Guideline G4

COORDINATION OF BENEFITS
This Guideline has been approved by CLHIA's Board of Directors. All member companies are expected
to comply with the CLHIA Guidelines. Companies are urged to bring Guidelines to the attention of their
Board of Directors or the Board Committee responsible for the company's compliance program with a
view to incorporating the Guidelines into the company's ongoing compliance program.

INTRODUCTION
The Coordination of Benefits Guidelines were developed for insurers to ensure
consistency within the industry in situations where a person can submit a claim to more
than one group plan. They are divided into two parts: Part A: Group Dental and Health
Benefits; and Part B: Out-of-Country/Province Health Care Expenses.

PART A: GROUP DENTAL AND HEALTH BENEFITS

1

PURPOSE

These Guidelines describe how to coordinate either dental or healthcare payments from
all group plans under which a person is covered, so that total payments do not exceed
total eligible expenses.
Plan is defined as group insurance or any other arrangement of coverage for
individuals in a group, whether on an insured or an uninsured basis, including any
prepayment coverage or capitation plan, as long as the group is not formed solely for
the purpose of obtaining insurance. This definition of plan does not include school
insurance or individual travel insurance.
2

ELIGIBLE EXPENSES

Payment on a particular claim cannot exceed 100% of the eligible expenses. Eligible
expenses are as defined in each carriers contract/plan document before payment
limitations like the deductible, co-insurance, lagging fee guides and/or maximums are
applied. In the case of dental, 100% of eligible expenses will be the appropriate
general practitioners or specialists current fee guide.
Each carrier adjudicates the claim taking into account reasonable and customary
charges, maximums and contractual fee guide limits in the normal fashion.
3

HOW DO THE PLANS COORDINATE BENEFITS?

The plan that determines benefits first (primary carrier) will calculate its benefits as
though duplicate coverage does not exist.

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The plan that determines benefits second (secondary carrier) limits its benefits to the
lesser of:
(i)

The amount that would have been payable had it been the primary carrier, or|

(ii)

100% of all eligible expenses reduced by all other benefits payable for the same
expenses by the primary plan.

This means that an individual may receive reimbursement for up to 100% of the eligible
expenses.
(Examples for dental and health claims are included in Appendix A for clarification.)

ORDER OF BENEFIT DETERMINATION

(1)

The plan with no Coordination of Benefits provision in the contract or plan

document determines benefits first.

(2)

If the other plan(s) has a Coordination of Benefits provision, priority goes to the
plan in the following order:
Employees/members
(i)

The plan where the person is covered as a member.

(ii)

If a person is a member of two plans, priority goes to:

(a)

the plan where the member is an active full-time employee,

(b)

the plan where the member is an active part-time employee,

(c)

the plan where the member is a retiree.

Dependents
Spouse

(iii)

The plan where the person is covered as a dependent spouse.

Dependent Children

(iv)

The plan of the parent with the earlier birth date (month/day) in the
calendar year.

(v)

The plan of the parent whose first name begins with the earlier letter in
the alphabet, if the parents have the same birth date.

(vi)

In situations where parents are separated/divorced, then the following

order applies:
(a)

the plan of the parent with custody of the child,

(b)

the plan of the spouse of the parent with custody of the child,

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(c)

the plan of the parent not having custody of the child,

(d)

the plan of the spouse to the parent in iii) above.

Dental Accidents
For dental accidents, health plans with dental accident coverage determine
benefits before dental plans.
Other Situations
If priority cannot be established in the above manner, the benefits will be prorated in proportion to the amounts that would have been paid had there been
coverage by just that plan.
5

ADMINISTRATIVE PROCEDURES

The primary carrier will provide the claimant with a complete explanation of benefits
(EOB) with service details, charges and amounts paid for the second carriers
assessment. The second carrier will not require the original claim form if a copy is
provided.
It is the claimants responsibility to retain a copy of the original claim form to apply for
the coordination of benefits provision.
It is up to the discretion of each carrier to adjust overpayments made by the first
payor.
6

