Coordination Of Benefits

Coordination of Benefits (COB) is a provision in group health and group dental contracts that prevents duplicate payments for the same covered medical or dental expenses. The COB provision applies only when a participant or eligible dependent is covered under more than one group health or dental program. When that is the case, the Welfare Fund will coordinate benefit payments with the other group plan. One group will pay its full benefit as the primary plan and the other group will pay secondary benefits (if necessary) to cover some or all of the remaining expenses. This COB provision prevents duplicate payments and overpayments. In no case should the benefits received from the two group plans in total be greater than the medical or dental allowed charges.

The rules to determine the order of payment under Welfare Fund coverage in those cases where there is coverage under more than one group plan are as follows:

A) If the other group plan does not have a COB provision similar to the Welfare Fund’s, then that group will be primary.

B)If both groups have a COB provision, the group covering the person as an employee is primary.

C)If a dependent child is covered under both parents’ group plan and the parents are not separated or divorced, the plan of the parent whose birthday falls earlier in the year will be primary. For purposes of determining the earlier birthday only the month and day are considered; the year of birth has no significance. If both parents have the same birthday, the plan which covered the parent longer will be primary. However, if the other group plan does not use the "birthday rule," but instead uses a rule based on the gender of the parent and as a result the two plans do not agree on which is primary, then the father’s group plan shall be primary.

D)If a dependent child is covered under both parents’ group plan and the parents are separated or divorced and there is no court decree which establishes financial responsibility for the child’s coverage, the plan of the parent who has custody (the custodial parent) shall be primary. However, if the custodial parent has remarried and the child is also covered as a dependent under the step-parent’s plan, the custodial parent’s plan will pay first, the step-parent’s plan second, and the non-custodial parent’s plan third.

E)If a court decree specifies which parent is to be responsible for the child’s coverage and that parent’s plan has actual knowledge of the decree, then that parent’s plan will be primary.

F)If a person is covered under one group as an active employee or as the dependent of an active employee and is also covered under another group as a retired employee or as the dependent of a retired employee, the group which covers that person as an active employee is primary. If the other group plan does not have this rule, and as a result the two plans do not agree on which is primary, then this rule will be ignored.

G)If none of the above rules determine which group plan is primary, the group plan covering the person for the longer period of time is primary.

Recovery Of Benefits From Alternative Sources

If a participant or qualifying dependent incurs covered medical expenses for which payment may be available from another source, a claim for these expenses may still be submitted for payment consideration by the Welfare Fund. The Welfare Fund may advance a benefit payment in order to assist the participant during a time of need. However, if another source is responsible for such expense under applicable provisions of the Welfare Fund and/or the law, the Fund retains the right to recover benefits paid from the responsible party despite any advance payment(s) it may make. In addition, the Welfare Fund will have the right to recover any payments which were made to the participant which duplicated another payment for the same expenses. The participant agrees to cooperate and assist the Welfare Fund in recovering any benefits for which other payment is available. Acceptance of benefits from the Welfare Fund automatically assigns to the Fund any right to recovery of alternate or duplicate payments.

In addition, if the participant recovers funds from another individual or insurer in connection with any covered medical expenses for which the Welfare Fund has already paid benefits, the Fund shall be entitled to recover the amount expended to or on behalf of the participant or his qualifying dependent(s) and by accepting benefits the participant agrees to reimburse the Welfare Fund.