Coordination of Benefits - Group Health and Dental

Coordination of benefits (COB) guidelines are developed by the Canadian Life and Health Insurance Association (CLHIA) to foster consistency within the industry. These guidelines determine the order in which benefits are determined in case of a patient having multiple insurance plans. The full document can be reviewed on the CLHIA website. Alberta Blue Cross, Canada Life and Sun Life also have detailed information available online.

The following scenarios occur most frequently:

Claims for Dependent Children

In cases where both parents have an insurance plan the primary plan is the one of the parent with the earlier birthdate (month/day) in the calendar year. If the parents have the same birthdate, the alphabetical order of the parents' first name determines the insurance order.

In cases of shared custody and multiple insurance plans the order is determined as follows:

1) Plan of the parent whose birthdate comes first in a calendar year

2) Plan of the second parent

3) Plan of the spouse of the parent whose birthdate comes first

4) Plan of the spouse of the second parent

In cases of single custody and multiple insurance plans the order is determined as follows:

1) Plan of the parent with sole custody

2) Plan of the spouse of the parent with sole custody

3) Plane of the second parent

4) Plan of the spouse of the second parent

Claims for Covered Individuals

The primary plan is the plan of the covered individual (Patient's own plan). The secondary plan is the plan where the patient is a dependent (Spouse's plan).

If a patient has more than one plan the order is as follows:

1) Plan of full-time job

2) Plan of part-time job

3) Retiree plan

If a patient works the same hours at both jobs or has 2 part-time jobs the primary plan is the one which has been in effect the longest

Government Supported Programs

In almost all cases private insurance plans are primary payors. Only the balance remaining can be submitted to government supported programs like the Alberta Dental Service Corporation plans (ADSC), Cleft Palate Dental Indemnity Program, Oral and Maxillofacial Devices and Services Program (OMDS), Non-Insured Health Benefits for First Nations and Inuit (NIHB) as well as Jordan's principle.

The only exception are some Manulife Insurance plans which are secondary to NIHB.