Coordination of Benefits Example R&C Limits

Jennifer is married with one child, Caleb, who is covered under the benefits plan. Caleb had a sports injury and needs physiotherapy.

Jennifer’s ONE-T benefits (through CAEAS-ECAB) covers 100% of Caleb’s physiotherapy expenses up to the $1,500 annual maximum. Caleb’s physiotherapist charged $125 per visit. Canada Life’s Reasonable & Customary (R&C) limit for physiotherapy is $100 per visit. 

Mark (Jennifer’s spouse) also has 100% coverage for physiotherapy under his employer’s benefits plan. Neither of them has made any prior physiotherapy claims for Caleb, and Jennifer’s birthdate is earlier in the year than Mark’s.

To maximize their coverage, Jennifer could:

1. Submit the claim to Canada Life for reimbursement from the ONE-T CAEAS-ECAB plan, subject to R&C limits, up to the plan maximum.  If she submits a claim after each of Caleb’s physiotherapy sessions, Jennifer would be reimbursed $100 R&C x 100% = $100 per visit.

2. She would then submit the claim to Mark’s plan for additional reimbursement. If Mark’s plan is also with Canada Life, the claim would be subject to the same R&C limit, so Canada Life would calculate the claim based on the lessor of:

(a) the amount that would have been payable had it been the first plan.
This would be $100 R&C x 100% = $100.


(b) 100% of the eligible amount (R&C) minus the benefits paid by the first plan (Jennifer’s plan).
This would be $100 R&C – $100 = $0.

The lesser of (a) and (b) is $0 so Mark would not be eligible for further reimbursement for Caleb’s claim via COB.

If Mark’s plan is with another insurance carrier the R&C limit may be different.

By coordinating benefits, Jennifer and Mark can maximize their benefits coverage and potentially get higher overall reimbursement for Caleb’s physiotherapy claim.

Through COB, the total reimbursement for Caleb’s physiotherapy visit was $100 from Jennifer’s plan + $0 from Mark’s plan = $100, but their expense was $125 per visit. $25 was not paid as a result of R&C.

Coordinating benefits AND using the HCSA…

Jennifer has not used her HCSA for the year, so she still has a balance of $750. In this case, Jennifer could submit the remaining unpaid expense of $25 for Caleb to be paid via her HCSA.

By coordinating benefits and using her HCSA, Jennifer gets the full $125 claim reimbursed.

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