Coordination of Benefits
Determining Which Plan Pays First
Information Required for Coordination of Benefits

Section 16: Coordination of Benefits

If you or your dependent is covered under more than one plan of group benefits, there may be instances where coverage is duplicated — two plans pay benefits for the same dollar of hospital and medical expense. For that reason, a coordination of benefits provision has been adopted to coordinate the benefits payable as described in your booklet with similar benefits payable under other plans.

Under the Coordination of Benefits provision, if you or any of your dependents are also covered under any other group plan, the total payment received for you or your dependent from all such programs combined may not amount to more than 100% of the “allowable expenses.” “Allowable expenses” are any necessary and reasonable expenses for medical services, treatment or supplies covered by one of the plans under which you or your dependent is covered.

The term “plan” means any program, other than individual insurance, that provides benefits or services for medical care or treatment through group insurance coverage or any other prepayment or service type plan (but not a state Medicaid program).

16.1 Determining Which Plan Pays First

If you or your dependents are covered by another plan or plans, the benefits under this Fund and the other plan(s) will be coordinated. This means one plan pays its full benefits first, then the other plan(s) pay(s).

1. The primary plan (which is the plan that pays benefits first) pays the benefits that would be payable under its terms in the absence of this provision.
   
   
2. The secondary plan (which is the plan that pays benefits after the primary plan) will limit the benefits it pays so that the sum of its benefits and all other benefits paid by the primary plan will not exceed the greater of:
   
   
   1. 100% of total covered expenses, or
      
      
   2. the amount of benefits it would have paid had it been the primary plan.
      
      

If you or your dependents are eligible under another plan, there are a few simple rules that determine the order in which benefits are paid.

1. When another plan does not have a Coordination of Benefits provision (COB provision), that plan must determine benefits first.
   
   
2. When another plan does have a COB provision, the first of the following rules that applies governs:
   
   
   1. If a plan covers the claimant as an employee, then that plan will pay its benefits first.
      
      
   2. For an eligible dependent child whose parents are not divorced or separated, the plan of the parent whose birthday (month and day) is earlier in the calendar year will pay first, except if both parents’ birthdays are the same day, rule (d) will apply.
      
      
   3. For an eligible dependent child whose parents are divorced or separated, the following rules apply:
      
      
      1. A plan that covers a child as a dependent of a parent who by court decree must provide health coverage will pay first.
         
         
      2. When there is no court decree that requires a parent to provide health coverage for a dependent child, the following rules will apply:
         
         
         • When the parent who has custody of the child has not married, that parent’s plan will pay first and the non-custodial parent’s plan will pay second.
           
           
         • When the parent who has custody of the child has remarried, then benefits will be determined by that parent’s plan first, by the stepparent’s plan second, and by the non-custodial parent’s plan third.
           
           
   4. If none of the above rules apply, the plan that has covered the claimant for the longest period of time will pay its benefits first, except:
      
      
      1. when one plan covers the claimant as a laid-off or retired employee (or a dependent of such an employee), and the other plan includes a COB rule for laid-off or retired employees, the plan that covers the claimant as other than a laid-off or retired employee (or a dependent of such an employee) will pay first,
         
         
      2. if both plans cover the claimant as a laid-off or a retired employee (or a dependent of such employee) the plan that covered the employee for the longest period of time will pay first.

If part of a plan coordinates benefits and a part does not, each part will be treated like a separate plan.

16.2 Information Required for Coordination of Benefits

For the purposes of Coordination of Benefits, the Fund Office:

1. May release to or obtain from any other plan or other organization or person any claim information, and any person claiming benefits under the Fund must furnish any information that the Fund may require to coordinate benefits,
   
   
2. Has the right, if an overpayment is made, to recover such overpayment from any other person or any other plan or organization, and
   
   
3. Has the right to pay to any other plan or organization an amount it will determine to be warranted, if payments that should have been made by the Fund have been made by such organization.
   

WARNING

If you or your dependents file a claim with the Welfare Fund Office and you or your dependent fail to disclose relevant information concerning your coverage by another plan or other matters relating to coordination of benefits, the Welfare Fund has the right to recover any and all over- payments directly from you, your dependent, your insurance company or any other person or organization and to withhold benefits from you or your dependents until such amounts are recouped.