Coordination of Benefits in Canada: How to Maximize Dual Coverage in 2026

For the thousands of Canadian families where both spouses have separate employer health insurance, a common question arises: how do the two plans work together? The answer lies in a process called Coordination of Benefits (COB).

COB rules establish a clear order for submitting claims, dictating which plan pays first (the primary) and which pays second. The goal is to ensure you are reimbursed for the maximum eligible amount, while preventing duplicate payments that insurers would otherwise have to reclaim.

Understanding how these rules work is crucial. It allows you to avoid frustrating claim rejections, speed up your reimbursements, and capture every dollar of coverage you’ve paid for.

Key takeaways

• Your own employer plan always pays your claims first
• The birthday rule determines which parent’s plan covers the children first
• Total reimbursement cannot exceed 100% of eligible expenses
• Claim deadlines vary by plan; it may be shorter or longer than the common 12-month period

What is Coordination of Benefits in Canada?

Coordination of benefits (COB) is the process that determines which health or dental plan pays first when you’re covered under more than one group insurance policy, ensuring you receive up to 100% reimbursement without duplicate payment.

COB applies whenever you have access to two or more group plans simultaneously. Common scenarios include your own employer plus your spouse’s employer, two jobs you work at the same time, a student plan combined with parent coverage, or a retiree plan alongside new employment benefits.

To keep the process consistent, most Canadian group insurers follow guidelines from the Canadian Life and Health Insurance Association (CLHIA). These guidelines were last revised in 2012 to foster consistency across the industry. (Source)

This means that while the general process is similar for major carriers like Manulife, Sun Life, and Canada Life, the specific details of your coverage are always dictated by your plan booklet.

In Which Situations Do You Need to Coordinate Benefits?

As previously mentioned, Coordination of Benefits (COB) becomes necessary whenever you or a dependent is covered by more than one group health insurance plan. This common situation, known as “dual coverage,” requires you to submit claims in a specific order.

You will almost certainly need to coordinate benefits in the following situations:

• Working Couples: You are covered by your own employer’s plan and are also listed as a dependent on your spouse’s plan.
• Parents with Separate Plans: Your dependent children are covered under the individual employer plans of both parents.
• Students with Coverage: You are a full-time student covered by a parent’s plan while also having benefits from your school or a part-time job.
• Multiple Jobs: You hold two separate jobs, and each provides you with its own health benefits package.
• Working Retirees: You have a retiree benefits plan, but have returned to the workforce and are now also covered by your new employer’s plan.

On the other hand, you do not need to coordinate benefits if:

• You are covered by only one active group plan.
• You have an individual insurance policy (e.g., one purchased as a self-employed individual or independent contractor). These private plans typically operate outside the group insurance framework and its COB rules.

If you are unsure whether your situation requires coordination, your benefits booklet or HR department can provide a definitive answer.

Which insurance Plan Pays First? The Primary vs. Secondary Payor Rules

When you have more than one health insurance plan, a common and crucial question arises: which one pays the bill first? The answer lies in a set of rules that determine which plan is the ‘primary payor’ and which is the ‘secondary payor’.

For Your Own Claims (Employee vs. Dependent Coverage)

Your own employer plan is always primary for your claims, even if your spouse’s plan offers superior coverage.

When you visit a physiotherapist for treatment, you submit that claim to your employer plan first. After your plan processes the claim and issues an Explanation of Benefits (EOB), you can submit the unpaid balance along with the EOB to your spouse’s plan for secondary consideration.

For Your Spouse’s Claims

Your spouse’s own employer plan is primary for their claims, and your plan (where they’re covered as a dependent) is secondary. Each person’s medical and dental expenses must be submitted to their own employer plan first.

For Dependent Children (The Birthday Rule)

The parent whose birthday (month and day only, ignoring the year of birth) falls earlier in the calendar year has the primary plan for dependent children.

If your child needs braces and the mother was born April 10 while the father was born October 5, the mother’s employer plan pays first, regardless of which parent has better orthodontic coverage.

If both parents share the same birthday (same month and day), alphabetical order of the parents’ first names determines the primary plan.

For Divorced or Separated Parents (Custody Rules)

When parents are divorced or separated, the coordination of benefits for their dependent children is determined by the legal custody agreement, not just by the parents’ birthdays. The rules differ depending on whether custody is sole or joint.

Scenario 1: Parents with Joint Custody

In cases of joint custody, the standard “birthday rule” applies to determine the order of submission. The claim should be submitted to the plans in the following sequence:

1. The plan of the parent whose birthday (month and day) occurs earlier in the calendar year.
2. The plan of the other parent.
3. The plan of the first parent’s current spouse (i.e., the child’s stepparent), if applicable.
4. The plan of the other parent’s current spouse, if applicable.

