Reso 2001-399 - Laserfiche WebLink

Home Browse Search

COORDINATION OF DENTAL EXPENSE BENEFITS -";FFECT ON BENEFITS, If a Covered Person is covered by another Plan, the Dental Expense BenefIts under this Policy and JenefIts under the other Plan( s) will be coordinated for the Claim Period. The Order of BenefIt Determination Rules on the next page decide which Plan pays fIrst. (1) Primary Benefits, When this Plan must pay its full benefIts fIrst, the Dental Expense BenefIts under this Policy will be paid as if the other coverage did not exist. (2) Secondary Benefits. When another Plan must pay its full benefIts fIrst, the Dental Expense BenefIts under this Policy: (a) will be calculated as if the other coverage did not exist; and then (b) will be reduced so that total benefIts, from all Plans combined, will not exceed 100% of the Allowable Expenses incurred by the Claimant during that Claim Period, BenefIts will be coordinated with any benefIt amounts that would be payable for the Allowable Expenses under the other Plan(s), whether or not claim is actually made. When this Plan's benefIts are reduced, each benefIt is reduced in proportion, Then, the reduced benefIt payments are applied towards the Maximums of this Plan. BENEFIT SAVINGS, The amount by which this Plan's benefIts have been reduced due to such coordination will accrue during the Claim Period. This amount will be used to pay any Allowable Expenses which: (I) are incurred by that Claimant during the same Claim Period; and (2) are not otherwise paid by any Plan, DEFINITIONS. The following definitions apply only to this coordination provision. "Plan" means any group hospital, surgical, medical or dental expense policy, group health care services plan, or group type self- insurance plan that provides protection or insurance against hospital, surgical, medical or dental expenses or services, including: (I) Blue Cross and Blue Shield group plans; (2) Health Maintenance Organization (HMO) and Dental Maintenance Organization (DMO) plans; and (3) other prepayment, group practice and individual practice plans. It also includes any coverage under a government medical or dental plan required or provided by law; except Medicaid, This Plan must pay its benefIts before Medicaid pays. Coordination with Medicare will be in accord with federal law. Each of the above coverages is a separate Plan. If an arrangement has two or more parts, and its coordination provision applies only to some benefIts or services; then each part is a separate plan, "Allowable Expense" means any necessary, reasonable and customary expense for dental care, which is at least partly covered under at least one of the Plans covering the Claimant. When a Plan provides benefIts in the form of services rather than cash payments, the reasonable cash value of each service rendered during the Claim Period will be considered Allowable Expense. "Claimant" means the Covered Person for whom claim is made, "Claim Period" means a calendar year (or part of a calendar year) during which the Claimant has been covered under this Policy. 23 Savings 09/01/01 GL11-17-COB FL