Dual insurance:CObra+secondary insurance from hubby's company:who should pay?

[gunnas]

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

I am difficult time to figure this out and would appricate any help.

I was working for a company with Primary insurance as UHC and also had secondary insurance thru my husbands company.
I was laid off in dec 31st 2007, and i was 8 months pregnant, i opted for cobra paid the premium for 2 months so that i would not have to pay later.

I had baby in FEB 13 2008
My doctor filed claim with UHC (which is thru cobra) and it was paid,now UHC is requesting for a refund(around july mid 2008), and the reason is since i had another insurance thru my hubbys comapny Oxford will become primary and UHC(thru cobra) will be secondary.and i was told to file a claim with oxford.

Now problem is Oxford has this rule that participating providers should file for the claim within 90 days from date of service, and since it already crossed 4 months, they are not willing to pay.

How should i handle this situation?,I am in no way capable of paying the bill by myslef.

what should be done when no one pays?legally who should pay in this situation.
Any help is appreciated

[cbg]

Who is primary and who is secondary depends on the wording of the specific policies.

Meaning no disrespect, you should have read both policies BEFORE submitting any claims.

Since we cannot read the policies in question, we cannot tell you which is primary and which is secondary. USUALLY the UHC policy would be primary for you, the Oxford policy would be primary for your husband, and the specific terms of the policies would determine who is primary for the baby. But if the specific policies say otherwise, the policies will rule.

IF it should turn out that Oxford is primary, all you can do is appeal and pray that they decide to be lenient.

[tranquility]

Are you allowed have COBRA when you are already covered by another policy?

[ecmst12]

The usual rule is that a plan through an active employer is primary over Cobra coverage.

[gunnas]

Originally Posted by ecmst12

The usual rule is that a plan through an active employer is primary over Cobra coverage.

I was not aware of this rule and I had no problem in enrolling for a cobra plan even though i had another insurance from my husbands company.

[gunnas]

Originally Posted by cbg

Who is primary and who is secondary depends on the wording of the specific policies.

Meaning no disrespect, you should have read both policies BEFORE submitting any claims.

Since we cannot read the policies in question, we cannot tell you which is primary and which is secondary. USUALLY the UHC policy would be primary for you, the Oxford policy would be primary for your husband, and the specific terms of the policies would determine who is primary for the baby. But if the specific policies say otherwise, the policies will rule.

IF it should turn out that Oxford is primary, all you can do is appeal and pray that they decide to be lenient.

UHC I was Primary
Oxford was from my hubby company, He was primary,and i was a dependent.
I was not aware of this rule that if you have a plan with cobra and a dependent coverage thru hubbys company, Dependent coverage will take precedence over Cobra coverage.

And in this case,UHC reported back the problem fter 3 months, if only they reported it earlier i would have filed with oxford
,whose mistake is that?and how should this be handled?

Thank you for your help

[ecmst12]

Have your doctors file the claims with Oxford and argue the timely filing with them.

[ajkroy]

If Oxford denies the payment for timely filing, then have the doctor refile to UHC with the denial. OP shouldn't have to pay because she had dual coverage.

[ecmst12]

If the doctors appeal the timely filing denial, it will probably be reversed, and if it is not, it will be a contractual write off and OP will not have to pay it.

[lkc15507]

As to order, Oxford dependent of active (spouse) employee coverage mostly likely primary at time of service, which was 2 months after layoff from poster's job. UHC COBRA most likely secondary. I agree with cbg that contractual plan language can change the order, but that is rarely the case and when it does happen it is usually done to be more generous than required (by federal regulation). That is why it rarely happens. Thus my supposition that active employee / dependent coverage (Oxford in this case) will likely be primary over COBRA (UHC in this case). I will make a practical suggestion that one challenge Oxford (if indeed the primary) via appeal procedures based upon 29 CFR 2560.503-1 Claims Procedure.* Whether or not it could prove successful or not, I don't know. In my opinion, is it worth a try. Yes.

My logic. A 90 day filing limit is very short. Short, but possible under federal ERISA and per the “participating provider” contract Oxford provisions that the poster mentions. However, 29 CFR describes reasonable claims adjudication procedures of a health plan not placing an undue burden upon the claimant (my summarization). If, as our poster describes, the incurring of claims was a mere 42 days following her lay-off, this placed the determining of primary vs. secondary in a serious state of ambiguity given that the COBRA election / coverage periods could be 60 days plus and this does not (might not) allow for adequate time to determine primary vs. secondary and notify all involved parties, including the contracted “participating provider”. UHC's payment of the claim based upon information available at the time likely impeded the proper filing with Oxford in that the claim was paid by UHC and did not generate any claim filing with Oxford. Again, in my opinion, one could make a case that all these factors placed an undue burden upon the claimant to file the claim with the primary payer timely in accordance with 29 CFR. So, in my opinion, unless the poster somehow intentionally deceived any of those parties, I think she is wide open to appeal based upon the Oxford (presumed primary) plan having placed an undue burden upon her to file the claim within 90 days.

With this edit, I want to further clarify what I classified as "my summarization" of 29 CFR. 29 CFR is a monster regulation that encompasses much, much, more than simply an undue burden on a claimat as I summarized it. It includes a plethora of federal guidelines for proper adjudication of heathcare claims of all types. I don't want anyone to take my summarization specific to this situation as an oversimplification of the federal regulation.

*(Code of Federal Regulations/ ERISA. This governs ALL health plans. Fully insured, self-insured or whatever. ERISA punts fully insured plans to the state governance, but in a dispute, federal ERISA will apply. State statute must be as generous or more so than federal. State statute cannot be less generous than federal ERISA.)

lkc15507

[momm2500]

did oxford tell you or did they actually send you an eob that they are not paying? you should send them an appeal and have the doctor also appeal explaining the situation