Scenario 2: One Parent has Sole Custody

When one parent has sole custody, the birthday rule does not apply. The plan of the custodial parent is always primary. The submission order is as follows:

1. The plan of the parent with sole custody.
2. The plan of the custodial parent’s current spouse, if applicable.
3. The plan of the non-custodial parent.
4. The plan of the non-custodial parent’s current spouse, if applicable.

For Full-Time Students with Multiple Plans

Full-time students covered under both their own plan (from work or school) and a parent’s plan follow this order: the student’s own plan (work or school, whichever started first) pays first, other student plans pay second, and the parent’s plan pays third.

Quebec residents face an exception for prescription drug claims. Due to Quebec’s provincial drug insurance mandate, Quebec residents must submit drug claims to their student plan last, after exhausting parent plan coverage. This exception applies only to prescription drug claims, not dental or other health services.

For Employees with Two Jobs or a Retiree Plan

Employees holding two jobs with benefits from each employer should submit claims to their full-time employer plan before their part-time employer plan. If both positions involve the same number of hours, the plan from the job you started first pays first.

Retirees who return to work and maintain both a retiree plan and a new employer plan must submit to the new employer plan first because active employment takes priority over retiree status.

How to Submit a Coordination of Benefits Claim (Step-by-Step)

See the steps below to learn how to submit a coordination of benefits claim correctly:

Step 1: Submit to Your Primary Plan

First, you must always submit your claim to the primary insurer.

If you’re submitting manually, you’ll need to complete that insurer’s claim form, making sure to write your name and policy details on all accompanying documents.

Fortunately, most insurers now offer convenient electronic submission through mobile apps or online portals. This often allows you to simply photograph your receipts and upload them instantly.

At the pharmacy, it’s even simpler. Just show your benefits card, and they’ll bill your primary plan automatically. You’ll only pay the leftover amount at the counter.

Key Tip: It’s best to submit your claims right away so you don’t lose receipts or miss deadlines.

Step 2: Obtain Your Explanation of Benefits (EOB)

After your primary plan processes your claim, they’ll send you a document called an Explanation of Benefits, or EOB. This is the most important document in the process.

The EOB clearly shows:

• How much you claimed
• How much the plan paid
• The remaining balance that wasn’t covered

You’ll usually find the EOB on your insurer’s online portal, or it will be mailed to you with your reimbursement cheque.

Step 3: Submit Remaining Balance to Secondary Plan

Now you’re ready to get the rest of your money back. Send the following three items to your secondary insurance plan:

• A new claim form for the secondary plan.
• The EOB you received from your primary plan.
• A copy of your original paid receipt.

Your secondary plan will then review the claim and pay its portion of the remaining cost. The goal is to cover as much of the eligible expense as possible, up to 100%, between the two plans. You’ll receive this final payment by direct deposit or cheque.

How Much Will You Be Reimbursed Under Coordination of Benefits?

The combined reimbursement from both your primary and secondary plans cannot exceed 100% of your eligible expenses. This means you may still have out-of-pocket costs if both plans have co-pays, deductibles, or coverage limits.

Also, coordination only works for services covered by both plans. If your primary plan excludes orthodontics entirely and you incur $4,000 in braces costs, your secondary plan will only pay if orthodontics is covered under that plan, up to that plan’s lifetime maximum.

Frequency limits are not cumulative either. If your primary plan covers one eye exam per year and you’ve used that benefit, your secondary plan will not provide an additional eye exam in the same year just because it also covers annual exams.

Common Coordination of Benefits Mistakes and How to Avoid Them

Having two benefits plans is a fantastic way to maximize your coverage, but a few common slip-ups can cause delays and frustration.

Here’s a look at the most frequent mistakes and how you can easily sidestep them to ensure a smooth process:

Mistake #1: Sending Your Claim to the Wrong Plan First

People often submit a claim, especially for a child, to the parent they think has the “better” plan, rather than following the official rules.

• The Problem: Insurance companies have strict rules for determining which plan is primary. For children, this is often the “birthday rule”.
• The Easy Fix: Before you submit, always confirm which plan is primary. If you’re unsure, a quick call to either insurance provider can help you prevent unnecessary delays.

Mistake #2: Missing the Claim Deadline

It’s easy to let receipts pile up, planning to sort them out “later.” Many people wait until tax season to organize a full year’s worth of medical expenses.

• The Problem: Most benefit plans have a firm deadline for submitting claims, typically 12 months from the date you received the service. If you wait too long, your claim will be past the deadline and you won’t be reimbursed.
• The Easy Fix: Submit claims as you go. Make it a habit to file a claim within a few weeks of your appointment while the receipt and details are still fresh in your mind.

Mistake #3: Forgetting to Include the Explanation of Benefits (EOB)

After your primary plan pays its share, you might be tempted to just send the original receipt to your secondary plan.

