Coordination of Benefits

[tranquility]

What is the name of your state? CA

Hello wise insurance peoples, I'm back for a moment with hat in hand to ask a question rather than answer. I've done a search and, while the topic is discussed, it doesn't really seem to be answered.

My wife is sick. When she was fired from her previous job for being sick, I got her covered as my spouse on my employer's group policy. That was about a year ago. About six months ago, she got another job and one of the fringe benefits of that job was health insurance. She is the subscriber on that insurance policy. Because she is really sick, I thought it wise to not drop her from my policy as spouse and was willing to pay the extra amount for this ace in the hole.

We have always provided both insurance cards to all providers. Hers, with her name on it and, mine, with my name on it (which covers her as well). It seemed like there was no problem. Well, now, problem. Somehow, her insurance policy has formed the opinion they are not the primary policy and refuse to pay until they receive my insurance policies benefits paid forms to do whatever they will do. Of course, my policy feels the same way. So now we have two fully-paid policies refusing to pay for services. The providers are kind so far, but I sense danger if this is not sorted out soon. The bills are not ones where a person gets into the change under the cushions in order to sort things out.

I've looked to the policy provisions of both, and it does not seem precisely clear who is primary or secondary based on contractual provisions and our situation. I've seen the California enactment of the National Association of Insurance Commissioners recommendations regarding the Coordination of Benefits and it seems like my wife's policy is primary. My understanding of the "rules" are:
1. (Not applicable as both have COB provisions.) Insurer without COB Provision is the Prime Carrier.
2. Insurer Covering the Patient as the Subscriber is the Prime Carrier.
3. Insurer Covering the Dependent Spouse for the Longer Period of Time is the Prime Carrier.
4....and so on.

I think rule 2 applies, but the wife's insurance company (through second-hand information from a provider's billing person) is claiming that because my insurance has covered her for a longer time that is the primary and they are secondary.

What do you think? What is the rule in California? I assume my next step is to write a letter stating the above to the insurance companies and my providers to try to prevent problems from becoming insurmountable, but is there anything else I should be doing to cover myself?

Thanks for the time.

 

[cbg]

My understanding is that rule #2 would apply, but I can't provide you with any laws to back it up. To be honest, I don't think it IS law; I think it is simply so deeply ingrained in how insurance policies generally operate that it's come to appear like law.

Let me put it this way; I will have been administrating employer-sponsored group policies for 27 years next month, in multiple states including California, and I have NEVER seen a group policy where #2 was not the case. But I still don't think it's law.

What does the COB section of HER policy say? Not what you were told over the phone; what you are reading in the print version of the policy? She should have been issued a copy of the SPD when she joiined the plan.

 

[ecmst12]

The insurance that you get from your own employer should, at least customarily, always be primary. I would suggest calling her insurance customer service yourself and try to get it straightened out. There's got to be SOME kind of regulation, otherwise how do you resolve if her policy uses rule 3 and his uses rule 2?

 

[tranquility]

As to the written policy, it is not here at work, but speaks of primary and secondary and the response to each. It does not speak to how primary or secondary is determined. However, I don't think it is the policy, but a 113 page summary of the policy.

I've tried to call customer service, but they won't talk to me right now. I've faxed a power of attorney, but they don't like it as it was not created on their form (Or was faxed, or whatever, but it seems like their form is the thing which will fix it--or so they say.) so they are sending out *their* power of attorney (And, HIPAA release. Even though that was supplied before as well.) which I will have to get signed and notarized even though the one already supplied was fine. I've found in my dealing with banks and brokerage houses, it's better to do what they say than to point to the statutes showing them they are wrong. It just goes faster that way. I figure I'll do that here too.

Unless I hear differently, I'll write a letter with the information repeated and use the stupid person "voice" about how it is my understanding that wife's is responsible as primary, but golly, gee, whillikers I don't know about such things and need to rely on professionals such as the billing departments of the providers and the insurance companies to deal with difficulties 'cause I'm a doofus.

Would that hurt me in any way? Should I firm it up at the end and suppose out loud that the California Department of Insurance may be able to guide me? Would such a "threat" help me get quick service or put me in the do-it-all-legal-like department?

 

[cbg]

If I may make a suggestion, you might get further with this issue if your wife did the calling and/or writing. It's her policy; they really have no legal obligation to talk to you. In fact, a very strict reading of HIPAA might suggest that they CANNOT talk to you.

 

[tranquility]

Please review my last post about a month and a half prior to the start of this one, if possible. Suffice to say, for numerous reasons, my wife will not be able to deal with the situation at this time. I am in a place where I am glad I have a health care power of attorney, durable power of attorney and living will all completed for her before any of this came down. I suggest everyone do the same. Get it done for the one's you love.

 

[fairisfair]

Please review my last post about a month and a half prior to the start of this one, if possible. Suffice to say, for numerous reasons, my wife will not be able to deal with the situation at this time. I am in a place where I am glad I have a health care power of attorney, durable power of attorney and living will all completed for her before any of this came down. I suggest everyone do the same. Get it done for the one's you love.

Tranq, try pm'ing moburkes. If she can't help you, she can direct you to some resources who can.

 

[ecmst12]

Actually the DOI sounds like a good resource at this time. Also your wife's HR department may be able to help.

 

[TIMMAAYY]

Good luck with the DOI....


( sorry... just couldn't resist! )

You'd be better off talking to the employer and the insurance carrier. IMHO, most of the people who work at the DOI do so because they probably got fired from the BMV.

 

[moburkes]

Hey, I resemble that remark!

I'm in agreement with the others - that #2 would be the right answer, but cbg is the resident expert on health policies. And, I'm surprised that not even TIMMAAYY had nothing to add.

I'm glad that your wife was able to get another job. From my outside looking in perspective, it *seems* to mean that her health is *somewhat* okay for the moment...

I'm sorry that I have nothing more to add. My response would have been to speak to the insurance company, then contact the department of insurance, for at least some clarification.

And, always remember, to document dates/times/names of the people with whom you spoke.

Please update...

Happy Holidays to all...From South Carolina, where it will be 74 degrees tomorrow.

 

[TIMMAAYY]

When it comes to which policy is going to cover what when you have double coverage, it's a box of chocolates. You never know what you're gonna get.

I tend not to say "they'll do this" or "they'll do that" when it comes to this type of question, because frankly, the insurance companies will ultimately do what they want, regardless of what we think they should do or could do.

My biggest argument and strongest stance is how to BUY insurance. All the red tape is... well... red tape.