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 expenses. For that reason, a coordination of benefits provision has been adopted to coordinate the benefits payable as described in this booklet with similar benefits payable under other plans.
Under the Coordination of Benefits (COB) provision for benefits other than dental services, if you or any of your Dependents are also covered under any other group plan, the total payments you will receive from all such programs combined will not amount to more than 100% of Medically Necessary Expensed up to the Reasonable and Customary amount.
Under the Coordination of Benefits (COB) provision for benefits that are dental services, if you or any of your Dependents are also covered under any other group plan, the total payments you will receive from all such programs combined will not amount to more than 100% of allowable expenses. If the allowable expense used by the Plan is lower than the amount used by the primary plan as the allowable expense, then the Plan will use the allowable expense amount used by the primary plan, which may be less than the actual charge. When the Plan pays dental benefits as the secondary payer, it deducts the primary payer’s payment from the total approved fee, and then it pays the lesser of the balance due or what it would have paid if the Plan had been the primary payer. When the Plan is the secondary payer, it determines payment on the total dollar amount of the approved fee for the dental claim, and not on a line by line basis. The Plan will pay only for dental care expenses that are covered by this Plan.
For COB purpose, 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 pre-payment or service type plan.