COORDINATION OF BENEFITS WITH CAPITATION OR PREPAID DENTAL

PLANS

The coordination of benefits between capitation and fee-for-service dental plans shall be
determined in the same manner as between fee-for-service plans.
The order of benefit determination (OBD) remains unchanged and the primary and
secondary carriers are determined by applying the OBD rules already outlined in the
CLHIA Guidelines.
If a person with dual insurance coverage is insured under a capitation plan and is
treated by a dentist who is a member under that plan, priority is established by
following the order of benefit determination.
When one of the dental plans is a capitation or prepaid dental plan, all insured
individuals must attend the participating dental offices in order to be entitled to the
Coordination of Benefits provisions.
If the insured individual attends a nonparticipating dental office, there will be no coordination of benefits with the capitation
plan since the capitation plan would not reimburse the fee-for-service carrier or the
insured for any expenses incurred. This is considered a fundamental principle of
capitation plans.
Capitation companies audit the dental services provided by their practitioners and they
consider the COB payment as part of the dentists payment when they establish the
capitation fee.
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When the capitation plan is primary, the dentist may collect the co-payment from the
secondary plan by assignment or directly from the patient.
When the capitation plan is secondary, the dentist should receive the payments from
the primary plan, but the dentist must waive the patients capitation plan co-payment.
(If the primary plan pays less than the co-payment, the patient will be required to pay
the difference.)

PART B: OUT-OF-COUNTRY/PROVINCIAL HEALTH CARE EXPENSES

1

PURPOSE

These Guidelines for insurers have been developed to encourage consistency within the
industry in claim situations where a person has travel health insurance coverage from
more than one policy (for example, from employment-related group insurance
contracts, individual or group travel or health policies, credit cared coverages or any
other private insurance sources).
It is necessary to establish guidelines since many contracts for these benefits contain a
provision that indicates that they will be last payor after claim payment has been made
under all other contracts, and often it is not readily apparent which contract should pay
first.
These Guidelines describe how to coordinate the payments from all such policies under
which an individual is covered, so that the total payments from all policies do not
exceed the total expenses incurred or, in the case of cash policies, do not encourage
multiple purchases. The intent is to establish a streamlined adjudication process that
allows for effective claim management; minimizes claim assessment and payment
delays; provides the greatest assistance to the insured in resolving the claim;
maximizes cost containment for all carriers sharing the liability; fairly coordinates
benefits among all policies involved; and discourages and identifies duplicate or
fraudulent claim submissions.
2

SCOPE

These Guidelines will apply to all contracts that provide travel health insurance
coverage. Contract wording should indicate that coverage will be coordinated with other
policies according to these Guidelines.
These Guidelines apply to expenses resulting from emergency or elective health care
provided outside Canada or outside the province of residence in excess of the provincial
health plan coverages. These benefits are generally referred to as travel health
insurance
and
can
include
coverage
for
the
following
expenses:

medical/surgical procedures
other physicians' services
confinement and hospital charges
repatriation costs including air ambulance and medical attendants
prescription drugs, para-medical services, etc.

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With respect to such expenses, these Guidelines also apply to reimbursement-type

hospital cash policies, and any other ancillary benefits which may be duplicated by
other coverages.
3

EXCEPTION FOR EMPLOYMENT-RELATED GROUP COVERAGE FOR

RETIREES WITH LIMITED LIFETIME MAXIMUMS

Retired employees may have extended health coverage through former employers
based on a lifetime maximum for all benefits, including both in-country and
out-of-country extended health coverage.
In order to avoid eroding those lifetime benefits, these guidelines make a provision not
to coordinate with such coverages, if the lifetime maximum is $50,000 or less. In these
cases, a retiree may use alternate coverage purchased through individual or group
travel health insurance products to cover out-of-country expenses. If the individual has
used up alternate coverage sources, the group retiree coverage will be responsible for
any remaining expenses covered under its contract.
If the lifetime maximum for all in-country and out-of-country benefits is greater than
$50,000, full coordination will take place above this amount as outlined in these
Guidelines.
4