• The Problem: The secondary insurer has no way of knowing what the primary plan covered without the official Explanation of Benefits (EOB). Without this document, they cannot process your claim.
• The Easy Fix: When submitting to your secondary plan, always include two documents: a copy of the original receipt and the EOB you received from your primary plan.

Mistake #4: Assuming You’ll Get 100% Back

It’s a logical assumption: if one plan covers 80%, the other must cover the remaining 20%. Unfortunately, it’s not that simple.

• The Problem: Both plans have their own rules, including deductibles, co-pays, annual maximums, and specific exclusions. The secondary plan will only pay its portion of costs that it also considers eligible, and it won’t pay more than 100% of the total expense.
• The Easy Fix: Set realistic expectations. Before a major medical or dental expense, review both plan booklets to understand what each one covers. This will give you a clearer picture of your potential out-of-pocket costs.

Mistake #5: Not Telling Your Insurer About Your Other Plan

During enrollment, you might forget to check the box indicating you have coverage under another plan.

• The Problem: Insurers need to know about other coverage to coordinate benefits correctly. Hiding or simply forgetting to disclose this information can cause processing errors and hold up your claims.
• The Easy Fix: Be transparent from the start. When you enroll, or as soon as you gain coverage from a second plan, notify both insurance companies.

What Happens if You Submit Claims in the Wrong Order?

If you accidentally submit a claim to the secondary plan first, the insurer may reject the claim or ask you to submit it to the primary plan before they can process it, causing delays but usually not permanent denial.

The secondary plan will typically send a letter explaining that they need proof that your primary plan processed the claim first.

This adds weeks or months to your reimbursement timeline. While the initial issue is a delay, the outcome depends on your plan’s specific terms and deadlines. If you miss the deadline, the secondary plan can deny your claim for good simply because it was submitted too late.

You need to correct the error by submitting to the correct primary plan, obtaining the EOB, and then resubmitting to the secondary plan with all required documentation.

In rare cases, a secondary plan might process a claim as if it were primary because it doesn’t yet know about your dual coverage. If they later discover the error, they may request repayment or deduct the overpayment from future claims.

So, prevention remains easier than correction. Always verify which plan is primary and which is secondary before submitting a claim. If you’re unsure about a complex situation, consult the decision tree or contact your insurer.

Coordination of Benefits with Health Spending Accounts (HSAs)

Health Spending Accounts (HSAs) are generally used to pay for costs after all other insurance plans have been claimed against. While this is the standard industry practice, some employer plans may specify a different order or give you the discretion to choose, so it is crucial to check your plan documents.

However, the recommended approach is to submit claims to your core health and dental plans first, then use your HSA for any remaining eligible expenses.

HSAs function as employer-funded accounts that reimburse eligible dental, medical expenses not covered by your core group insurance, including laser eye surgery, fertility treatments, and alternative practitioners.

Because HSA funds come from a limited annual pool allocated by your employer, you should not waste HSA dollars on expenses your core plans fully cover.

That said, the typical submission order for an employee with core coverage, spouse coverage, and an HSA is: your core plan first, spouse’s core plan second, your HSA third for any remaining eligible balance.

Coordination of Benefits and the Canadian Dental Care Plan (CDCP)

If you have access to any private dental insurance, you are not eligible for the Canadian Dental Care Plan (CDCP).

This includes dental coverage available through:

• Your employer or a family member’s employer (e.g., a spouse, common-law partner, or parent).
• A dental plan you purchased yourself
• A Wellness Spending Account (WSA), which is also considered access to dental coverage

While having private insurance makes you ineligible, you can be covered by the CDCP and another government-funded social program at the same time (e.g., a provincial, territorial, or federal plan). When you have coverage from both, the benefits are coordinated.

In these specific situations, the CDCP is considered the primary payer.

You must submit dental claims to the CDCP first. After the CDCP has processed the claim, you can then submit a claim for any unpaid balance to the territorial or other government program.

Don’t forget to include the Explanation of Benefits document from the CDCP when you submit the claim to your secondary plan. The secondary plan will then assess the remaining balance according to its own fee guide rates.

If a dental service requires preauthorization (pre-approval) under CDCP rules, you must submit the preauthorization request to the CDCP before the treatment is performed. This is a mandatory step, even if the territorial or other program also covers that service.

Most Canadians with employer group benefits remain ineligible for CDCP, so coordination between CDCP and private insurance applies mainly to those transitioning between coverage types or those with territorial or Indigenous programs.

Source: https://www.canada.ca/en/services/benefits/dental/dental-care-plan/providers/fact-sheet-nt.html

The bottom line

If you’re paying for two health plans, make sure you’re using both. Most families stop after the first claim pays out and do not realize the second plan exists to cover what’s left. That’s your money sitting unclaimed.

Know which plan pays first for each family member, keep your payment statements, and submit both claims every time. Remember, your benefits only work if you actually claim them.

FAQs About Coordination of Benefits in Canada