Secondary insurance

[stormy]

What is the name of your state? Ohio

My primary insurance paid 80% of my medical bill but my secondary insurance is not paying anything. They stated on the explanations benefit that the reason for nonpayment is as follows: "We can't approve payment for the service because your primary insurer has paid the most that we would have paid". My question is can they refuse to pay since they are only a secondary insurance plan and should pick up at least 17% of what is left of the bill?

[THE PRACTICE-04]

Originally Posted by stormy

What is the name of your state? Ohio

My primary insurance paid 80% of my medical bill but my secondary insurance is not paying anything. They stated on the explanations benefit that the reason for nonpayment is as follows: "We can't approve payment for the service because your primary insurer has paid the most that we would have paid". My question is can they refuse to pay since they are only a secondary insurance plan and should pick up at least 17% of what is left of the bill?

My response:

Please write out your entire Policy, exactly as written, so that we can review whether or not they "can't approve payment for the service because your primary insurer has paid the most that we would have paid".

Failing that, call your State Insurance Commission.

IAAL

[ShyCat]

It's not at all unusual for secondary insurance to end up not paying anything. In my experience, the secondary insurance we had only paid if their benefit payment (if they'd been the primary or only insurance) would have been more than the primary insurance paid. In that case only, the secondary insurance would pay the difference between what they would have paid and what was paid by the primary.

For example, if Primary Insurance Company pays 80% of $100 bill and Secondary Insurance Company would have paid 85% of that same bill if they'd been the primary insurance, Secondary Insurance Company would pay $5, the difference between their theoretical $85 payment and the actual $80 payment made by Primary Insurance Company.

If Secondary Insurance Company would have paid less than or the same 80% as paid by Primary Insurance Company, there is no difference in benefits and so no additional benefit payment.