Common use of Order of Benefit Determination Clause in Contracts

Order of Benefit Determination. When a person who received care is covered as an employee under one group Contract, and as a Dependent under another, then the employee coverage pays first. – When a Dependent child is covered under two group contracts, the Contract covering the child as a Dependent of the parent whose birthday falls earliest in the Calendar Year pays first. (If one Contract does not follow the “birthday rule” provision, then the rule followed by that Contract is used to determine the order of benefits.) However, when the Dependent child’s parents are separated or divorced, the following rules apply: o If the parent with custody of the child has not remarried, the coverage of the parent with custody pays first. o When a divorced parent with custody has remarried, the coverage of the parent with custody pays first and the stepparent’s coverage pays second before the coverage of the parent who does not have custody. o Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child’s health care expenses, the coverage of that parent pays first. – When none of the above circumstances applies, the coverage you have had for the longest time pays first, except that a Contract which covers you as a laid-off or retired employee or as a Dependent of such person pays after a Contract which covers you as other than a laid-off or retired employee or Dependent of such person. – When the Plan requests information from another carrier to determine the extent or order of your benefits under an Other Contract, and such information is not furnished after a reasonable time, then the Plan shall: o Assume the Other Contract is required to determine its benefits first; o Assume the benefits of the Other Contract are identical to the Benefits of this coverage and pay its Benefits accordingly. Once the Plan receives the necessary information to determine your benefits under the Other Contract and to establish the order of the benefit determination under the rules listed above, prior payments under this coverage will be adjusted accordingly (if the above rules require it). – If the other carrier reduces your benefits because of payment you received under this coverage and the above rules do not allow such reduction, then the Plan will advance the remainder of its full Benefits under this coverage as if your Benefits had been determined in absence of an Other Contract. However, the Plan shall be subrogated to all of your rights under the Other Contract. You must furnish all information reasonably required by the Plan in such event, and you must cooperate and assist the Plan in recovery of such sums from the other carrier. – If the other carrier later provides benefits to you for which the Plan has made payments or advances under this Coordination of Benefits provision, you must hold all such payments in trust for the Plan and must pay such amount to the Plan upon receipt.