Longer/Shorter Length of Coverage Clause Samples

Longer/Shorter Length of Coverage. If none of the above rules determine the order of benefits, the benefits of the plan which covered a member or subscriber longer are determined before those of the plan which covered that person for the shorter term. In general, if you use more benefits than you are covered for during a benefit period, the following formula is used to determine coverage: The insurer covering you first will cover you up to its allowance. Then, the other insurer will cover any allowable benefits you use over that amount. It will never be more than the total amount of coverage that would have been provided if benefits were not coordinated. Maximum benefits paid by primary insurer + Any remaining allowable expense to be paid by secondary insurer

Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the Plan that covered the person for a longer period of time is primary to the Plan which covered that person for the shorter time period. Two consecutive Plans shall be treated as one Plan if: 1. That person was eligible under the second Plan within 24 hours after the termination of the first Plan; and 2. There was a change in the amount or scope of a Plan's benefits or there was a change in the entity paying, providing or administering Plan benefits; or 3. There was a change from one type of Plan to another (e.g., single employer to multiple employer Plan).

Longer/Shorter Length of Coverage. The plan that covered you as an employee, member, subscriber or retiree longer is primary. Note: Under this contract, PIC will not pay more than it would pay as the primary plan. The Effect of the Benefits of this Plan: When this plan is secondary, it may reduce its benefits at the time of processing, so that the total benefits paid or provided by all plans for each claim are not more than 100% of total allowable expenses for such claim. The reduction in this plan’s benefits is equal to the difference between: 1. The benefit payments that this plan would have paid had it been the primary plan; and 2. The benefit payments that this plan actually paid or provided. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion to any applicable limit, such as the deductible of this plan.

Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the Plan that has covered a Subscriber longer is Primary to the Plan which has covered the Subscriber for the shorter time. Effect of COB on the Benefits of this Plan When Health Plan is the Primary Plan, COB has no effect on the benefits or services provided under this Agreement. When Health Plan is a Secondary Plan as to one or more other Plans, its benefits may be coordinated with the Primary Plan carrier using the guidelines below. COB shall in no way restrict or impede the rendering of services provided by Health Plan. At the Member’s request, Health Plan will provider or arrange for covered services and then seek coordination with a Primary Plan. 1. Coordination with This Plan's Benefits. Health Plan may coordinate benefits payable or may recover the reasonable cash value of services it has provided when the sum of: a. The benefits that would be payable for, or the reasonable cash value of, the services provided as Allowable Expenses by Health Plan in the absence of this COB provision; and b. The benefits that would be payable for Allowable Expenses under one or more of the other Plans, in the absence of provisions with a purpose like that of this COB provision, whether or not a claim thereon is made; exceeds Allowable Expenses in a Claim Determination Period. In that case, the Health Plan benefits will be coordinated, or the reasonable cash value of any services provided by Health Plan may be recovered, from the Primary Plan, so that they and the benefits payable under the other Plans do not total more than the Allowable Expenses.

Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan that covered an employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time. If a covered person is entitled to coverage under a group health care plan which primarily covers services or expenses other than dental care, and if the covered person first became eligible under the Plans on the same date, this Plan shall be the secondary payor for those services covered by both Plans.

Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the Program which covered a Member longer is Primary to the Program which covered that Member for a shorter time.

Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan that covered an employee or member longer are determined before those of the Plan which covered that person for the shorter time. If a Covered Person is entitled to coverage under a group health care plan which primarily covers services or expenses other than dental care, and if the Covered Person first became eligible under the Plans on the same date, this Plan shall be the secondary payor for those services covered by both Plans. Effect on the Benefits of This Plan 1) In accordance with order of benefit determination rules, this plan is a secondary plan as to one or more other plans. In that event, benefits of this plan may be reduced under this paragraph so that the total benefits paid or provided by all plans during a claim determination period are not more than the total allowable expenses. 2) Reduction in this plan’s benefits. The benefits that would be payable under this plan in the absence of this COB provision will be reduced by the benefits payable for the total allowable Expenses in a claim determination period under the other plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made. When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an expense incurred and a benefit payable. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan. 3) No rule in other plan. If the other plan does not have rules coordinating benefits with those of this plan, the benefits of the other plan are determined first. Right to receive and release needed information Delta Dental has the right to decide the facts it needs to apply these rules. Delta Dental may get needed facts from or give them to any other organization or person without the consent of the insured but only as needed to apply coordination of benefits rules. Medical and dental records remain confidential as provided by applicable state and federal law. Each person claiming benefits under this plan must give Delta Dental any facts it needs to process the claim. Right of recovery If the amount of the payments made by Delta Dental is more than it should have paid under coordination of benefits, it may recover the excess, at its option, from one or more of: (1) the persons it has pa...