If you are covered by more than one group medical plan (e.g., your spouse's employer's medical plan), to the extent possible, the Plan will attempt to coordinate benefits, with the intent not to reimburse more than 100% of the amount of the charges.
However, if you or a family member is covered under an individual medical plan (e.g., auto insurance, homeowners insurance personal injury protection, etc.), the coordination of benefits provision does not apply.
One of the plans covering you is the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits indicating the amount paid by the primary plan.
For example, if you, as an employee in this option, incur covered expenses, this Plan is primary and your spouse's plan is secondary. However, if your spouse incurs the expenses, his or her plan is primary and this Plan is secondary.
The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.
Refer to Special provisions for coordination of benefits for the Prescription drug program.
Coverage of a child
When a child is covered under both parents' plans, the "birthday rule" is used: the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or the spouse's plan has not adopted the birthday rule, the Plan will consider the plan that has covered the child longer as primary.
There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary, and the plan of the non-custodial parent is last.
If payment for covered medical expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.
Incorrect computation of benefits
If you believe that the amount of the benefit you receive from the Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services.
If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. See Claims and Administrative and ERISA information sections.
Recovery of overpayment
If the calculation of your or your beneficiary's benefit results in an overpayment, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The Plan Administrator may make reasonable arrangements with you for repayment, see Fraud against the Plan above.