Primary vs. Secondary Policies

[WFPKAlumna]

What is the name of your state? North Carolina

In January my son was in the hospital for several days, and he is covered by both an individual policy and a group policy through my husband's employer. We bought the individual policy for him when he was a baby and my husband worked at a small software company. After we got the policy we found out that our son has a life-threatening illness that will cause him to periodically have complications and end up in the hospital. Soon thereafter, my husband went to work for a larger corporation and we got group coverage. We never used the individual policy but kept it in case my husband were to ever get laid off or something worse happened. The individual policy is with Blue Cross and Blue Shield and my husband's group insurance is now with the same company of this January. The problem is that the group policy is not paying and BCBS is saying that the individual policy takes precedence in medical cases. (We can choose whether to use the group or the individual for pharmacy, however.) Obviously, the difference we will have to pay out of pocket is substantial, but we don't know what to do. Do individual policies always serve as the primary and the group serve as the secondary?

[cbg]

No, not always. It depends on how the specific policies define primary and secondary coverage.

[WFPKAlumna]

I'm not sure what you mean. I apologize but I'm really confused about all of this right now because I've been given so much conflicting information from BCBS. Would it be possible for you to elaborate?

[cbg]

It's not a question of, group policies are always primary over individuals, or individuals are always primary over group. It's, how does THIS policy, BCBS policy #123456789 or Humana policy ABCDEFG or UHC policy #987654321, define who will be primary in the case of two insurance plans.

It might be which policy was issued first. It might be which one is on the individual himself and which one is he a dependent. In the case of a child whose double coverage is through his parents' employment, it might be the "birthday rule" - i.e., which parent has a February birthday and which one has the October - the February birthday parent's policy is primary. It could be something else I haven't thought of.

But what you have to do is look at YOUR TWO POLICIES and see what they say about primary and secondary coverage. The law does not dictate which policy will be primary - it's a contractual issue.