Can you claim the same expense on two benefits plans?

Which plan goes first depends on who was treated

Your own employer’s plan is primary for you. Your spouse’s plan, where you sit as a dependant, is secondary for you. For your spouse it is the other way around.

That symmetry is the thing households get wrong. The same physiotherapy receipt goes to a different insurer first depending on whether the appointment was yours or theirs.

It does not matter which plan is more generous and it does not matter who is older. If one person holds two plans of their own, the order follows employment status: active full-time, then part-time, then retiree.

For a child, it is whose birthday falls earlier in the year

Only the month and day count. A parent born in March 1990 comes before a parent born in August 1980, because March comes before August.

Step-parents come after both biological parents. Where parents are separated the order follows custody instead: the custodial parent first, then their spouse, then the other parent and theirs.

Two 80% plans can cover the whole bill

The second plan pays the lesser of two things: what it would have paid if it had been first, or 100% of the expense minus whatever the first plan already paid.

So the cap is the size of the bill rather than the size of your coverage. Two plans that each cover 80% of a $200 dental visit reach the full $200 between them, and each one draws down its own maximum doing it.

This is the part people talk themselves out of. The received wisdom is that a second plan barely helps, and for money-denominated coverage that is simply wrong.

Where it stops adding up

• Visit limits do not stack. Twenty massage appointments on each plan is twenty appointments, not forty. For coverage counted in visits the second plan makes each visit cheaper rather than buying you more of them.
• Per-visit maximums bite. The second plan is capped at what it would have paid as the first. Two plans that each cover $30 of a $100 massage pay $60 between them.
• The second plan only pays for what it considers eligible. Plans cover different lists of services. The second one may not recognise the expense at all.
• Deductibles and co-pays survive. Two plans does not mean everything is free, which is the other assumption that costs people money.

How the claim actually reaches the second plan

Submit to the primary plan first. It sends back an Explanation of Benefits saying what it paid. You then send that document, with the claim, to the secondary plan.

That middle step is manual and it is where the money goes missing. Nothing prompts you to take it. The first plan’s Explanation of Benefits never mentions that a second plan exists, because the first insurer has no idea it does.

The mistakes that cost the most

• Never submitting to the second plan at all. The most common one and the most expensive. Everything else on this list is smaller.
• Submitting in the wrong order. The claim comes back rejected or underpaid, and it reads as though the treatment was not covered.
• Missing the window. Plans usually want a claim within 12 to 18 months. A top-up nobody chased expires quietly.
• Not telling either insurer about a change. A marriage, a separation or a new dependant can break the coordination you were relying on, and nothing announces it.

Quebec runs on different ordering rules from the rest of the country. If you are covered there, none of the order described above is safe to assume.

What Benloop does

If two people in a household each have Benloop and both agree to share, Benloop shows which plan each of them should claim to first. It names the insurers and nothing else. Neither person sees the other’s balances.

That is the question no insurer can answer, because no insurer has ever seen both plans. Sun Life does not know a Manulife plan exists and has no reason to look.

The rest of what Benloop does is the same for one plan or two: every service you are covered for, what is left in each, and the date it resets, with a reminder before that date arrives.