Group Accident & Sickness Insurance
Core concepts
Group A&S covers a defined group under a master policy, with individuals receiving certificates of insurance. Key features: eligibility (who can join), enrollment periods, actively-at-work requirements, contributory vs. non-contributory plans, and coordination of benefits (COB).
COB prevents over-insurance: when two plans cover the same person, the primary plan pays first and the secondary plan pays the remainder up to the allowable expense. For dependent children, the birthday rule (parent whose birthday falls earlier in the year is primary) often applies. Group plans are typically experience-rated or pooled, and the employer may self-fund.
Traps in questions
- Confusing master policy (employer/insurer) with the certificate (employee).
- Forgetting that a non-contributory plan usually requires no active-at-work proof at enrollment but may for late entrants.
- Misapplying COB: total reimbursement cannot exceed 100% of the expense.
- Assuming group coverage is individually owned - it is not portable.
Rule of thumb
In COB questions, add payments but cap at the actual expense. Identify primary first, then secondary pays the balance.
Worked example
An employee's spouse has group coverage. The employee's plan is primary (birthday rule). The expense is $1,000; primary pays $700; secondary pays the remaining $300, not the full $1,000.