When a claim has coverage under multiple health plans, which provision applies?

When a claim is covered under multiple health plans, the provision that applies is coordination of benefits. This concept is essential in situations where an individual is eligible for benefits under more than one health insurance policy. Coordination of benefits helps determine the order in which the policies will pay claims, ensuring that the insured does not receive more than 100% coverage for a single expense.

This provision typically dictates which plan is considered primary and which is secondary. The primary plan pays first, covering the costs up to its limits, and the secondary plan can then cover any remaining eligible expenses within its own limits. This system is designed to minimize the overlapping of benefits and to streamline the claims process.

While deductible sharing refers to the allocation of deductible expenses between plans, subrogation involves the insurer seeking reimbursement from a third party responsible for a claim, and policy limits define the maximum amount an insurer will pay under a policy, none of these options adequately address the need to manage multiple health plans when a claim arises. Therefore, coordination of benefits is the correct application in this scenario.