We maintain 2 medical insurance coverage policies. The reasons are complex but it is worth it to us. I carry a family coverage through my employer, my wife carries an individual coverage through her employer. Our family coverage is better for most expenses. Up until now I have managed to avoid problems, but this year they forced me to admit to the insurance companies that we have 2 policies. Well, it has been bad. Numerous charges that used to be covered are going unpaid. Some providers allow us to use either policy, some refuse to consider that option no matter what. Is there any way I can arrange things so that we can choose which policy covers which expense? Failing that, is there any way to send all the bills to the family insurer?
Of course the obvious solution is to drop the individual policy, saves us money and increases the cost to the family insurer. Everyone is fine with that solution-except us. We lose certain benefits that we have paid for years to maintain.
We are paying more for insurance and getting less in return. Is there any way out of this trap?
No, there is no way out. I work for a giant benefits clearinghouse and that is something that you don’t want to get into. The insurance companies will fight among themselves and leave you on the hook in the process. Sometimes it never gets worked out and there is no tiebreaker to use to see who should pay for it. That type of thing is strongly discouraged to protect yourself.
Also, failing to acknowledge that you have other coverage can be considered fraud by the company you’re filing with.
The principle is that an insurance company does not want to pay anything that another insurance plan paid for *or would have paid for * had a claim been filed.
It may be possible, if for some reason you wanted to do this, to drop your wife from the family coverage and keep her under the individual policy only. You would need to drop her during the open enrollment period. This may or may not result in savings on your premium, depending on how your employer structures the rates.
I think there is a tiebreaker, though. IIRC your wife’s plan is defined as primary, since she is an active employee there, not a dependent. However, even with the tiebreaker rule in theory, actual practice is every bit the mess Shagnasty describes. This link describes the standard practice, as well as an “innovation” called Wrap-Around that makes it even messier if a company has that provision. http://www.spencerfane.com/content/content/2005-141151-239.asp
Yet another reason why health insurance companies are evil.
(I am a political analyst for the largest health insurance association and I see what types of tactics they use. I have a lot of concrete reasons for thinking they are evil.)
rbroome, I would suggest contacting the Louisiana insurance department to seek advice about this, and to complain.
I have seen a lot of legislation in various states aiming to prevent this kind of abuse by insurers. So, complaints from citizens are needed to encourage the state to reform the system by passing laws governing this type of thing.
To complain about what? That they have to admit they’ve been lying to their insurance companies? I don’t understand what abuse you’re talking about. Asking for advice from the DOI is a great idea, but I don’t see where the insurance companies have acted in bad faith from the OP’s description of events.
Well how would any reasonable person even know that it was illegal to have two insurance policies and not to inform the insurers of the other’s existence. Heck, I specialize in state health insurance legislation and regulations and I didn’t even know that.
The abuse is the insurance company’s denial of coverage that they promised and been paid for, just because the insurer finds out there is another insurance policy, and they begin a back-and-forth game of “hot potato” with the poor policy holder. I think it’s a consumer issue - the consumer is paying for a product and are not receiving it. That is why the OP needs to complain. That is what the state insurance departments are there for - to serve and protect the interests of the consumers who are citizens of their state.
I’m looking at two plan summeries from a major health insurer. (I don’t have an EOC here at home to get the full description) They both have coordination of benefits and third party liability clauses. If they are not notified that there is another provider they are not being given the opportunity to determine their obligations correctly.
Just a quick note; I never said anything about illegal, that was your term.
I was the one who used the term fraud, because it can be fraud. Even being perceived as attempting fraud on his employer’s insurance is a headache the OP doesn’t need.
Note: The fraud they are most concerned about is someone with two 80/20 plans that tries to get the 80% paid by both plans. But the nature of the beast is that they don’t want to pay any claim they don’t have to.
Nevertheless, it is a common feature of claim forms to ask if there is other coverage. I realize a lot of people don’t file their own claim forms if the provider does it. But if the form asks if there is other coverage and you “conveniently” forget to mention it, the insurance company won’t take kindly to it. The form has your signature and probably some statement regarding “correct and complete information.” As **Antinor01 ** pointed out, the plan language isn’t usually hard to find if you look for it.
I ran into this problem some years ago when I was in college.
I was a dependent of my stepfather who was in the Army, so I was covered by CHAMPUS.
My real father had a family Blue Cross/Blue Shield policy that I was listed under as well. He had recently renewed, and since I was attending college in Texas near him, he decided to list me as well, which he’d never done before, because I’d grown up living with my mother and step-father.