DETERMINATION OF UNITS OF COORDINATION

Except as noted below, each coverage, whether purchased as an individual, through a

group, credit card, tour operator, travel wholesaler or financial institution is considered
as a separate unit of coordination for the purposes of these Guidelines.
Exception: When an individual is covered as a member or as a dependent under one or
more employment-related group plans1 to which Part A of these Guidelines (Group
Dental and Health Benefits) apply, all such group plan coverages will be combined and
considered a single unit of coordination. Part B of the Guidelines will be followed to
determine the liability for that unit, and Part A will then be applied to allocate liabilities
within that unit, if necessary.
Refer to Appendix B for examples.
5

DETERMINATION OF THE FIRST CARRIER

The carrier that is first contacted for the purposes of claimant contact, or to whom the
claim is initially submitted by the insured, is considered to be the First Carrier for the
purposes of these Guidelines.

In these Guidelines, plan is defined as group insurance or any other arrangement of coverage
for individuals in a group, whether on an insured or an uninsured basis, including any
prepayment coverage or capitation plan, as long as the group is not formed solely for the
purpose of insurance. This definition of plan does not include school insurance or individual
travel insurance.
For the purposes of coordinating Out-of-Country/Province Health Care Expenses, that definition is
interpreted as including any plan covering extended health benefits as a whole (not travel health
coverage only), that is offered to employees/retirees as a group and is sponsored by an
employer/union/recognized professional association or by a multi-employer association.
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Any other carrier that shares a liability for the claim is defined as an Other Carrier. If
there are more than two policies, there can be two or more Other Carriers.
An insurer cannot systematically or otherwise deflect calls by referring them to another
carrier to avoid becoming the First Carrier. If a carrier feels that its claim assistance
services are not adequate, this matter should be negotiated with the Other Carrier.
6

THE RESPONSIBILITY OF THE FIRST CARRIER

The First Carrier will take the initiative in the case management and claims
assessment and will pay the claim first, according to the terms; and conditions of its
contract, and reserving all rights to recovery from the Other Carrier(s) and from
provincial health plans. (The First Carrier is never expected to pay more than the
liability under its contract). Wherever possible, the rights to recovery should be made
transparent to the claimant so the individual is aware that the insurance carriers will
coordinate payment of the claim.
Case management includes, but is not limited to: taking the initiative to involve an
assistance group or service provider, choosing a preferred provider organization,
monitoring to ensure appropriate medical care and/or repatriation.
7

NOTIFICATION OF OTHER CARRIER(S)

The First Carrier must establish whether an Other Carrier exists as quickly as
possible, and must notify each identified carrier. Notification for all in-patient
hospitalizations must occur immediately. For all other claims, notification shall be as
soon as possible.
Prompt notification to all Other Carriers involved in the claim is critical to the effective
coordination of coverages. The initial notification will be a phone call to the Other
Carrier(s) followed by written notification sent within 48 hours.
The initial notification will include all relevant available information2, including for
example (but not limited to):

Name of Individual
Age
Individual or Group Policy Number
Social Insurance Number or Certificate Number
Detailed Diagnosis
Date of Hospital Admission
Name and Location of Hospital
Medical Treatments Provided to Date
Costs Incurred to Date
Departure Date
Government Health Insurance Plan (GHIP) Number

It is important to note that notification by the claimant to the First Carrier is deemed
notification to all Other Carriers that are known and identified at the time and will
serve as notification to those carriers.

Personal information held by one carrier cannot be communicated to another carrier without the consent of the
person concerned. The First Carrier should seek such consent on its claim form or other initial contact.

