Our benefit plans contain a non-profit provision coordinating them with other existing plans so that the total benefits available will not exceed 100% of the allowable expense. An “allowable expense” is any necessary, reasonable and customary expense covered, at least in part, by one of the plans.
“Plans” means these types of medical and dental care benefits: (a) coverage provided by a governmental program or provided or required by statute; and (b) group insurance or other coverage for a covered employee or such covered employee’s spouse.
The Fund uses the “Birthday Rule” to determine primary coverage, (i.e. If two people in a household have coverage, the one whose birthdate in the household comes first in the year is primary.)
If you and your spouse are divorced and have dependent children, there are further rules. Benefits will be paid in the following order, unless a court decree specifies otherwise:
Separated or Divorced Parents: Not Remarried
1. The plan of the parent with custody pays first.
2. The plan of the parent without custody pays second.
Separated or Divorced: Remarried
1. The plan of the parent with custody pays first.
2. The plan of the step-parent with custody pays second.
3. The plan of the parent without custody pays last.
Finally, if there is a court decree that establishes financial responsibility for the medical, dental, or other healthcare expenses with respect to the child(ren), the plan that covers the child(ren) as a dependent(s) of the parent with such financial responsibility will pay benefits before any other plan covering the child(ren) as a dependent.
When ours is the secondary plan, and its payment is reduced to consider the primary plan’s benefits, a record is kept of the reduction. This amount will be used to increase our Plan’s payments on the patient’s later claim in the same calendar year to the extent there are allowable expenses that would not otherwise be fully paid by our Plan and the others.
