Coordination of Benefits
Members
of a family are often covered by more than one group health insurance plan. As
a result, two or more plans are paying for the same expense. To avoid this
costly problem, your health plan provides a Coordination of Benefits
("COB") provision.
When dual coverage exits, the following rules shall apply for
determining how benefits will be coordinated between this Plan and another
plan:
1. A member will be primarily
covered for benefits under the DC 37 Health and Security Plan.
2. A member's spouse will be
primarily covered for benefits under the spouse's separate plan.
3. A member's dependent child will
be primarily covered for benefits under the plan which covers the parent whose
birthday occurs first in the year.
4. When both parents
are covered by the DC 37 Health and Security Plan, the children will be covered
by the Plan of the parent whose cover age is more comprehensive, and each
member will be covered only through his/her membership.
When dual coverage exits, the following rules of
payment shall apply:
1. When this Plan provides primary
coverage to the member and eligible dependents, the Plan will pay full
benefits, up to the Plan's maximum coverage.
2. When the Plan provides
secondary coverage to an eligible dependent, the Plan will pay the difference
between the dependents' out-of-pocket expense or the usual customary cost for
the covered treatment, service or Prescription Drugs, whichever is lower, and
the amount of reimbursement or payment received by or on behalf of the eligible
dependent from the other plan.
Reimbursement
under the Prescription Drug Benefit, regardless of whether the Plan is the
primary or secondary carrier, will not exceed the Plan's allowance of a
prescription Drug, minus the co-payment, or the actual out-of-pocket cost of
the prescription Drug, whichever is lower. If the primary carrier has paid less
than the Plan's allowance, the Plan will pay the difference, but no additional
payments will be made by the Plan if the primary carrier has reimbursed up to
the Plan's allowance.
In
order to consider payment of any benefits because of the negligence or other
wrongdoing of a party, and you sue that party for hospital bills, medical
bills, prescription drug bills, loss of earnings, etc., then you must sign an
assignment in favor of the Plan, as a condition of receiving your benefits, so
that the Plan may be reimbursed in full in the event you obtain a recovery
against that party.
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