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CONSULTATIONS/SECOND OPINIONS

In assessing significant or difficult claims, or if the First Carrier does not have
adequate preferred provider or travel assistance arrangements, the First Carrier may
contact the Other Carrier sharing in the claim liability to request assistance, to discuss
the claim or, to ask for a second opinion.
9

OTHER CARRIER'S INVOLVEMENT

Upon receipt of notification, the Other Carrier(s) may offer to provide consultation on
case management to the First Carrier and may provide cost containment options.
Consultation may include but not be limited to the involvement of an assistance group
or service provider, the choice of a preferred provider organization, monitoring to
ensure appropriate medical care and/or repatriation.
Ultimate decisions for the case management remain the responsibility of the First
Carrier.
10

TRANSFER OF RESPONSIBILITY BY MUTUAL AGREEMENT

An Other Carrier may take on the responsibility of First Carrier if there is mutual
agreement between the carriers to do so. This would be particularly appropriate if the
First Carrier recognizes that its liability for the claim is limited (for example, if the First
Carrier's liability will be $10,000 and the claim is expected to be $50,000 or more).
11

IF THE FIRST CARRIER HAS NO LIABILITY

If the First Carrier has no liability for the claim (for example, if a pre-existing
condition has been clearly established), the First Carrier's responsibility ceases once it
determines it has no liability for the claim and has informed the insured. When this
occurs, the First Carrier will instruct the insured to contact the Other Carrier, if any,
to pursue the claim. To speed up the adjudication process, the First Carrier will still
provide notification to any Other Carrier known at that time, as outlined above.
12

RECOVERY

The process of recovery will take place after the First Carrier has made its assessment
and paid the claim in accordance with its contractual liability. [Recovery between
carriers is net of provincial government health insurance plans (GHIP)
reimbursements.] Copies of the claim documents will then be sent to each of the Other
Carriers involved.
Each carrier receiving the claim documents will assess the claim independently based
on the terms of its own contract, and will identify in a detailed fashion what its payment
would have been if that was the only coverage for this claim. This information will then
be sent back to the First Carrier.
Once all of these responses have been received by the First Carrier, it will determine
the Other Carriers' portion of liability for the claim and it will have the right to recover
from the Other Carrier(s) by using the following rules:

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(1)

Mutually covered expenses3 will be shared equally among all units.

(2)

Deductibles will consistently be applied to the largest common expense item.

Each Carrier will reimburse the First Carrier for its share of the payment already
made, and will pay the providers or the insured directly for any remaining expenses for
which it has liability. Refer to examples in Appendix B.
Payments and reimbursements will be made as soon as possible.
If the First Carrier has identified the involvement of only one Other Carrier, the
Other Carrier will be informed of this so it can complete the calculations and send its
payment directly to the First Carrier, reducing the need for further correspondence
between the carriers.
13

ADJUSTMENTS

Adjustments will be made if GHIP settlements are subsequently adjusted, additional

items are submitted or an additional carrier is identified.
14

ORIGINAL CLAIM DOCUMENTS

The First Carrier will indicate to the Other Carrier(s) where the original documents
are retained.
15

DISPUTE RESOLUTIONS

The parties may agree that binding arbitration by an independent review committee,
mutually agreed upon by the parties involved, will be used to settle any disputes.

Part A revised November 1990

Part B adopted December 1994

In addition to the actual health care expenses incurred, the following allocated expenses paid during the claim
adjudication process can also be coordinated:
Fees charged by a preferred provider organization (PPO), usually as a percentage of savings, to obtain a
reduction in charges by hospitals, physicians, etc.
Medical reports obtained from hospitals and doctors.
Repatriation as a cost saving measure.
Other appropriate expenses incurred for the purposes of significant cost saving such as outside investigation
expenses, utilization reviews or audit fees, legal fees, etc. should he pre-negotiated between carriers.
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APPENDIX A
COORDINATION OF BENEFIT SAMPLES DENTAL AND HEALTH

INDEX COB Samples

Dental (Samples 1-5) ............................................................................ 10

Drugs (Samples 1-6) ............................................................................ 15

Vision (Samples 1-2) ............................................................................ 19

Hospital (Samples 1-3) ......................................................................... 20

Supplementary (Sample 1) ................................................................... 21

Coordination of Benefits Worksheet ..................................................... 22

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DENTAL

(5 Samples)

DENTAL Sample #1
Expenses eligible under both plans:
Carrier A payment
Plan based on current fee guide.
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89

Procedure
Code
23222
23221
23221
23222

TOTAL
*

Submitted

Eligible

87.00
46.00
40.00
70.00

79.99*
46.00
40.00
70.00

$243.00

$235.99

Payable at
80%
80%
80%
80%

Payment
63.99
36.80
32.00
56.00
$188.79

$7.01 declined as being over the fee guide.

