Unreimbursed medical/dental expenses

[SMinNJ]

What is the name of your state? NJ

Dad is NCP with joint legal. Mom is PPR. Child is getting braces. Ortho requires some money up front. Original divorce decree, which contained custody, ordered "Husband shall maintain health insurance on behalf of the minor child as same is being offered through his employment at a reduced rate. Wife is responsible for the first $250 per year of any unreimbursed ordinary medical expenses in accordance with the guidelines. Any additional unreimbursed expenses shall be split equally, 50%, between the parties."

In 2004, in a separate pj order, mom was ordered to maintain health insurance as it was offered free at her employment. There was no clause included which would change the responsibility for the first $250 to dad.

It is dad's understanding that the guidelines referred to in the original order are the child support guidelines.

It is also dad's understanding that because the clause was not changed in the second order, the orders are now reflecting mom providing the health insurance as well as being responsible for the first $250. Mom has never, in seven years since the divorce, requested payment for any medical expenses from dad, which has allowed her to avoid notifying dad of any health-related appointments.

Mom has asked for dad to pay the ortho directly for the first half of the first payment.

The ortho, knowing that this is a divorce situation, requires both parents to sign the financial agreement before braces are placed. Dad has continued to carry dental insurance for the child on his own, and his plan is more comprehensive and would result in no out of pocket expenses. He has requested a court order to reflect that his dental insurance should be used as primary for the ortho only.

The ortho's financial agreement clearly does not state this, and dad wishes to wait until the insurance is properly used before signing the financial agreement. Mom's counsel demands that dad sign now, and that he pay for half of what the financial agreement stipulates, which, in order to put the braces on, would be $150 split between the two parents - clearly less than the $250 of unreimbursed which he believes mom is responsible for. This is only the first payment - the costs get much higher.

Mom and dad are in the middle of a court dispute not involving the ortho. Their judge has, in the past, ordered that Dad give mom his dental card for child so that they can minimize the costs. Dad is pro se, and has asked mom, through counsel, several times, to sign a consent order to be signed by their current judge, to order dad's insurance to be used as primary, which is what the ortho requires in order to file as such with insurance. Apparently, in the absence of a court order, the insurance company will go by the first parental birthday in the calendar year, which would be mom. Mom provided no court order to the ortho for this process, and in fact told the ortho that there was no applicable court order.

Is mom responsible for the first $250?

 

[fairisfair]

legally, at this point. maybe.

morally, no.

and if she asks for clarification from the court, most likely not.

 

[SMinNJ]

legally, at this point. maybe.

morally, no.

and if she asks for clarification from the court, most likely not.

Thanks

 

[JBMD]

What is the name of your state? NJ

Dad is NCP with joint legal. Mom is PPR. Child is getting braces. Ortho requires some money up front. Original divorce decree, which contained custody, ordered "Husband shall maintain health insurance on behalf of the minor child as same is being offered through his employment at a reduced rate. Wife is responsible for the first $250 per year of any unreimbursed ordinary medical expenses in accordance with the guidelines. Any additional unreimbursed expenses shall be split equally, 50%, between the parties."

In 2004, in a separate pj order, mom was ordered to maintain health insurance as it was offered free at her employment. There was no clause included which would change the responsibility for the first $250 to dad.

It is dad's understanding that the guidelines referred to in the original order are the child support guidelines.

It is also dad's understanding that because the clause was not changed in the second order, the orders are now reflecting mom providing the health insurance as well as being responsible for the first $250. Mom has never, in seven years since the divorce, requested payment for any medical expenses from dad, which has allowed her to avoid notifying dad of any health-related appointments.

Mom has asked for dad to pay the ortho directly for the first half of the first payment.

The ortho, knowing that this is a divorce situation, requires both parents to sign the financial agreement before braces are placed. Dad has continued to carry dental insurance for the child on his own, and his plan is more comprehensive and would result in no out of pocket expenses. He has requested a court order to reflect that his dental insurance should be used as primary for the ortho only.

The ortho's financial agreement clearly does not state this, and dad wishes to wait until the insurance is properly used before signing the financial agreement. Mom's counsel demands that dad sign now, and that he pay for half of what the financial agreement stipulates, which, in order to put the braces on, would be $150 split between the two parents - clearly less than the $250 of unreimbursed which he believes mom is responsible for. This is only the first payment - the costs get much higher.

Mom and dad are in the middle of a court dispute not involving the ortho. Their judge has, in the past, ordered that Dad give mom his dental card for child so that they can minimize the costs. Dad is pro se, and has asked mom, through counsel, several times, to sign a consent order to be signed by their current judge, to order dad's insurance to be used as primary, which is what the ortho requires in order to file as such with insurance. Apparently, in the absence of a court order, the insurance company will go by the first parental birthday in the calendar year, which would be mom. Mom provided no court order to the ortho for this process, and in fact told the ortho that there was no applicable court order.

