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insurance/copay what's correct?

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mridley

Junior Member
What is the name of your state (only U.S. law)? California

In our court order for insurance coverage for our children, it states "Both parties shall provide such medical, dental, hospital, and prescription drug insurance coverage as is available to them through their employment at a reasonable cost. Petitioner and Respondent shall each be responsible for one-half of all such expenses not otherwise covered by such insurance and incurred on behalf of the minors."
I have provided all medical, dental, rx, coverage since the divorce through my work for the past 10 years. The copays are $5 and $10.
My ex didnt like my insurance and chose not to use it. My ex purchased an outside medical plan and paid cash for md visits, rx and other medical bills. It had extremely high copays and limited coverages. Dental, medical and rx bills have been ran up over the last 4+ years. Last week I received a letter from the ex stating I was to pay half of the amounts (which I was not aware of until last week) or else....
do I owe half of the charges incurred by the other insurance since the insurance I provided covered everything? what should I do??
 


What is the name of your state (only U.S. law)? California

In our court order for insurance coverage for our children, it states "Both parties shall provide such medical, dental, hospital, and prescription drug insurance coverage as is available to them through their employment at a reasonable cost. Petitioner and Respondent shall each be responsible for one-half of all such expenses not otherwise covered by such insurance and incurred on behalf of the minor"

I have provided all medical, dental, rx, coverage since the divorce through my work for the past 10 years. The copays are $5 and $10.

My ex didnt like my insurance and chose not to use it. My ex purchased an outside medical plan and paid cash for md visits, rx and other medical bills. It had extremely high copays and limited coverages. Dental, medical and rx bills have been ran up over the last 4+ years. Last week I received a letter from the ex stating I was to pay half of the amounts (which I was not aware of until last week) or else....
do I owe half of the charges incurred by the other insurance since the insurance I provided covered everything? what should I do??
Do you share joint legal custody or does one of you have sole legal custody? If one of you has sole legal custody, that could point at who has final say in making medical decisions.

Was the policy your ex purchased considered reasonable by state standards? And was insurance available through her employer?

Also - whose birthday falls first within the year? For example even if you are older, if your birthday falls in February and hers falls in March, Insurance will bill the person's policy whose birthday falls earliest in the year; therefore YOUR insurance would be the primary policy and hers would be secondary.

Does your order state a time period for which the "coordinator" has to provide the other parent with billing information? For example: "Coordinator to provide other parent with copies of receipts for payment of services within 30 days and request reimbursement, due in 30 days"

I think the primary/secondary policy question needs to be addressed first before determining what you're obligated to reimburse.

I am answering this based on my own experience dealing with insurance, but I'm fairly certain this rule applies everywhere (whose policy is primary/secondary).

Hope this helps.
 

LdiJ

Senior Member
What is the name of your state (only U.S. law)? California

In our court order for insurance coverage for our children, it states "Both parties shall provide such medical, dental, hospital, and prescription drug insurance coverage as is available to them through their employment at a reasonable cost. Petitioner and Respondent shall each be responsible for one-half of all such expenses not otherwise covered by such insurance and incurred on behalf of the minors."
I have provided all medical, dental, rx, coverage since the divorce through my work for the past 10 years. The copays are $5 and $10.
My ex didnt like my insurance and chose not to use it. My ex purchased an outside medical plan and paid cash for md visits, rx and other medical bills. It had extremely high copays and limited coverages. Dental, medical and rx bills have been ran up over the last 4+ years. Last week I received a letter from the ex stating I was to pay half of the amounts (which I was not aware of until last week) or else....
do I owe half of the charges incurred by the other insurance since the insurance I provided covered everything? what should I do??
Would your insurance have covered the events your ex is expecting you to pay? Would your insurance have allowed the children to see doctors within a reasonable distance of their primary home? Whose insurance was legally primary? Can the costs still be submitted to your insurance? Did you provide your insurance information to mom?
 

mridley

Junior Member
the insurance answers

Yes, All of the events would have been paid from my insurance company, most of them @ 100%.
I have Kaiser Permanente insurance and they have offices located throughout California. There are many offices here locally where we live.
Since each party could carry the insurance, it was stated that "through their employment" the ex is self employed and obtained other insurance.
The costs I was "sent" last week date back to 2005 to current. The current (2008)charges were on the Kaiser insurance plan and they were @ $5 and $15 copays.
The insurance cards and booklets were provided to the ex since 1999.
Joint legal and physical custody were awarded.
The ex is self employed and purchased the policy knowing I had one already.
I am older than the ex.
There was no "coordinator".