Carrier B payment
Plan based on current fee guide. We would not consider $7.01 as eligible because it is
over the fee guide. However, we would consider the 20% balance on all eligible
expenses.
16.00
9.20
8.00
14.00
$47.20
Since we would have paid $188.79 if we had been the only carrier (assuming 80%
reimbursement), we would pay $47.20 ($235.99 - $188.79).

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DENTAL Sample #2
One of the plans has a contract based on an older fee guide.
Carrier A payment
Plan based on 1989 fee guide.
Date of
Service
1.2.90
1.2.90

Procedure
Code
01103
01242

TOTAL
*

Submitted
73.98
16.53
$90.51

Eligible
69.96*
15.63*

Payable at
100%
100%

$85.59

Payment
69.96
15.63
$85.59

$4.92 declined as being over the 1989 fee guide.

Carrier B payment
Plan based on current fee guide.
Date of
Service
1.2.90
1.2.90

Procedure
Code
01103
01242

TOTAL

Submitted

Eligible

Payable at

73.98
16.53

73.98
16.53

80%
80%

$90.51

$90.51

Payment
59.18
12.50
$71.68

Since the dentist is not charging more than the current appropriate provincial fee guide,
we will pay $4.92 ($90.51 - $85.59).

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DENTAL Sample #3
Both plans cover general practitioners only but work is performed by specialist
(endodontist):
Carrier A payment
Plan based on current GP fee guide.

1.2.90
1.3.90

Procedure
Code

Submitted

Eligible

01205
33101

88.77
295.00

73.98*
246.00*

TOTAL
*

$383.77

Payable at
100%
100%

$320.58

Payment
73.98
246.00
$320.58

$63.19 declined as being over the 1990 GP fee guide.

Carrier B payment
Plan based on current GP fee guide.
Date of
Service
1.2.90
1.3.90

Procedure
Code
01205
33101

Submitted

Eligible

Payable at

Payment

88.77
295.00

73.98*
246.60

80%
80%

59.18
197.28

$383.77
*

$320.58

$256.46

$63.19 declined as being over the 1990 GP guide. Since the dentist has not
overcharged according to the current appropriate (endodontist) fee guide, we will
pay $63.19 ($383.77 - $320.58).

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DENTAL Sample #4
Expenses eligible under other carrier but not under our plan:
Carrier A payment
Plan based on current fee guide.
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89

Procedure
Code
23222
23221
23221
23222

TOTAL

Submitted

Eligible

87.00
46.00
40.00
70.00
$243.00

Payable at

79.99*
46.00
40.00
70.00
$235.99

80%
80%
80%
80%

Payment
63.99
36.80
32.00
56.00
$188.79

Note: * $7.01 declined as being over the fee guide.

Carrier B payment
Plan based on current fee guide.
Procedure code 23222 is not eligible under our plan.
The balance of 23222 should not be considered under our plan.
The balance of 23221 can be considered.
9.20
8.00
$17.20
Since we would have paid $68.80 for these two services if we had been the only carrier
(assuming 80% reimbursement), we would pay $17.20.

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DENTAL Sample #5
Expenses which are not eligible under either plan:
Carrier A payment
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89

Procedure
Code
23222
23221
23221
23222

TOTAL
*

Submitted

Eligible

87.00
46.00
40.00
70.00

0.00*
46.00
40.00
0.00*

$243.00

$86.00

Payable at
80%
80%

Payment
0.00
36.80
32.00
0.00
$68.80

not eligible under plan.

