Common use of Double Coverage Clause in Contracts

Double Coverage. It is common for family members to be covered by more than one health care plan. This happens, for example, when a husband and wife both work and choose to have family coverage through both employers. When you are covered by more than one health plan, state law permits your insurers to follow a procedure called “coordination of benefits” to determine how much each should pay when you have a claim. The goal is to make sure that the combined payments of all plans do not add up to more than your covered health care expenses. COB is complicated and covers a wide variety of circumstances. This is only an outline of some of the most common ones. If your situation is not described, read your evidence of coverage or contact the Texas Department of Insurance. Primary or Secondary? You will be asked to identify all the plans that cover members of your family. We need this information to determine whether we are the “primary” or “secondary” benefit payer. The primary plan always pays first when you have a claim. Any plan that does not contain Texas’ COB rules will always be primary unless the provisions of both plans state that the complying plan is primary. When This Plan is Primary If you or a family member is covered under another plan in addition to this one, we will be primary when: Your Own Expenses  the claim is for your own health care expenses, unless you are covered by Medicare and both you and your spouse are retired. Your Spouse’s Expenses  the claim is for your spouse, who is covered by Medicare, and you are not both retired. Your Child’s Expenses  the claim is for the health care expenses of your child who is covered by this plan and: o you are married and your birthday is earlier in the year than your spouse’s, or you are living with another individual, regardless of whether or not you have ever been married to that individual, and your birthday is earlier than that other individual’s birthday. This is known as the “birthday rule”; or o you are separated or divorced and you have informed us of a court order that makes you responsible for the child’s health care expenses; or o there is no court order, but you have custody of the child.