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Coordination of benefits

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bruce s.

Junior Member
What is the name of your state (only U.S. law)? California
I purchased a mini med plan underwritten by Fairmont Specialty, United States Fire Insurance Company, marketed by and administered by Sasid, out of Janesville WI.

I recently had outpatient surgery and filed a claim with this Limited Medical Benefits Plan. I recieved a reply saying that this plan has coordination of benefits and that I have to provide them with any and all insurance companies that I have so they can coordinate the payment. I read the complete certificate and there was no mention of any coordination of benefits in it. But there is a "right to reimbursement: If a person recieves a benefit payment from a third party by judgement, settlement, compromise, or otherwise for an injury or sickness and we have paid benefits for same injury or sickness, we reserve the right to be reinbursed from the third party in an amount to the amount we paid to the covered person."

This is a Limited Medical Benefits Plan supplement that states it is not a major medical and pays a pre-determined (indemnity) set amount for hospitilization (hip) DR visits, surgeries, Etc.
When I did purchase this plan I did ask the agent specificly about coordination of benefit. She said there was none, as this is only a supplemental and not meant to replace a major medical policy.
If it does not state that there is coordination of benefits in the policy certificate can they demand that their is? Does the area "right of reinbursement" in the certificate actualy mean coordination of benefits? I was always under the impression that "right to reimbursement" or Subrogation was intended to the person or company that was responsible for the injury or illness.
 


ecmst12

Senior Member
It sounds to me like you are right, but have you read the ENTIRE policy? This type of policy typically does not coordinate and does not care whether you are getting paid more then your actual out of pocket costs were. But you have to read the whole thing.
 

bruce s.

Junior Member
Company responce

The company came back stating we were correct that if the contract does not say they have a coordination of benefits clause, there isn't one.
 

ecmst12

Senior Member
I'm glad you got things straightened out. Claims and customer service people are only human, and this type of policy is so uncommon anymore that it's possible that person had never dealt with it before!
 

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