SECTION 13 COORDINATION OF BENEFITS

This section only applies if you, your spouse, or a Dependent is covered both under this Plan as well as under another group health plan or program. Coordination of benefits (COB) means that the coverage provided by this Plan is coordinated with coverage that may be available under the other plan, so that there is no duplication of payment or overpayment.

When You Have Other Health Benefits. When you are covered under this Plan as well as another plan, you have what is known as “primary” and “secondary” coverage. The primary plan is the one that pays its benefits first. The secondary plan is the one that pays second. When that is the case and you receive a service which would be covered by both plans, we will coordinate benefit payments with any payment made under the other plan. One company will pay its full benefit as the primary plan. The other company will pay secondary benefits, if necessary, to cover all or some of your remaining expenses. The following are considered to be health insurance plans for purposes of coordination of benefits:

Any group or blanket insurance contract, plan or policy, including HMO and other prepaid group coverage, except that blanket school accident coverage or such coverages offered to substantially similar groups (e.g., Boy Scouts, youth groups) shall not be considered a health insurance contract, plan or policy;
Any self-insured or non-insured plan, or any other plan arranged through any employer, trustee, union, employer organization, or employee benefit organization; Any Blue Cross, Blue Shield, or other service type group plan;
Any coverage under governmental programs, or any coverage required or provided by any statute. However, Medicaid and any plan whose benefits are, by law, excess to those of any private insurance plan or other non-governmental plan shall not be considered health insurance policies; and
Medical benefits coverage in group and individual mandatory automobile “no-fault” and traditional “fault” type contracts.

How We Determine Which Plan Pays First. To decide which plan is primary and pays first, we use the
following rules:

If the other plan does not have a provision similar to this one, then it will be primary;
If you are covered under one plan as an employee and you are only covered as a dependent
under the other plan, the plan that covers you as an employee will be primary; except that if you
are retired and covered by Medicare, Medicare will be considered primary to your coverage under
this contract unless, as a result of federal law, Medicare is deemed to be secondary. If so, the
following rules apply:
1. The program covering you as a dependent of a person in current employment status pays first;
2. Medicare pays second; and
3. The program covering you as a retired employee pays third.
Subject to the provisions regarding separated or divorced parents below, if you are covered as a child under both plans, the plan of the parent whose birthday (month and date) falls earlier in the year is primary. If both parents have the same birthday, the plan which covered the parent longer is primary. If the other plan does not have the rule described immediately above, but instead has a rule based on gender of a parent and, as a result, the plans do not agree on which shall be primary, then the rule in the other plan will determine the order of benefits.
There are specific rules for a child of separated or divorced parents:
- If the terms of a court decree specify which parent is responsible for the health care expenses of the child, and that parent’s plan has actual knowledge of the court decree, then that parent’s plan shall be primary.
- If no such court decree exists or if the plan of the parent designated under such a court decree as responsible for the child’s health care expenses does not have actual knowledge of the court decree, benefits for the child are determined in the following order:
If you are covered by one of the plans as an active employee, neither laid-off nor retired, or as the dependent of an active employee, and you are covered as a laid-off or retired employee or a laidoff or retired employee’s dependent under the other plan, the plan covering you as an active employee will be primary. However, if the other plan does not have this rule in its coordination of benefits provision, and as a result the plans do not agree on which shall be primary, this rule shall be ignored.
If none of the above rules determine which plan shall be primary, then the plan which has covered you for the longest time will be primary.

Payment of Benefits When This Plan is Primary. When we are primary, we will pay benefits covered under this Plan as if there were no COB provision.

Payment of Benefits When This Plan is Secondary. When this plan is secondary, the benefits of this plan will be reduced so that the total benefits payable under the other plan and this plan do not exceed your expenses for an item of service. However, we will not pay more than we would have paid if we were primary. We count as actually paid by the primary plan any items of expense that would have been paid if you had made the proper and timely claim. We will request information from that plan so we can process your claims. If the primary plan does not respond within 30 days, we will assume its benefits are the same as ours. If the primary plan sends the information after 30 days, we will adjust our payment, if necessary.

Coordination of Benefits with Non-complying Plans. This Plan complies with New York State coordination of benefits regulations, and is referred to in this section as a “complying” plan. We will coordinate our benefits with a plan that is an excess or always secondary plan, or a plan that uses order of benefit determination rules that are inconsistent with those contained in New York Regulations (known as a “non-complying” plan) as follows:

If this Plan is the primary plan, we will pay benefits first, and the non-complying plan will pay second.
If this Plan is the secondary plan, we will pay benefits first, but the amount of benefits paid will determined as if we were the secondary plan. That payment will be the limit of our liability.
If the non-complying plan does not provide the information we need to determine our benefits within 30 days after we request it, we will assume that the benefits of the noncomplying plan are identical to ours, and we will pay our benefits accordingly. We will however, adjust our payments if information is received later that specifies the actual benefit of the noncomplying plan.

Effect on Deductible and Co-payment Obligations. Any expense paid by another plan which is primary to this Plan pursuant to this COB provision, or which is charged against the primary plan’s deductible and/or co-payment obligation of the Covered Person, will be counted toward any deductible and/or co-payment obligation of the Covered Person under this Plan, provided the expenses would be covered under this Plan if it was primary.

Except as otherwise provided below, Medicare will be primary and this Plan will be secondary.

Active Employees Medicare-Eligible Due to Age. If a covered active Employee (or his Dependent) is eligible for Medicare due to age, this Plan will continue to be primary coverage for that covered Employee or Dependent, provided the Employee remains working actively and the Employee’s Employer has 20 or more Employees.
Employees & Dependents Medicare-Eligible Due to Disability or End-Stage Renal Disease. If a Covered Person is eligible for Medicare due to disability or end-stage renal disease (ESRD), this Plan will coordinate its benefits with Medicare as follows:
1. This Plan will be primary only if (a) the disabled person is an active Employee (or covered Dependent of an active Employee), and at least one Employer participating in this Plan has 100 or more Employees, or (b) the person becomes eligible for Medicare due to endstage renal disease while an active Employee (or covered Dependent of an active Employee).
2. This Plan will be primary for the first 30 months of Medicare-eligibility of a covered Employee or his covered Dependent who is eligible for Medicare due to end-stage renal disease. After 30 months, Medicare will become primary for that person.
Failure to Enroll in Medicare.If a Covered Person is eligible for Part A and/or Part B of Medicare, but does not enroll in one or both parts, the benefits payable under this Plan will be reduced by the amount he would have received if he had actually enrolled. A Covered Person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him. It is important to enroll in Medicare as soon as you are eligible, so that you do not lose any benefits the Plan would otherwise pay.

Right to Receive and Release Needed Information.We have the right to release or obtain information which we believe necessary to carry out the purpose of this section. We need not tell you or obtain anyone’s consent to do this except as required by Article 25 of the New York General Business Law. We will not be legally responsible to you or anyone else for releasing or obtaining this information. You must furnish to us any information which we request. If you do not furnish the information to us, we have the right to deny payments.

Our Right to Recover Overpayments and Repayment to Other Plans. In some cases, we may have made payment even though you had coverage under another plan. Under these circumstances, it will be necessary for you to refund to us the amount by which we should have reduced the payment we made. We also have the right to recover the overpayment from the other health benefits plan if we have not already received payment from that other plan. You must sign any document which we deem necessary to help us recover any overpayment.

Payments to Others. We may repay to any other person, insurance company or organization the amount which it paid for your covered services and which we decide we should have paid. These payments are the same as benefits paid.