Carrier B payment
We would not consider either 23222 amounts since they are not eligible under our plan.
We would consider the balance of:

9.20
8.00
$17.20

Since we would have paid $68.80 if we had been the only carrier, we would pay $17.20.

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DRUGS

(6 Samples)

DRUGS Sample #1
Carrier A payment

50.00
80%
$40.00

Carrier B payment

50.00
80%
$40.00

submitted
co-insurance
paid

submitted
co-insurance
we would have paid

Since out-of-pocket is less than we would have paid, we pay $10.00.

DRUGS Sample #2
Carrier A payment
Drugs submitted are $2.00; $5.00; $10.00
17.00
80%
$13.60

submitted
co-insurance
paid

Carrier B payment
The $5.00 drug is ineligible with us, so we pay 20% of the eligible drugs only.
17.00
12.00
20%

submitted
eligible
(out-of-pocket)

$2.40

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DRUGS Sample #3
Carrier A payment

50.00
-25.00
80%

submitted
deductible

$20.00

paid

50.00
-50.00

deductible

Out-of-pocket - $30.00.

Carrier B payment
We would have considered:

$0.00
The out-of-pocket is $30.00. (We only pay up to what we would have paid, if we were
the first carrier.)

DRUGS Sample #4
Carrier A
50.00
-50.00
$ 0.00

Carrier B
deductible

50.00
-50.00

deductible

$ 0.00

The deductibles are satisfied under both plans. The out-of-pocket expense is $50.00.

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DRUGS Sample #5
Drugs submitted:
2.00
5.00
10.00
10.00
Carrier A Payment

Carrier B payment

Ineligible with 2nd carrier

27.00
-20.00

deductible

$ 7.00

paid

27.00
- 5.00

ineligible

$22.00
-10.00
80%

deductible

$ 9.60

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DRUGS Sample #6
Drugs submitted:
2.00
5.00
10.00
10.00

Ineligible with 2nd carrier

$27.00
Carrier A payment

27.00
- 7.00

deductible

$20.00
80%
Out-of-pocket $11.00

Carrier B payment

$16.00

27.00
- 5.00

paid

ineligible

$22.00
80%
$17.60
We do not know which expenses were applied towards the deductible by the first
carrier. We would have paid more than the out-of-pocket amount, so we pay all of the
out-of-pocket $11.00.

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VISION

(2 Samples)

VISION Sample #1
Glasses $210.00
Carrier A pays:

150.00
-25.00

deductible

$125.00
80%
Out-of-pocket - $110.00.

Carrier B pays:

B pays

$100.00

150.00 maximum
100%
$110.00

VISION Sample #2
Glasses $240.00
Carrier A pays:

Out-of-pocket - $90.00.

Carrier B pays:

150.00 maximum
100%
$150.00

100.00
-25.00 deductible
$75.00
80%
$60.00

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HOSPITAL

(3 Samples)

HOSPITAL Sample #1
($50.00 SP, $40.00 PR, $90.00 per day private)
Carrier A:

Carrier B:

Covers semi-private at 100%; Private 80%

Paid:
50.00 x 100% = 50.00
40.00 x 80%
= 32.00

Covers semi-private only at 100%

Decline balance for private room coverage.

HOSPITAL Sample #2
(SP $50.00, Private $40.00)
Carrier A:

Carrier B:

Covers semi-private at 80%, no private

Paid: $50.00 SP at 80% = $40.00
$40.00 for private room is declined

Covers semi-private and private

Pays $50.00 ($10.00 for semi-private and $40.00 for private).

HOSPITAL Sample #3
($40.00 SP; Private $30.00)
Carrier A:

Carrier B:

Covers SP + $10.00 per day private

Pays $40.00 SP and $10.00 private = $50.00

Covers $50.00 per day maximum

Pays $20.00 ($70.00 - $50.00)

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SUPPLEMENTARY

(1 Sample)

SUPPLEMENTARY Sample #1
Massage visits - 10 visits at $25.00 each = $250.00
Carrier A pays:

250.00

submitted

200.00
-50.00

maximum eligible
deductible

$150.00
80%
$120.00

paid

Carrier B pays:
Our maximum is $250.00 at 80%.
We pay $130.00 in full.

