Insurance Claim question?

Question

I have medical Insurance through my job which I started on 04/01/08. I took this position because my 2 kids and I did not have insurance for a year. So my son gets sick and I take him to the dr on 4/16/08. I pay the deduct. then the drs office calls me to tell me they have rejected the claim. long story short, the Insurance company wants a support order or divorce decree to "make sure" they do not have other insurance. I send them a letter and copies of my child support which only states that my ex will have to pay me half for any ins. I have. Still they have rejected it saying that the children have "other insurance" I am so fed up with this BS!! I now have the drs. office calling me expecting me to pay them!! What can I do? i have ALOT of money taken out of my weekly paycheck to pay for this ins, there has to be some kind of legal rights for them doing this to me!! if anyone has had this happen or works in the field, please give me some advice on my rights!! This is WRONG!!

Answer 1

Do not pay the doctor yet. YET. If you do, once the claim is processed, you may have to go through red tape to get a refund.

Ask your benefits manager to contact the plan administrator and claims processors and have the claim reprocessed. They have the power to do that. It may just take a little time to get it reprocessed, but if the orders do not state that one parent or another is responsible for carrying health insurance, then they can only ask if your ex has insurance on them. If there is not other insurance, then there should be no problem. It's just a matter of time.

Also, since it was illness and not a pre-existing condition, they cannot ding you for it.

Answer 2

File a bad faith lawsuit today.  DO not delay, you are limited time.  Health insurance companies usually reside/domiciled in a state other than yours.  This is one of the ways to avoid paying claims.  Call your insurance commissioner TODAY and demand help.  I have been an insurance adjuster for a long time and each time I or my family uses a hospital or ER I file a bad faith lawsuit with the state the same or the very next day.  I do not wait for the c**p to start.  I know every game that they play.  If your employer is self insured you will have a dickens of a time.

Answer 3

Go to your H.R. function and ask them to get their (the employer's) insurance broker to intercede with the insurance company.  A lot of times the brokers can cut through the red tape there.

In the meantime, go ahead and pay the doctor.

Answer 4

You need to complain, in writing, to the state insurance commissioner.  Be sure to include all the denial letters, and also include the support papers.

You'll have a response within 30 days.  

Meanwhile, explain to teh doctor, that you're doing this, and expect a response soon, and ask them to give you a month.

Answer 5

You should be able to get this resolved pretty easily.  Its a standard thing for them to inquire about other insurance.  Honestly, if the office visit was just on April 16th of this year, it sounds like its still going through the channels.

Call the insurer and ask whether they now have all the documentation that they need.  You may find out that the claim has already been adjusted - if not, ask them what other information they need from you.

If you haven't made a phone call to them yet, you definitely need to call.  Many insurers will even take a verbal confirmation on a phone call...only way you know is to ask.