How We Calculate Benefits Under These Rules Clause Samples
This clause defines the method and criteria used to determine the amount and eligibility of benefits provided under the agreement or policy. It typically outlines the formulas, factors, or conditions that are considered when calculating benefits, such as length of service, salary, or specific qualifying events. By clearly specifying the calculation process, this clause ensures transparency and consistency, helping to prevent disputes and misunderstandings regarding benefit entitlements.
How We Calculate Benefits Under These Rules. When this plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all plans are not more than the total allowable expenses. In determining the amount to be paid for any claim, the secondary plan will calculate the benefits it would have paid in the absence of other healthcare coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other healthcare coverage.