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Which of the following statements is true regarding the coordination of benefits clause for medical services covered by the group policies for the following case?
A husband and wife work for different companies.  The husband works for ABC Company. The wife works for XYZ company.  Each has group health insurance coverage from their employer that also insures their spouse.  Both plans have a coordination of benefits clause. 



A. The wife receives medical care. ABC group insurer is primary
B. To reduce the risk of over-insurance, neither insurer will pay any benefits on any claim that is totally or partially covered by the other insurer if the other insurer is the primary carrier
C. The primary carrier determines what they ow for a claim by finding out what the secondary carrier will not pay
D. The husband receives medical care. XYZ group insurer is secondary.

This question is part of Test your Life & Health - Practice Exam 5 Quiz
Asked by Wyatt Williams, Last updated: Sep 10, 2020

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2 Answers

Jason B. Elster

Jason B. Elster

Jason B. Elster
Jason B. Elster

Answered Apr 20, 2018

To answer this question, The husband receives medical care. XYZ group insurer is secondary.
Numerous designs usually discuss rates with doctors, facilities and different suppliers that are lower than the suppliers' typical and standard charges utilizing other repayment approach, for example, relative esteem plan repayment or other comparable repayment system. Since the supplier has consented to acknowledge the arranged installment, less any required deductibles, coinsurance or co-installments for the administrations, COB isn't to be utilized to expand the supplier installment.

On the other hand, in light of the fact that the supplier has consented to acknowledge the arranged installment, less any required deductibles, coinsurance or co-installments for the administrations, COB isn't to be utilized to diminish the sum the supplier has consulted to acknowledge in installment for the administrations. This arrangement limits COB allowable expense to the arranged rate. Plans ought to incorporate arrangements in their supplier contracts to represent installments under coordination of advantages.

The meaning of "allowable expense" may bar certain kinds of scope or advantages, for example, dental care, vision mind, physician recommended medication or amplifiers. An arrangement that confines the use of COB to certain scope or advantages may restrain the meaning of allowable expense in its agreement to expenses that are like the expenses that it gives. At the point when COB is limited to particular scope or advantages in an agreement, the meaning of allowable expense should incorporate comparative expenses to which COB applies.

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Wyatt Williams

Wyatt Williams

Wyatt Williams
Wyatt Williams

Answered Nov 15, 2017

The husband receives medical care. XYZ group insurer is secondary.
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