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COORDINATION OF BENEFITS WORKSHEET

Date of
Service

Procedure/
Service

G4 Coordination of Benefits

Amount
Charged

Payment by
1st Carrier

Balance

2nd Carrier
Could Have
Paid

Amount
Covered

Out-ofPocket

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APPENDIX B
COORDINATION OF BENEFIT SAMPLES: OUT-OF-COUNTRY/
PROVINCIAL HEALTH CARE EXPENSES

Index - Examples of Settlement

Example 1 .......................................................................................................24
Example 2 .......................................................................................................25
Example 3 .......................................................................................................26
Example 4 .......................................................................................................27
Example 5 .......................................................................................................28
Example 6 .......................................................................................................29
Example 7 .......................................................................................................30

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Example 1

ITEM
Hospital Ward
(25 days)
Semi-private excess
Physician
Private Duty Nursing
Repatriation
Accompanying Family Member
TOTAL

Liability if
Carrier 1
alone
($)

Liability if
Carrier 2
alone
($)

Common
Core
($)

50,000

50,000

49,000

49,000

2,000

n/a

2,000

20,000

20,000

20,000

20,000

5,000

n/a

5,000

5,000

5,000

15,000

5,000

15,000

5,000

10,000

15,000

1,000

n/a

1,000

1,000

1,000

93,000

75,000

92,000

Total bill
after GHIP
($)

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

1,000

Total
($)
50,000

2,000

2,000
20,000

74,000

1,000

18,000

93,000

Share of Carrier 1 ($)

37,000

1,000

n/a

38,000

Share of Carrier 2 ($)

37,000

n/a

18,000

55,000

n/a

n/a

n/a

n/a

Share of Insured ($)

Note: Carrier 2 has a $1,000 deductible

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Example 2

ITEM

Total Bill
after
GHIP
($)

Carrier 1
Liability
if alone
($)

Carrier 2
Liability
if alone
($)

Carrier 3
Liability
if alone
($)

Common
Core
($)

Hospital
(140 days)

700,000

280,000

560,000

700,000

280,000

Physician

150,000

150,000

120,000

150,000

120,000

50,000

5,000

40,000

50,000

5,000

35,000

10,000

50,000

2,000

1,600

2,000

1,600

400

2,000

902,000

435,000

721,600

902,000

405,000

30,000

316,600

150,400

902,000

Share of Carrier 1 ($)

135,000

15,000

n/a

n/a

n/a

n/a

150,000

Share of Carrier 2 ($)

135,000

n/a

158,300

n/a

n/a

n/a

293,300

Share of Carrier 3 ($)

135,000

15,000

158,300

n/a

n/a

150,400

458,700

n/a

n/a

n/a

n/a

n/a

n/a

Repatriation
-ambulance
MRI
TOTAL

Share of Insured ($)

Note:

n/a

1&2
Only
Jointly
($)

1&3
Only
Jointly
($)

2&3
Only
Jointly
($)

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

280,000

Carrier 3
Exclusive
($)

Total
($)

140,000

700,000

30,000

150,000

Carrier 1 has a $2,000 daily limit and a $5,000 repatriation maximum

Carrier 2 pays 80% since it is a pre-existing condition
Carrier 3 has no limit

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Example 3: Two Group Carriers

ITEM

Total bill after GHIP

Carrier 1 Liability if alone

Carrier 2 Liability if alone

Common Core

Hospital

80,000

80,000

80,000

80,000

Physician

20,000

20,000

20,000

20,000

TOTAL

100,000

100,000

100,000

100,000

Share of Carrier 1

100,000

Share of Carrier 2

n/a

Share of Insured

n/a

Note:

Patient is covered under two distinct group policies

Under Carrier 1s policy, the patient is the insured
Under Carrier 2s policy, the patient is the spouse of the insured
The Group Coordination of Benefits Guidelines apply in this case

