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Why you should file your claim even if you aren’t eligible for benefits
By: Benefits by Design | Tuesday April 8, 2025
There are a lot of moving parts to an employee benefits plan, and even if you aren’t eligible for benefits, there are times when it is important to file your claim. It keeps records accurate, but more importantly, it ensures that all of the group insurance coverages are being coordinated so employees can maximize the possible benefits.
We outline three scenarios where it is imperative that employees submit a claim, even if they aren’t eligible for benefits directly through that coverage.
Auto-coordination with spousal plan
When an employee has health and dental coverage through a spousal plan, they should always file the claim under both coverages. Remember that their employer’s plan is always the first payor, and they should submit the claim to that plan first. Afterwards, they can submit the claim, along with the explanation of benefits (EOB) or proof of claim payment from the first insurer.
This is beneficial for the following reasons:
- If the first plan only covers 80% (or another percentage), the spousal plan will reimburse them for the remainder.
- Once annual maximums and frequency limits are reached, the spousal plan will kick in and the employee would be eligible for benefits through that plan. This can be especially useful for families with ongoing monthly medications or medical supply needs, such as those needed for diabetes.
- If there are deductibles for either plan, then submitting the claim starts to count towards the deductible (if no reimbursement is made), and plan members can access their coverage faster.
Coordination of Benefits: Can I Have More Than One Benefit Plan?
Catastrophic coverage and health care spending accounts
When employees have health coverage combined with a health care spending account (HCSA), they should always submit their claims to their health care plan first and then submit it to their HCSA. Even if they are not eligible for reimbursement, it goes towards satisfying the deductible.
This is even more important when employees have catastrophic health coverage, because the deductible is usually quite high. This is to achieve lower rates while still providing coverage for high-cost medical expenses. However, when combined with a HCSA, the plan allows employees to use the HCSA to cover smaller expenses while still satisfying their deductible.
Disability leaves
Employees who have disability coverage should always submit a claim if they become injured or ill, even if it occurred at work and they are eligible for Workers Compensation. The benefits through the various provincial boards for workplace injuries usually pay a higher percentage of earnings than the disability benefits. Therefore, they negate any benefit payments that might be received through short- or long-term disability insurance.
The reason employees should still submit a claim is to ensure:
- The insurer is aware of the disability, and they can proceed with a waiver of premium (WOP).
- A WOP means the disabled employee will not have to pay premiums for any life insurance, accidental death and dismemberment (AD&D) insurance, or disability insurance.
- Should the company change carriers, the new carrier would not be responsible for taking on the risk, and the WOP and risk would remain with the previous insurer.
In these situations, employees should still submit a claim to the insurers when they are not eligible for benefits. Although they may not receive a direct reimbursement at the time, the claim submission may provide access to further coverage or eligibility. They may also provide relief for some premium payments or go towards satisfying a deductible.
Find out other instances where not filing a claim correctly can negatively impact the benefits.
8 Common Mistakes People Make When Filing Group Insurance Claims