Is mom responsible for the first $250?

Just a heads up ... and maybe a possible avoidance of court issues!!

Since dad cover's his child on his insurance, he can submit any payments to the insurance company himself! He doesn't have to go throught the dentist (and usually when two insuarances are involved the dentist will submit to both) mom's would be primary as she is CP, but Dad's insurance will still cover the cost.

Maybe make a call to the insurance company to verify coverage before making such a huge deal of this!

ANd if mom won't agree to submitting to dad's insurance, dad just needs to make sure that he has a copy of the reciept to submit to his insurance for reimbursement. It seems odd that mom doesn't want to use dad's insurance as it would also save her money ... but i suppose you just never know!! UGH!!!

 

[SMinNJ]

Just a heads up ... and maybe a possible avoidance of court issues!!

Since dad cover's his child on his insurance, he can submit any payments to the insurance company himself! He doesn't have to go throught the dentist (and usually when two insuarances are involved the dentist will submit to both) mom's would be primary as she is CP, but Dad's insurance will still cover the cost.

Maybe make a call to the insurance company to verify coverage before making such a huge deal of this!

ANd if mom won't agree to submitting to dad's insurance, dad just needs to make sure that he has a copy of the reciept to submit to his insurance for reimbursement. It seems odd that mom doesn't want to use dad's insurance as it would also save her money ... but i suppose you just never know!! UGH!!!

Thanks for your input.

The problem is not submitting to dad's insurance - the problem is the order in which it is submitted.

Mom's insurance only covers the first $1500. Dad covers everything but $1000. So, here's an example:

Braces cost $5k. Ortho submits to mom's, they pay $1500, leaving $3500. Then, ortho submits to dad's, they pay all but a $1k co-pay. So, dad's insurance pays $2500, leaving the parents to pay $1000.

If ortho submits to dad's, dad's insurance pays $4000, leaving a $1000 co-pay. Then, the ortho submits to mom's, which pays the entire co-pay, since it is less than $1500. No out-of-pocket for the parents.

Dad has spoken to the insurance company to confirm that this is what would happen if they are the primary. Dad has explained this ad nauseum to mom and her attorney, both before and after the current court action.

I hope this clarifies.

 

[Ohiogal]

Actually:
Mom is responsible for the first $250 of out of pocket because she is the obligee and receives child support -- hence a portion of child support is assumed to cover some medical. Therefore mom does have to pay the first $250 if dad is paying child support -- but that is of ALL out of pocket for the year not per appointment.
Second, mom's insurance is NOT necessarily primary. The court order may state it is primary (which could make it so) but if they both have insurance it is based on the birthdates of the parents as to which insurance is primary and which is secondary. NOT on who is CP and who is not.

 

[fairisfair]

Actually:
Mom is responsible for the first $250 of out of pocket because she is the obligee and receives child support -- hence a portion of child support is assumed to cover some medical. Therefore mom does have to pay the first $250 if dad is paying child support -- but that is of ALL out of pocket for the year not per appointment.
Second, mom's insurance is NOT necessarily primary. The court order may state it is primary (which could make it so) but if they both have insurance it is based on the birthdates of the parents as to which insurance is primary and which is secondary. NOT on who is CP and who is not.

yes, but, wasnt' that based on the fact that at the time dad was paying for the insurance for the child as well??

 

[TinkerBelleLuvr]

Actually:
Mom is responsible for the first $250 of out of pocket because she is the obligee and receives child support -- hence a portion of child support is assumed to cover some medical. Therefore mom does have to pay the first $250 if dad is paying child support -- but that is of ALL out of pocket for the year not per appointment.
Second, mom's insurance is NOT necessarily primary. The court order may state it is primary (which could make it so) but if they both have insurance it is based on the birthdates of the parents as to which insurance is primary and which is secondary. NOT on who is CP and who is not.

When we specified the order of the insurance submissions in our court order, the insurance companies complied.

 

[SMinNJ]

Actually:
Mom is responsible for the first $250 of out of pocket because she is the obligee and receives child support -- hence a portion of child support is assumed to cover some medical. Therefore mom does have to pay the first $250 if dad is paying child support -- but that is of ALL out of pocket for the year not per appointment.
Second, mom's insurance is NOT necessarily primary. The court order may state it is primary (which could make it so) but if they both have insurance it is based on the birthdates of the parents as to which insurance is primary and which is secondary. NOT on who is CP and who is not.