thank you for all of your feedback :)
 

Ohiogal

Queen Bee
Take it back to court and get an order requiring her to pay all those charges that were NOT submitted to your insurance or covered by your insurance since she made the decision to go with another insurance.
 

wileybunch

Senior Member
Hmm, Kaiser? Did you guys hash this out? Because I could see someone NOT wanting to use Kaiser if they had another choice. It's a closed system (or last I knew it was) and so if you have Kaiser, you have to use their hospitals, their doctors, etc. There's no coordination of benefits.
 
Yes, All of the events would have been paid from my insurance company, most of them @ 100%.
I have Kaiser Permanente insurance and they have offices located throughout California. There are many offices here locally where we live.
Since each party could carry the insurance, it was stated that "through their employment" the ex is self employed and obtained other insurance.
The costs I was "sent" last week date back to 2005 to current. The current (2008)charges were on the Kaiser insurance plan and they were @ $5 and $15 copays.
The insurance cards and booklets were provided to the ex since 1999.
Joint legal and physical custody were awarded.
The ex is self employed and purchased the policy knowing I had one already.
I am older than the ex.
There was no "coordinator".

thank you for all of your feedback :)
Well, I know people have their opinions about Kaiser but as with any other insurance provider, it's all about knowing how to use the system to maximize your benefits. The last time I had Kaiser, it had improved tremendously since my previous enrollment and they even had the option to assign a primary care physician. Most physicians would schedule a pre-meeting so you could decide who was best for you (and your family).

If your ex bought a separate policy and added your child; as joint custodians, she should have informed you of your child's healthcare at the time of service; NOT three years later! Also, if your birthday falls earlier on the calendar than hers, YOURS is the primary coverage. My ex and I were 3 days apart on the calendar, even though though he was/is 2 years older; my birthday was before his. Therefore, MY policy was billed first, then his picked up whatever portion was not covered. That's how insurance billing works. I would also place a call to Kaiser to see how coverage works when one parent has Kaiser and the other has another plan outside their network.

Has ex ever provided YOU with HER insurance information? If not - ask for it. If it's a benefit to your child, you are both entitled to process claims against that policy for your child - not just HER.

I would try to find out what the statute of limitations is for requesting reimbursement. At best, I would think it would have to be within the plan year. Do your homework and offer to reimburse half of 2008's co-pays, and explain why you are not obligated to reimburse the rest. Provide backup to your arguement!

"Coordinator", by definition means which ever parent arranged for the health care. If you took your child to the physician and paid the co-pay, YOU are the coordinator and should inform your ex and include a copy of the services rendered, what was paid, etc. She should have been doing this too, but apparently did not. Her lack of administrative skills should not be your punishment.
 
What is the name of your state (only U.S. law)? California

In our court order for insurance coverage for our children, it states "Both parties shall provide such medical, dental, hospital, and prescription drug insurance coverage as is available to them through their employment at a reasonable cost. Petitioner and Respondent shall each be responsible for one-half of all such expenses not otherwise covered by such insurance and incurred on behalf of the minors."
I have provided all medical, dental, rx, coverage since the divorce through my work for the past 10 years. The copays are $5 and $10.
My ex didnt like my insurance and chose not to use it. My ex purchased an outside medical plan and paid cash for md visits, rx and other medical bills. It had extremely high copays and limited coverages. Dental, medical and rx bills have been ran up over the last 4+ years. Last week I received a letter from the ex stating I was to pay half of the amounts (which I was not aware of until last week) or else....
do I owe half of the charges incurred by the other insurance since the insurance I provided covered everything? what should I do??
Is there anything in your CO that specifies a time frame on the medical bills. It's not usually looked kindly upon when you save the bills up and try to go back for multiple years.

