Texas General Lines — Life, Accident, Health and HMOTexas Statutes and Rules Specific to Accident, Health and HMOMedium
A Texas resident is covered under a group health insurance policy. The policy includes a 'Coordination of Benefits' (COB) provision. The insured also has individual health coverage. According to Texas COB rules, which policy is typically considered primary when both policies cover the same loss, assuming no other specific rules apply (e.g., 'birthday rule')?
- AThe group health insurance policy.
- BThe policy with the higher deductible.
- CThe individual health coverage.
- DThe policy that has been in effect the longest.
Show answer & explanationAnswer & explanation
Correct answer: A. The group health insurance policy.
Under Texas Coordination of Benefits (COB) rules, when an individual is covered by both group health insurance and individual health insurance, the group policy is generally considered primary. This is a common rule to prevent over-insurance and ensure fair payment of claims.
Why the other options are wrong
- B. This is incorrect; the deductible amount does not determine primary/secondary status in this scenario.
- C. This is incorrect; individual coverage is typically secondary to group coverage.
- D. This is incorrect; the length of time a policy has been in effect is not the primary determinant here.
COB Rule: Group vs. Individual (TX)
In Texas, when an individual has both group health insurance and individual health insurance, the group policy is generally considered the primary payer under Coordination of Benefits (COB) rules.
- Applies when multiple policies cover the same loss.
- Group policy is usually primary.
- Individual policy is usually secondary.
- Prevents over-insurance.
Memory trick: Think 'Group First' – the bigger umbrella usually pays first.