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Example 4: One Individual Policy and Two Group Policies

Total Bill
after
GHIP
($)

Carrier 1
Liability
if alone
($)

Carrier 2
Liability
if alone
($)

Carrier 3
Liability
if alone
($)

Group Unit
Carrier 2 &
3 if alone 1
($)

Common
Core 2
($)

Hospital

80,000

80,000

80,000

72,000

80,000

80,000

80,000

Physician

20,000

20,000

20,000

18,000

20,000

20,000

20,000

100,000

100,000

100,000

90,000

100,000

100,000

ITEM

TOTAL

100,000

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

Carrier 3
Exclusive
($)

Total
($)

Share of Carrier 1 ($)

50,000

n/a

n/a

n/a

50,000

Share of Carrier 2 ($)

50,000

n/a

n/a

n/a

50,000

Share of Carrier 3 ($)

n/a

n/a

n/a

Share of Insured ($)

n/a

n/a

n/a

n/a

n/a

Note:

1
2
3

Carrier
Carrier
Carrier
Carrier

1
2
2
3

is an individual policy
and 3 are group policies offered through employment
is the insureds plan
is the insureds spouses plan and has 90% coverage

Coordination of Benefits Guidelines apply

For common core breakdown purposes, all group carriers are treated as one unit
Determined by application of Group COB Guidelines

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Example 5: High Deductible Individual Policy and Limited Lifetime Retiree Group Policy
Total bill
after GHIP
($)

ITEM

Carrier 1
Liability if
alone
($)

Carrier 2
Liability if
alone
($)

Common
Core 1
($)

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

Total
($)

Hospital

80,000

75,000

50,000

50,000

75,000

5,000

80,000

Physician

20,000

20,000

20,000

20,000

100,000

95,000

50,000

50,000

95,000

5,000

100,000

Share of Carrier 1 ($)

95,000

95,000

Share of Carrier 2 ($)

n/a

5,000

5,000

n/a

n/a

n/a

TOTAL

Share of Insured ($)

n/a

100,000
Note:
1

Carrier 1 is an individual policy with a $5,000 deductible

Carrier 2 has a $50,000 (retiree) lifetime group coverage maximum

These Guidelines do not coordinate lifetime coverage limits under $50,000

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Example 6: High Deductible Individual Policy and Group Policy

Total bill
after GHIP
($)

Carrier 1
Liability if
alone
($)

Carrier 2
Liability if
alone
($)

110,000

105,000

100,000

100,000

5,000

105,000

20,000

20,000

20,000

20,000

130,000

125,000

100,000

100,000

25,000

125,000

Share of Carrier 1 ($)

50,000

25,000

75,000

Share of Carrier 2 ($)

50,000

50,000

n/a

n/a

n/a

ITEM

Hospital
Physician
TOTAL

Share of Insured ($)

Common
Core
($)

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

Total
($)

5,000
130,000

Note:

Carrier 1 has a $5,000 deductible

Carrier 2 is a group policy with no deductible and a Calendar Year Maximum of $100,000

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Example 7: High Deductible Individual Policy and Group Policy

Total bill
after GHIP
($)

Carrier 1
Liability if
alone
($)

Carrier 2
Liability if
alone
($)

110,000

105,000

110,000

105,000

5,000

110,000

20,000

20,000

20,000

20,000

130,000

125,000

110,000

105,000

20,000

5,000

130,000

Share of Carrier 1 ($)

52,500

20,000

72,500

Share of Carrier 2 ($)

52,500

5,000

57,500

Share of Insured ($)

n/a

n/a

n/a

ITEM

Hospital
Physician
TOTAL

Common
Core
($)

Carrier 1
Exclusive
($)

Carrier 2
Exclusive
($)

Total
($)

130,000

Note:

Carrier 1 has a $5,000 deductible and no maximum on hospital

Carrier 2 has a group policy with no deductible and no maximum

Canadian Life and Health Insurance Association Inc., 2004.

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