Payment on a particular claim cannot exceed 100% of the eligible expenses. Eligible expenses are as defined in each carrier’s contract/plan document before payment limitations like the deductible, co-insurance, lagging fee guides and/or maximums are applied. In the case of dental, 100% of eligible expenses will be the appropriate general practitioner’s or specialist’s current fee guide.
Each carrier adjudicates the claim taking into account reasonable and customary charges, maximums and contractual fee guide limits in the normal fashion.
HOW DO THE PLANS COORDINATE BENEFITS?
The plan that determines benefits first (primary carrier) will calculate its benefits as though duplicate coverage does not exist. The plan that determines benefits second (secondary carrier) limits its benefits to the lesser of:
(i) The amount that would have been payable had it been the primary carrier, or
(ii) 100% of all eligible expenses reduced by all other benefits payable for the same expenses by the primary plan.
This means that an individual may receive reimbursement for up to 100% of the eligible expenses.
Source: Canadian Life and Health Insurance Association Inc.