Common use of RULES FOR THE ORDER OF BENEFIT DETERMINATION Clause in Contracts

RULES FOR THE ORDER OF BENEFIT DETERMINATION. The benefits of the Plan that covers the [Member] as an employee, member, subscriber or retiree shall be determined before those of the Plan that covers the [Member] as a Dependent. The coverage as an employee, member, subscriber or retiree is the Primary Plan. The benefits of the Plan that covers the [Member] as an employee who is neither laid off nor retired, or as a dependent of such person, shall be determined before those for the Plan that covers the [Member] as a laid off or retired employee, or as such a person’s Dependent. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. The benefits of the Plan that covers the [Member] as an employee, member, subscriber or retiree, or Dependent of such person, shall be determined before those of the Plan that covers the [Member] under a right of continuation pursuant to Federal or State law. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are neither separated nor divorced, the following rules apply: The benefits of the Plan of the parent whose birthday falls earlier in the [Calendar] [Plan] Year shall be determined before those of the parent whose birthday falls later in the [Calendar] [Plan] Year. If both parents have the same birthday, the benefits of the Plan which covered the parent for a longer period of time shall be determined before those of plan which covered the other parent for a shorter period of time. Birthday, as used above, refers only to month and day in a [Calendar] [Plan] Year, not the year in which the parent was born. If the other plan contains a provision that determines the order of benefits based on the gender of the parent, the birthday rule in this provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are separated or divorced, the following rules apply: The benefits of the Plan of the parent with custody of the child shall be determined first. The benefits of the Plan of the spouse of the parent with custody shall be determined second. The benefits of the Plan of the parent without custody shall be determined last. If the terms of a court decree state that one of the parents is responsible for the health care expenses for the child, and if the entity providing coverage under that Plan has actual knowledge of the terms of the court decree, then the benefits of that plan shall be determined first. The benefits of the plan of the other parent shall be considered as secondary. Until the entity providing coverage under the plan has knowledge of the terms of the court decree regarding health care expenses, this portion of this provision shall be ignored. If the above order of benefits does not establish which plan is the Primary Plan, the benefits of the Plan that covers the employee, member or subscriber for a longer period of time shall be determined before the benefits of the Plan(s) that covered the person for a shorter period of time.