When I lacerated my back and had to get it stitched up, neither insurance would pay. CHAMPUS (now TRICARE) is run by the U.S. government, and by law always pays last. Blue Cross/Blue Shield didn’t feel that they should have to cover the bills because I was had CHAMPUS. What’s worse, neither insurance would talk to me because I was not the primary policy holder. It was a Catch-22, and I was getting the bills.
After I was contacted by a collection agency, I just paid the bills myself to be rid of it.
I’m sure my father didn’t mean any harm when he put me down on his Blue Cross/Blue Shield policy, but it ended up costing me hundreds of dollars.
Pretty idiotic that extra insurance was basically equivalent to no coverage. :rolleyes:
I had two policies (one from my job, one from DH’s job) when I had a very expensive kid. I had very little trouble getting bills paid. One policy was deemed primary, one was secondary, and whatever one policy didn’t cover just rolled over to the second policy.
After my son was born, he qualified for the state Medicaid program and they then became the primary. I had no choice in that, it’s some kind of stare rule based on birthweight.
Ultimately, the kid cost $740,000 of which I owed about $5,000.00 for stuff that was missed or not covered by any policy.
Why did I have so little trouble getting stuff covered and you have so much trouble? I’m in Texas, if that helps.
The difference might be that the OP suggested that he hid the fact that he had two insurance policies (“they forced me to admit to the insurance companies that we have 2 policies”), whereas it sounds like Ca3799 might have been upfront about it.
It sounds like you may have had a regular insurance plan and a supplemental insurance plan designed to work with that (I can’t be sure). That is vey different than having two different policies designed to be primary plans.
This is from a pediatric office, so it’ll be a little different but… In cases I encountered where a family had two policies, I was told(repeatedly, because this sounded so stupid to me) that the parent whose birthday month came first in the year would be designated as the primary insurance holder regardless of the year. So Mom could have been born in Jan. 1968 and Dad Dec 1962 and Mom would be assigned Primary coverage. Tricare, as was mentioned before, was the exception. It always payed last. If a family had secondary insurance at our clinic, it was assumed the secondary payer would pick up the copay.
And then the idjits stopped accepting secondary insurance so it didn’t matter. BUT it was very important for claims purposes to know if a patient had secondary insurance. Insurance companies are looking for any reason to deny a claim, and neglecting to tell them about about each other is a perfect oppurtunity.
Now I have to go call United Healthcare and ask them(again!) why they’ve denying payment on surgery for my broken arm in June 2006. Fuckers.
-Lil
How would an insurance company find out if you have another insurance policy, if you didn’t disclose that?
I’ve only got the one policy, but recently I had this issue come up where I had to get stitches at the ER, the ER billed my insurance, and then, a couple months later, I got a letter from the ER stating that they haven’t received payment. So, I called my insurance company, and they stated that the claim was paid by my other insurance, which is odd, since I don’t have any. I told the guy that, and he said he had to research it and call me back the next day, which he didn’t, and I eventually called back and talked to someone else who, I guess, looked me up in their system and said, “hey, you’re right, you don’t have other insurance! Sorry, I’ll get your claim redone and the ER will get the payment in a couple days.” Which they must have, since it’s been a month and I haven’t heard any further complaints.
How did she know that? Was she just taking my word for it? Is there any way my insurance company could have said, “nuh uh, you do too have other insurance! we’re not paying!” Could it have progressed to the point where I would have had to prove I didn’t have any other insurance, and how would I have done that?
I don’t understand why insurance companies are permitted to collect premiums and then not pay just because you have more than one policy. I can have more than one life insurance policy, but they don’t argue who pays my family when I die. They should both pay, and I reap a nice little bonus everytime I get sick. Or refund my premiums, with interest. They can’t have it both ways.
I have insurance for both Mr. K and myself for dental, as does he. They pay on each of us as the primary and secondary so that we end up paying next to nothing for our general cleaning and minor stuff. I could carry two health policies, but mine is much more expensive than Mr. K’s so we just carry his.
Thanks for all the advice. As I mentioned, carrying two policies is worth it to us as insurance (by signing up when we did, we are grandfathered in to be able to switch her coverage from single to family at any time. If we had missed the opportunity, there would have been a long waiting period when she retires. We want her insurance because it covers retirees-which mine does not). And by force, what I meant is that up till now I had always been able to tell her insurance that since we never use it, there was no reason to consider it. Seemed flakey to me but it always worked on the ladies on the phone. Till this year. Guess I finally got someone who understands the rules. Sigh. Anyway, it certainly does seem unfair that we pay for both but don’t have the right to pick which one to use. As I siad, in the past we simply never used her insurance. It is OK but mine happens to be better in most cases and the occasinal difference wasn’t worth the trouble.