Revised coordination of benefits guideline effective January 1, 2009
The Canadian Life and Health Insurance Association (CLHIA), made up of representatives of the Canadian life and health insurance industry, is introducing a revised coordination of benefits (COB) guideline, effective January 1. Group insurers use CLHIA's COB guideline whenever a person is covered for health and dental benefits under more than one plan.
CLHIA’s COB guideline helps ensure consistency in claims adjudication across all insurers. The guideline determines the priority payments are made – which plan pays first, which pays second, etc. - and outline the minimum amount payable by each plan.
Coordinating benefits is not always simple; not only do many families today have two working adults, but many situations exist that can complicate coordinating benefits, from joint-custody arrangements for dependent children to working retirees with dual coverage.
CLHIA recently revised their COB guideline with the intention of providing clarity, primarily in the order of benefit determination and the basis used for calculating payments:
- The clarification on calculating payments may affect some Sun Life plans where a COB (second payer) claim for private hospital room accommodation is received on a plan that limits coverage to semi-private. However, based on the low volume of claims, we have determined the impact on experience to plans with semi-private hospital coverage is minimal.
- There is no impact on plans that include coverage for private hospital room accommodation.
Starting with claims we process on January 1, we’ll take into account the revised COB guideline.
Here’s a high-level overview of the key points of clarification made to the guideline:
Key points of clarification to CLHIA’s COB guideline
We currently include COB information in materials such as contracts, employee booklets, and our website, etc. and we’ll update those documents at our earliest opportunity to reflect these changes.
CLHIA is planning to include an article about the revised COB guideline in a future edition of Benefits Canada, and a consumer brochure is in the works.
Please contact your Sun Life Financial group representative.