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Coordination of Benefits

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Ron Horner

Junior Member
What is the name of your state? Kentucky

My daughter had two health insurance plans when she had surgery. The secondary insurer paid some of the doctor's bill and applied the balance to the $500 deductible. The secondary insurer also paid some of the anesthesiologist's bill and the remaining was applied to the deductible which now totaled the $500 deductible. The primary insurer paid part of the hospital bill and the secondary insurer paid part of the hospital bill. They did not coordinate benefits so the hospital was overpaid. My daughter brought it to the secondary insurer's attention that the hospital was overpaid and asked that the overpayment money be used to pay the $500 deductible. The secondary insurer recovered the hospital overpayment but refuses to pay the deductible. Is the coordination of benefits being applied properly?
 


lkc15507

Member
Very unclear about the payments by either insurer in your post. But, I almost want to say that you answered your own question by the statement that "they did not coordinate benefits so the hospital was overpaid". My main question is whether the $500 deductible you refer to is the deductible for the primary plan or the secondary plan. I am guessing that in a nutshell you are expecting 100% coverage as two plans were in place. That would not be correct. In most situations (COB rules differ plan to plan) you will be responsibile for a minimum of the lesser deductible of the two plans. IE, plan A has a 1000 ded, plan B a 200 ded. You would likely have 200 out of pocket. That speaks to deductibles only and not any other possible out of pockets such as coinsurance, copayments, or usual and customary amounts. I suggest reading both plan documents carefully. Best to you. lkc15507
 

momm2500

Member
first are these 2 group insurance plans or is one an individual plan. second, no matter if there is coordination of benefits or not....you have to meet a deductible under the plan. it also depends on which claims came in first to the insurance company. here is an example.
doctor charges $100 for a visit. first plan pays a straight 80% and sends a check for $80. the second plan has a $200 deductible. well because you did not meet the deductible for the second plan, the total charge of $100 will be applied to the deductible and you will owe $20 or 20%.
 

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