideration of payment, if applicable.

Definition for Coordination of Benefits Section

Plan means:

  • other group benefit programs;
  • any other arrangement of coverage for individuals in a group;
  • and individual travel insurance plans.

Plan does not include school insurance or Provincial Plans.

Notes

Other Plan does not have Coordination of Benefits

If the other Plan does not provide for Coordination of Benefits, it will be considered as the Primary Carrier, and will be responsible for making the initial payment toward the eligible expense.

Dependent Child(ren) of separated or divorced parents

If you and your Spouse are separated or divorced, the following order applies:

  • the Plan of the parent with custody of the child;
  • then the Plan of the Spouse of the parent with custody of the child (i.e., if the parent with custody of the child remarries or has a common-law Spouse, the new Spouse’s Plan will pay benefits for the Dependent Child);
  • then the Plan of the parent not having custody of the child;
  • then the Plan of the Spouse of the parent not having custody of the child (i.e., if the parent without custody of the child remarries or has a common-law Spouse, the new Spouse’s Plan will pay benefits for the Dependent Child).

Where you and your Spouse share joint custody of the child, the Plan covering the parent whose birthday (month/day) is earlier in the calendar year pays benefits first. If both parents have the same birth date, the Plan covering the parent whose first name begins with the earlier letter in the alphabet pays first.

Additional Rules

If the order of benefit payment cannot be determined from the above, the benefits payable under each Plan will be in proportion to the amount that would have been payable if Co-ordination of Benefits did not exist.

If the insured person is also covered under an individual travel insurance plan, benefits will be co-coordinated in accordance with the guidelines provided by the Canadian Life and Health Insurance Association.