tranquility
Senior Member
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.
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.