Unreimbursed medical/dental expenses

[SMinNJ]

Originally Posted by Zephyr

if dad wants his billed first- why not take his card to the dentist, sign the paper give them the card and request they notify of any charges not covered....then the ball is in mom's court she can use her insurance or not

That's already been done. Child's first appointment was the middle of December - the ortho had the card in October. The problem is not using both cards - the problem is the order in which they are used. Since mom's insurance only covers a finite amount, and dad's covers everything BUT a finite amount, it makes more financial sense to use dad's card as primary, to be billed first. The problem is that mom's birthday is in the spring, and dad's birthday is in the fall, and this is the criteria the insurance companies use for determining which is primary. So, Mom's insurance gets submitted first, as primary.

As I said above, if the bill is $5000, there is the following scenario using mom's insurance as primary.

$5000 - $1500 (mom's insurance pays only $1500 total) = $3500 - $2500 (total submitted to dad's insurance minus $1000 co-pay) = $1000 parental responsibility

If dad is primary:

$5000 - $4000 (total submitted to dad's insurance minus $1000 co-pay) = $1000 - $1500 (amount mom's insurance will pay) = $00000 out of pocket.

So, they go from having to pay $1000 between them to having to pay nothing between them. And that is with both of them using their insurance, in both cases.

It is necessary for dad to be primary. Perhaps someone can help dad write this out so that it is crystal clear for the attorney and mom.

Thanks.

[Zephyr]

will the insurance company approve this change in primary for a particular procedure and then revert back to mom being primary?

[SMinNJ]

Originally Posted by Zephyr

will the insurance company approve this change in primary for a particular procedure and then revert back to mom being primary?

The dental insurances carried by each parent are with different companies than the medical insurances. So, I think it doesn't matter. Regardless, dad carries both medical and dental for the child, since he pays as much to cover the three in our nuclear family as he does including his daughter, so if they insurance companies won't allow it, she would still be covered permanently under his plan.

Dad is unable to prove, but believes, that the original reason mom requested the switch is because she did not want dad to have access to the EOB's. Mom has stated that she is required to give no information to dad regarding the child's health unless it is interferes with his parenting time. While he understands that is technically true, it complicates matters when he wants to know if she's sick, because it clearly would not be practical to call all of her health care providers each week to find out if the child has been in for a visit. Additionally, her pediatrician has advised him that they won't give information like that over the phone. In order to find out if she has been in for a visit, he must pay a $15 photocopy fee to get a copy of her records. It is also impossible, without an EOB, for him to know who the child is seeing for a particular service. It took four years of him asking for mom to reveal the name of the child's dentist. It took over a month for mom to tell him who had prescribed for the child the glasses she showed up for parenting time with. The child was court-ordered into counseling, but mom and her counsel have refused for over four months to provide the dad with the name, if any, of the counselor the child is seeing. Dad currently has no parenting time (separate issue), but even when he was seeing the child every week, it is impractical, and perhaps bordering on involving the child in the parental issues, to ask whether she had been to the doctor, eye doctor, dentist, or counselor that week.

[Zephyr]

this is absolutely ridiculous!!!!!! if he ever wants to not have this headache- he must get this back in court and get mom's responsibilities listed out specifically.....a motion for clarification -or your state's equivalent, might help in that regard

[SMinNJ]

Originally Posted by Zephyr

this is absolutely ridiculous!!!!!! if he ever wants to not have this headache- he must get this back in court and get mom's responsibilities listed out specifically.....a motion for clarification -or your state's equivalent, might help in that regard

Please don't think that I am arguing with you - legally, you are absolutely right.

But this reminds me of the earlier flames regarding the father's rights and MS conversations - and I'm not necessarily talking about father's rights, I'm talking about law versus practice.

In each of the previous two cross motions dad filed, after original motions by mom, dad submitted parenting plans which would fix these issues - mom notifying dad within one week of any doctor appointments, sending dad copies of notices sent home from school, etc. Each time, by the time the issues that mom brought up were decided (pretty much all in dad's favor, by the way), the judges were tired of the whole situation and just sent everyone home, without adjudicating any of the side matters. This summer, dad filed for custody, primarily on child's request, but with these side issues as evidence of mom's inability to co-parent. Immediately, mom filed an ex-parte, stating that the child never wanted to see dad again. So, you can guess where they have been since JUNE - evaluators and GAL's and counselors, who will focus on the issue that doesn't exist - the child's relationship with dad, and I'm willing to bet, at the end of the day, the issues that dad brought up will be tossed. In the last court action, in which dad's parenting time was suspended, after the judge talked to the child, everything was put back to normal - a year later. The judge refused to discuss makeup time, which had been requested by dad's attorney. In NJ, family court judges rotate in and out of family court, so for four actions (divorce and 3 pj's), there have been four different judges - never able to get a handle on the manipulations going on.

So, dad has pretty much reconciled himself to getting through this, knowing that things will go back the way they were, and never trying anything again.

Practice versus reality - a judge must do something about a motion brought before him - right? But in reality, nothing is completed.

Thanks for your help.

