PSI Ohio Insurance Practice Exam

If an individual is insured by both their own health insurance policy and their spouse's policy, which policy pays first in the event of an illness?

1. The individual's policy pays first, the spouse's policy pays the remaining.

2. The spouse's policy pays first, the individual's policy pays second.

3. Both policies pay equally.

4. The employer’s policy pays first if applicable.

The correct answer is: The individual's policy pays first, the spouse's policy pays the remaining.

When an individual is covered by their own health insurance policy as well as their spouse's policy, the coordination of benefits typically follows a specific hierarchy. In this case, the individual’s own policy pays first. This is based on the principle known as "birthday rule," where the policyholder’s own insurance coverage is considered primary if they are the one seeking health care services. After the individual's policy pays, if there are remaining eligible expenses, the spouse's policy may then cover the remaining costs. This primary role of the individual’s policy is crucial to ensuring that claims are processed efficiently and according to standard insurance practices. The other options do not align with these standard practices. For example, the spouse's policy paying first would be contrary to the established reasoning for determining primary coverage. Additionally, both policies paying equally is not typically how insurance works, as one policy must take precedence over the other for coordination of benefits to be effective. The mention of the employer's policy only applies if a different scenario, such as the individual also being covered through employment, comes into play; however, in the context of the question, the primary insurer is determined based on which policyholder is seeking care.