PSI Ohio Insurance Practice Exam

In the case of health insurance, which policy pays first if an individual has both their own and their spouse's policy?

1. The spouse's policy pays first

2. Both policies pay equally

3. The individual's policy pays first

4. A secondary policy does not apply

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

In situations where an individual has both their own health insurance policy and a spouse's policy, the standard practice is that the individual's policy pays first. This is known as the "birthday rule," which is a common guideline used by insurers to determine the order of payment when both partners have coverage for the same dependent. According to this rule, if a dependent child is covered by both parents’ insurance plans, the parent's policy that covers the child for a longer duration will typically be the primary payer. In cases where the individual themselves is insured along with a spouse, the individual policy is prioritized for benefits since it is viewed as primary coverage. This ensures that the individual receives the maximum benefit available from their own policy before any potential supplementary payment from the spouse's policy. The other choices generally misinterpret the order of benefit rules. The spouse's policy does not automatically become primary simply because it is an additional policy, neither do both policies share the costs equally in this scenario. Moreover, secondary policies, such as the spouse's insurance, do come into play after the primary policy has made its payments, thereby allowing for additional coverage toward out-of-pocket costs.