[wileybunch]

Originally Posted by SMinNJ

Dad is unable to prove, but believes, that the original reason mom requested the switch is because she did not want dad to have access to the EOB's.

BINGO. ...

[SMinNJ]

Originally Posted by wileybunch

BINGO. ...

I'm sorry - BINGO as in Bingo, that's what Mom's trying to do? Or BINGO... something that I don't get :-)

[Zephyr]

I believe that was bingo as in, agreement...

[SMinNJ]

Originally Posted by Zephyr

I believe that was bingo as in, agreement...

Thanks, that was what I thought, but I thought I'd clarify...

Not up for discussing it this evening, but we're thinking mom's attorney just pulled a fast one that blows our minds...

[escape2paradise]

Originally Posted by SMinNJ

Thanks, that was what I thought, but I thought I'd clarify...

Not up for discussing it this evening, but we're thinking mom's attorney just pulled a fast one that blows our minds...

Ahhh, cliffhanger, darn!

[LdiJ]

Originally Posted by Ohiogal

No. NOt necessarily. In Ohio and several other states that I have looked at the obligee (person receiving child support) is responsible for a certain amount of out of pocket before any division kicks in and that is based on the fact that they RECEIVE child support and NOT who provides insurance.

Indiana does the same. The amount of out of pocket that the obligee must pay is a percentage of the child support received. I think its 7% of the yearly amount of child support, but I admit its been a while since I looked it up.

[wileybunch]

Originally Posted by Zephyr

I believe that was bingo as in, agreement...

Totally. We have not gone through this very scenario, but the goal on Mom's side was to keep from having Dad have access to medical insurance information, just anything to keep him at a distance b/c it threatens the alpha. I just recognized the earmarks. I also wondered if Mom in your case has another account or dental plan of some sort (from a new husband?) to run the claims through so she isn't really going to be left paying as much as you think, but I think the withholding as much info away from Dad is likely the primarily or only goal.

At least in our case the Mom was cooperative with braces so my insurance was primary (so long as someone else's info is first) and her husband's was secondary and the balance left to pay OOP split was only $900.

[SMinNJ]

Originally Posted by wileybunch

Totally. We have not gone through this very scenario, but the goal on Mom's side was to keep from having Dad have access to medical insurance information, just anything to keep him at a distance b/c it threatens the alpha. I just recognized the earmarks. I also wondered if Mom in your case has another account or dental plan of some sort (from a new husband?) to run the claims through so she isn't really going to be left paying as much as you think, but I think the withholding as much info away from Dad is likely the primarily or only goal.

At least in our case the Mom was cooperative with braces so my insurance was primary (so long as someone else's info is first) and her husband's was secondary and the balance left to pay OOP split was only $900.

Updating this thread for posterity and future educational sake... Heard from the ortho, who spoke to dad's insurance company. The simple fact that there are court orders do NOT dictate who will be used as primary or secondary. The court order must specifically state that the policy is to be used as the primary policy, or else it will go by the birthday rule. In my husband's situation, the orders simply state that mom (or dad) will be responsible for maintaining health coverage. According to the insurance company, that does not mean that the insurance company must use the ordered insurance as primary. If mom goes ahead and gets coverage after dad's is ordered, and if mom's birthdate occurs before dad's in the calendar year, then mom's coverage will be used as primary, regardless of whether dad has been ordered to maintain coverage.

After speaking with the ortho and the insurance company, dad spoke to his employer's benefits office, who indicated that whatever the insurance company said is the rule and they won't help get dad's used as primary.

So, in dad's case, he has sent a proposed consent order to mom's attorney stating specifically that dad's will be used as primary, mom's will be used as secondary, and that mom is responsible for the first $250 of any out of pocket expenses, as dictated by the child support guidelines.

I thought this might be educational for those who come after. We'll see what happens for dad.

[wileybunch]

Originally Posted by SMinNJ

The simple fact that there are court orders do NOT dictate who will be used as primary or secondary. The court order must specifically state that the policy is to be used as the primary policy, or else it will go by the birthday rule.

Right -- the court order must be specific WHO is primary to override insurance company's default rules.

Originally Posted by SMinNJ

So, in dad's case, he has sent a proposed consent order to mom's attorney stating specifically that dad's will be used as primary, mom's will be used as secondary, and that mom is responsible for the first $250 of any out of pocket expenses, as dictated by the child support guidelines.

Yep, sounds good.

[SMinNJ]

Originally Posted by wileybunch

Right -- the court order must be specific WHO is primary to override insurance company's default rules.

Yep, sounds good.

So, apparently this sounded good, but not to mom or her counsel. After receiving the consent order proposed by dad, mom's counsel wrote back that insurance companies have their own policies as to how things are billed and are not bound by any court order in which the company is not a party to the action and that attempting to manipulate the policies simply because mom and dad are divorced does not appear proper. This is why they can't consent.

Clearly, none of this would be an issue if the parties are not divorced, and the insurance companies very clearly say, when asked, that if the order says who will be primary, they will process accordingly. However, the insurance companies claim they have nothing in writing that they can send which will state this.

Uggh.