Take it back to court and get an order requiring her to pay all those charges that were NOT submitted to your insurance or covered by your insurance since she made the decision to go with another insurance.
I would do as Ohiogal said, take it back to court and get that order. I would also request that a timeframe be placed into the order regarding submission of medical bills that are to be split. It avoids any misunderstandings in the future...
 

wileybunch

Senior Member
Well, I know people have their opinions about Kaiser but as with any other insurance provider, it's all about knowing how to use the system to maximize your benefits. The last time I had Kaiser, it had improved tremendously since my previous enrollment and they even had the option to assign a primary care physician. Most physicians would schedule a pre-meeting so you could decide who was best for you (and your family).
But who's to say one parent's choice of insurance, particularly one that's a closed system that forces you to use their providers, their insurance-company owned hospitals, etc. should be the insurance coverage that must be used?

He knew ex purchased another plan and no one moved to resolve that loggerhead. I don't see where OP's insurance should be considered supreme in this case unless I'm missing something.

What OP didn't know until now were the various bills incurred. For that, as has been mentioned, is there a time period specified in the CO that the bills must be presented? If not, I think OP can *arbitrarily* pick a time limit for now and I wouldn't agree to go back to 2005 unless there was some reason it took a couple years for insurance to figure out the insured's share. Otherwise, at this point, I would say OP should only offer to be responsible back to 1/1/2008.

But, this all needs to be hammered out by stipulation or by having the matter in front of the judge personally, both the insurance coverage in the first place and the deadline for turning in receipts/EOBs for reimbursement.
 
But who's to say one parent's choice of insurance, particularly one that's a closed system that forces you to use their providers, their insurance-company owned hospitals, etc. should be the insurance coverage that must be used?

He knew ex purchased another plan and no one moved to resolve that loggerhead. I don't see where OP's insurance should be considered supreme in this case unless I'm missing something.
The CO could state that one parent's policy is preferred over the other but I know for a fact that insurance bills the primary coverage first and the way it's determined which policy is primary, is by the way I described. If the child needs to see a specialist that is outside of the Kaiser network, maybe that can be singled out as a reason for preference. Just a thought.

What OP didn't know until now were the various bills incurred. For that, as has been mentioned, is there a time period specified in the CO that the bills must be presented? If not, I think OP can *arbitrarily* pick a time limit for now and I wouldn't agree to go back to 2005 unless there was some reason it took a couple years for insurance to figure out the insured's share. Otherwise, at this point, I would say OP should only offer to be responsible back to 1/1/2008.
Yes - I agree. The CO should state a specified period for which reimbursement needs to be submitted. My own order stated 30 days to submit and 30 days to respond.

If the CO does not specify time - I agree with you that holding onto bills for over three years is not reasonable. I'd find something published on the subject from several sources to support my argument.

But, this all needs to be hammered out by stipulation or by having the matter in front of the judge personally, both the insurance coverage in the first place and the deadline for turning in receipts/EOBs for reimbursement.
It's fun little battles like these that make you re-examine the wording of the existing order so you can modify what needs to be less ambiguous.

Personally, I'd try to settle the matter with the ex and if you can't agree, then do as wiley says - stipulate to avoid confusion in the future and/or have a judge settle it for you.

Good luck!
 
It's fun little battles like these that make you re-examine the wording of the existing order so you can modify what needs to be less ambiguous.

Personally, I'd try to settle the matter with the ex and if you can't agree, then do as wiley says - stipulate to avoid confusion in the future and/or have a judge settle it for you.

Good luck!
Makes me almost thankful that our order just goes on the assumption that we will meet the Catastrophic Limit every year and they calculate it into the order. I'm waiting for that sweet someday when I can ask for a modification because we didn't meet the limit!:p Life is too stressful as it is without fighting about 3yo bills...Good luck to you...
 

mridley

Junior Member
kaiser insurance in our area

I have had kaiser ins for over 10 years now. The plan is a Point of Service plan and I can pick any doctor, change @ anytime, which I have. Any of the members on my plan can pick and choose who they see. For special needs, authorizations, and referrals to an "outside" doctor the services have never been denied. If something is needed, just ask. We have regular hospitals that they are contracted with kaiser and the nearest "Kaiser" hospital is 2+ hours away. For the extra amount I pay for the insurance to have this type of plan, its well worth it. Its not the kaiser that people use to know. The ex was given cards for the kids and a member services book from the beginning. It was provided by me but my ex didnt like it...
 

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