Co-ordination of Benefits
Co-ordination of Benefits With Spouse’s Plan
When you and your spouse both have benefit coverage with your respective employers, the following rules govern the reimbursement of claims as set by the Canadian Life & Health Insurance Association (CLHIA):
- Each of you is required to submit to your own plan first for reimbursement. If any expenses remain outstanding after the adjudication process, the residue expenses are then submitted to your spouse's plan for consideration. Please ensure you include the Explanation of Benefits (EOB).
- In the case where claims are made for dependents, the spouse whose birthday (by month or day if necessary) occurs first in the calendar year, shall submit claims through their own plan first. Any remaining expenses are then submitted to your spouse's plan for consideration. Please ensure the Explanation of Benefits (EOB) from the first plan is included for this process. The total amount received from all plans cannot exceed 100% of the eligible expenses incurred.
The Co-ordination of Benefits provisions also apply when both spouses are employed by the University and are eligible for benefit coverage as an Academic or Support Staff member.
Co-ordination with Alberta Blue Cross Senior’s Program
Once you or your spouse reach the age of 65 a change will occur in how you submit your supplementary health claims. Upon 65th birthday coverage under the provincial Alberta Blue Cross Senior’s Program will commence. At this point in time the Alberta Blue Cross Senior’s Program will become the first payer. After expenses have been adjudicated by Alberta Blue Cross, you are then in a position to submit any residual amount to Sun Life for reimbursement.
In the case of prescription medication, it may be possible for the pharmacist to electronically submit the claim under both Alberta Blue Cross and your Sun Life plan provided by the University of Alberta. If the pharmacist is unable to submit electronically under both plans it will be necessary to complete an Extended Health Claim Form. Send the completed form along with the receipt from the pharmacy for the portion of the prescription unpaid by Alberta Blue Cross and submit to the Sun Life for reimbursement.