Define: Coordination-Of-Benefits Clause

A Coordination-of-Benefits clause is a provision in an insurance policy that determines how benefits are coordinated when a person is covered by more than one insurance plan.

When a person is covered by multiple insurance plans, the Coordination-of-Benefits clause determines which plan is the primary payer and which is the secondary payer. The primary payer covers the costs first, and the secondary payer covers any remaining costs up to the policy limits.

It is important because it helps prevent overpayment by insurance companies and ensures that the insured person receives the maximum benefit available to them without receiving duplicate payments.

In the event of a conflict between Coordination-of-Benefits clauses in different insurance policies, the policies may have a provision for resolving the conflict, such as following the “birthday rule” or “gender rule” to determine the primary payer.

A Coordination-of-Benefits clause should not affect your medical treatment, as it is a provision for determining how insurance benefits are coordinated and paid.

In some cases, you may be able to waive the Coordination-of-Benefits clause in your insurance policy, but this would depend on the specific terms and conditions of your policy and the regulations in your state.

If you have questions about the Coordination-of-Benefits clause in your insurance policy, you should contact your insurance company or agent for clarification.

A Coordination-of-Benefits clause should not affect your ability to file a claim, as it is a provision for determining how benefits are coordinated between multiple insurance plans.

Yes, there are state and federal laws and regulations that govern Coordination-of-Benefits clauses to ensure fair and consistent application of these provisions.

If you disagree with a decision made based on the Coordination-of-Benefits clause, you may have the right to appeal the decision through the insurance company’s appeals process or through a regulatory agency.