Section 0780-01-53-.01 - PURPOSE AND SCOPE(1) The purpose of this regulation is to adopt the Model Group Coordination of Benefits Regulation, as promulgated by the National Association of Insurance Commissioners. This regulation is intended to establish uniformity in the permissive use of overinsurance provisions and to avoid claim delays and misunderstandings that could otherwise result from the use of inconsistent or incompatible provisions among Plans. Except as specifically provided in subsection 4 below, it is contrary to the public policy of this state for a Plan to declare its coverage to the "excess" to all others, or always secondary'', or to reduce its benefits because of the existence of duplicate coverage in a manner other than as permitted by this regulation; or to reduce its benefits because a person covered by the Plan is eligible for any other coverage. It is requested that courts give effect to this public policy when they consider the interrelation of Plans with order of benefit determination rules which comply with this regulation and Plans with order of benefit determination rules which differ from those set forth in this regulation.(2) A Coordination of Benefits (COB) provision is one that is intended to avoid claims payment delays, to aid with the enforcement of T.C.A. §68-11-219 concerning prompt payment, and avoid duplication of benefits when a person is covered by two or more Plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which Plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It avoids duplication of benefits by permitting a reduction of the benefits of a Plan when, by the rules established by this regulation, it does not have to pay its benefits first.(3) This regulation permits, but does not require, Plans to include COB provisions.(4) If a group contract includes a COB provision, it must be consistent with this regulation. A Plan that does not include such a provision may not take the benefits of another Plan as defined in rule 0780-1-53-.02 DEFINITIONS into account when it determines its benefits. There is one exception: a contract holder's coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder.Tenn. Comp. R. & Regs. 0780-01-53-.01
Original chapter filed June 4, 1986; effective July 4, 1986.Authority: T.C.A. §§ 56-1-701 and 56-2-301.