Which Insurance is Primary?

[GoodDadtoBK]

What is the name of your state (only U.S. law)? CA

In a case where both parents (divorced) have medical coverage for a child, how is it determined which insurance policy will be the primary and which will be the secondary?

 

[CJane]

I believe it's handled by determining which parent's birthday is first on the calendar.

 

[mistoffolees]

I believe it's handled by determining which parent's birthday is first on the calendar.

Usually. It is technically controlled by the policies themselves. USUALLY, the parent with the earliest birthday is primary, but there apparently can be exceptions.

 

[GoodDadtoBK]

Thanks for the quick response, Jane.

My next question would be this: If my wife is the policy holder, would they go by her birthdate or mine?

 

[CJane]

Thanks for the quick response, Jane.

My next question would be this: If my wife is the policy holder, would they go by her birthdate or mine?

IF that's the way your insurance handles it, I'd presume it would go by the policy holder's birthdate.

And I don't believe it includes years, which is why I phrased it the way I did. It's not necessarily the 'older' person whose policy is first.

 

[OHRoadwarrior]

Usually it goes by the birthday of the primary policy holder. An example...

My stepdaughter has 3 insurances. Her real father is first in the year. My wife is second and my birthday is third. My coverage, reverses from that of my wife and son, because the policy is in my name. So my wife and son have her insurance primary and mine secondary. I have mine primary and my wife's secondary.

 

[tranquility]

There are guidelines, but the law does not seem clear. (At least when I looked at this extensively about three years ago.)

The first tiebreaker is the COB statements inside the policies themselves. If that does not work, the NAIC (National Association of Insurance Commissioners) guidelines recommend:

• Non-dependent/Dependent Rule: The first rule governing the order of benefit
determination is that the plan covers the individual as an employee, member or
subscriber before plan benefits in which the individual is considered a dependent.

• Active/ Inactive Rule: A policy which covers an individual as an active employee is
the primary payer over the policy covering the individual as a retired or laid off
employee. This rule also applies to dependents covered under two policies.

• Birthday Rule: This is a method used to determine when a plan is primary or secondary
for a dependent child when covered by both parents' benefit plan. The parent whose
birthday (month and day only) falls first in a calendar year is the parent with the
primary coverage for the dependent. If both parents have the same birthday, then the
plan that has been in effect the longest pays as primary.

 

[cbg]

Which insurance is primary is not determined by law, which is why the law is unclear.

It is determined by the COB (coordination of benefits) clauses of the policies themselves. Many policies use the so-called "Birthday rule". Some do not. The law does not tell them how to do it - just that they follow whatever the established procedure is.

For the same reason, the law does not dictate whether it's the parent's date of birth or the policyholder's date of birth, when the two are not the same. It's up to the individual policies.

No one who has not read BOTH policies in their entirety can say for certain which one is going to be primary.

This is what I do for a living.

 

[stealth2]

My insurance follows the court order, which states that the ex must provide coverage. Since I am not required to, his is primary.

 

[mistoffolees]

My insurance follows the court order, which states that the ex must provide coverage. Since I am not required to, his is primary.

I think there must be more to it than that.

Your insurance company is not required to follow your divorce decree. I would bet that they're accepting primary responsibility because that's what their terms provide for and not because of the court order. I just can't imagine too many (if any) insurance companies saying "our policy is that we should not be primary, but since your divorce decree says we should, then we will do that".

 

[stealth2]

I think there must be more to it than that.

Your insurance company is not required to follow your divorce decree. I would bet that they're accepting primary responsibility because that's what their terms provide for and not because of the court order. I just can't imagine too many (if any) insurance companies saying "our policy is that we should not be primary, but since your divorce decree says we should, then we will do that".

Actually, that is what both insurance companies told me, By the birthday rule, mine should be primary. But both companies told me that, if there is a court order, they follow what the order states. <shrug>

 

[mistoffolees]

Actually, that is what both insurance companies told me, By the birthday rule, mine should be primary. But both companies told me that, if there is a court order, they follow what the order states. <shrug>

That's rather odd - they can't legally be forced to do that. I guess it's easier to put that into their COB clause then to spend the money on lawyers.

 

[GoodDadtoBK]

Thanks for all of the help!

 

[gr8rn]

While the birthday rule has been a standard for a long time, there are many different factors that are used nowadays.

The best way to make this determination is to call both companies and notify them of each other, then they will use their own formulas to determine which is primary. It is not always so cut and dried as the "birthday rule".