New York Child Abuse Identification and Reporting Practice Exam

In the case of dual health insurance policies, which policy pays first in the event of an illness?

1. The spouse's policy pays first

2. The individual's policy pays first

3. Whichever policy was purchased first pays first

4. The policy with the higher coverage limit pays first

The correct answer is: The individual's policy pays first

The principle that governs which health insurance policy pays first in the case of dual coverage is known as "coordination of benefits." In general, when an individual has health insurance through their own employer or as an individual policy, that person's own policy will often pay first, regardless of the presence of a spouse's policy. This is known as the "employee's policy pays first" rule. This approach helps streamline the claims process and ensures that claims are processed in a consistent manner. By allowing the individual's policy to take precedence, it minimizes complications and potential disputes over payment responsibilities between different insurance providers. The spousal coverage can then act as secondary insurance, covering any remaining balances after the primary policy has been applied. Other options suggest different criteria for determining which policy pays first, such as the source of the policy or financial limits, but they do not align with the standard practices established in health insurance coordination of benefits.