Connecticut Administrative Code › Title 38a - Insurance Department › 554 - Coordination of Benefits › Section 38a-554-3 - Effect on benefits

Current through July 10, 2024
(A) This provision
			 shall apply in determining the benefits as to a person covered under this Plan
			 for any Claim Determination Period if, for the Allowable Expenses incurred as
			 to such person during such Claim Determination Period, the sum of (1) the
			 benefits that would be payable under this Plan in the absence of this
			 provision, and (2) the benefits that would be payable under all other Plans in
			 the absence therein of provisions of similar purpose to this provision would
			 exceed such Allowable Expenses.
(B)
			 As to any Claim Determination Period with respect to which this provision is
			 applicable, the benefits that would be payable under this plan in the absence
			 of this provision for the Allowable Expenses incurred as to such person during
			 such Claim Determination Period shall be reduced to the extent necessary so
			 that the sum of such reduced benefits and all the benefits payable for such
			 Allowable Expenses under all other plans, except as provided in item (C) of
			 this section, shall not exceed the total of such Allowable Expenses. Benefits
			 payable under another plan include the benefits that would have been payable
			 had claim been duly made therefor.
(C) If (1) another plan which is involved in
			 item (B) of this section and which contains a provision coordinating its
			 benefits with those of this plan would, according to its rules, determine its
			 benefits after the benefits of this plan have been determined, and (2) the
			 rules set forth in item (D) of this section would require this plan to
			 determine its benefits before such other plan, then the benefits of such other
			 plan will be ignored for the purposes of determining the benefits under this
			 plan.
(D) For the purposes of item
			 (C) of this section, the rules establishing the order of benefit determination
			 are:
(1) The benefits of plan which covers the
			 person on whose expenses claim is based other than as a dependent shall be
			 determined before the benefits of a plan which covers such person as a
			 dependent;
(2)
(i) except for cases of a person for whom
			 claim is made as a dependent child whose parents are separated or divorced, the
			 benefits of a plan which covers the person on whose expenses claim is based as
			 a dependent of a person whose date of birth, excluding year of birth, occurs
			 earlier in a calendar year, shall be determined before the benefits of a plan
			 which covers such person as a dependent of a person whose date of birth,
			 excluding year of birth, occurs later in a calendar year. If either plan does
			 not have the provisions of this paragraph (2) (i) regarding dependents, which
			 results either in each plan determining its benefits before the other or in
			 each plan determining its benefits after the other, the provisions of this
			 paragraph (2) (i) shall not apply, and the rule set forth in the plan which
			 does not have the provisions of this paragraph (2) (i) shall determine the
			 order of benefits.
(ii) In the case
			 of a person for whom claim is made as a dependent child whose parents are
			 separated or divorced and the parent with custody of the child has not
			 remarried, the benefits of a plan which covers the child as a dependent of the
			 parent with custody of the child will be determined before the benefits of a
			 plan which covers the child as a dependent of the parent without
			 custody;
(iii) In the case of a
			 person for whom claim is made as a dependent child whose parents are divorced
			 and the parent with custody of the child has remarried, the benefits of a plan
			 which covers the child as a dependent of the parent with custody shall be
			 determined before the benefits of a plan which covers that child as a dependent
			 of the stepparent, and the benefits of a plan which covers that child as a
			 dependent of the stepparent will be determined before the benefits of a plan
			 which covers that child as a dependent of the parent without custody;
(iv) In the case of a person for whom claim
			 is made as a dependent child whose parents are separated or divorced, where
			 there is a court decree which would otherwise establish financial
			 responsibility for the medical, dental or other health care expenses with
			 respect to the child, then, notwithstanding paragraphs (ii) and (iii) above,
			 the benefits of a plan which covers the child as a dependent of the parent with
			 such financial responsibility shall be determined before the benefits of any
			 other plan which covers the child as a dependent child.
(3) When rules (1) and (2) do not establish
			 an order of benefit determination, the benefits of a plan which has covered the
			 person on whose expenses claim is based for the longer period of time shall be
			 determined before the benefits of a plan which has covered such person the
			 shorter period of time, provided that:
(i) The
			 benefits of a plan covering the person on whose expenses claim is based as a
			 laid-off or retired employee, or dependent of such person, shall be determined
			 after the benefits of any other plan covering such person as an employee, or
			 dependent of such person; and
(ii)
			 if either plan does not have a provision regarding laid-off or retired
			 employees, which results in each plan determining its benefits after the other,
			 then the provisions of (i) above shall not apply.