Thank you. Prime example of me truly appreciating advice when it agrees with what I thought . More the better that it comes from one of the seniors (who are all amazingly smart).

He understands that it is for the year, not the appointment. Since the year is fresh and new, most likely it is the only unreimbursed so far. She has never requested any unreimbursed medical from him in the past, so he has no way truly of knowing what she ever pays out in medical, but it seems from his perusal of the child's medical records that she has had perhaps five to six appointments per year, which might make it impossible for there to have ever been more than $250 in unreimbursed costs.

He also understands that it is not the CP issue that makes it or breaks it. The insurance companies, and the ortho, agree that barring a court order, it goes by birthdays, and mom's is before dad's. That is why he has been trying to get mom to sign a consent order to have signed by the court - to overrule the birthdays just for the dental. To be perfectly straight, his medical benefits cost no more to cover her than it does to cover the rest of the family, so he has kept her on his medical plan as well. Such was the case when mom requested that she be the primary insurer - and it hasn't changed, so it would be no big deal if he were required to carry her on both by the court order.

Thanks again Ohiogal, and the others...

 

[Ohiogal]

yes, but, wasnt' that based on the fact that at the time dad was paying for the insurance for the child as well??

No. NOt necessarily. In Ohio and several other states that I have looked at the obligee (person receiving child support) is responsible for a certain amount of out of pocket before any division kicks in and that is based on the fact that they RECEIVE child support and NOT who provides insurance.

 

[Ohiogal]

When we specified the order of the insurance submissions in our court order, the insurance companies complied.

They can and that doesn't surprise me. I just didn't want to give a guarantee as insurance law is regulated on a federal level I do believe and that would override state decisions.

 

[Ohiogal]

Thank you. Prime example of me truly appreciating advice when it agrees with what I thought . More the better that it comes from one of the seniors (who are all amazingly smart).

He understands that it is for the year, not the appointment. Since the year is fresh and new, most likely it is the only unreimbursed so far. She has never requested any unreimbursed medical from him in the past, so he has no way truly of knowing what she ever pays out in medical, but it seems from his perusal of the child's medical records that she has had perhaps five to six appointments per year, which might make it impossible for there to have ever been more than $250 in unreimbursed costs.

He also understands that it is not the CP issue that makes it or breaks it. The insurance companies, and the ortho, agree that barring a court order, it goes by birthdays, and mom's is before dad's. That is why he has been trying to get mom to sign a consent order to have signed by the court - to overrule the birthdays just for the dental. To be perfectly straight, his medical benefits cost no more to cover her than it does to cover the rest of the family, so he has kept her on his medical plan as well. Such was the case when mom requested that she be the primary insurer - and it hasn't changed, so it would be no big deal if he were required to carry her on both by the court order.

Thanks again Ohiogal, and the others...

Dad needs to pound home how much money it will save mom if his insurance covers first and that it makes fiscal sense and that she (mom) will have more money to spend on herself and junior.

 

[SMinNJ]

No. NOt necessarily. In Ohio and several other states that I have looked at the obligee (person receiving child support) is responsible for a certain amount of out of pocket before any division kicks in and that is based on the fact that they RECEIVE child support and NOT who provides insurance.

I took this directly from New Jersey's Child Support Guidelines - Appendix IX-A
Unreimbursed Health Care Up to and Including $250 Per Child Per Year - Unreimbursed health-care expenditures (e.g., medical and dental) up to and including $250 per child per year are included in the schedules. Such expenses are considered ordinary and may include items such as non-prescription drugs, co-payments or health care services, equipment or products. The parent's cost of adding a child to health insurance policy is not included in the schedules.

This indicates to me what Ohiogal said above... Later in the Appendix it speaks of certain things that can be added to the guidelined child support - certain predictable medical expenses over $250 and Health Insurance for the Child - The parent's marginal cost of adding a child to a health insurance premium is not included in the support schedules and should be added to the basic obligation if incurred.

In dad's case, since neither mom nor he pay additional money for the core medical insurance, this might not apply. Dad, at least on his part, pays for a family plan for both medical and dental, which means no matter how many dependents he has covered, he pays the same amount. Mom, in the amended order, stated that her medical insurance was provided free from her employer.

 

[SMinNJ]

Dad needs to pound home how much money it will save mom if his insurance covers first and that it makes fiscal sense and that she (mom) will have more money to spend on herself and junior.

Trust me, dad has pounded this. In letters to both mom and her counsel, he has laid out, with exact figures, how much more they would pay if mom's insurance was primary. Mom and her counsel have never once addressed this back to dad. Dad wanted them to agree to use his as primary before any appointments took place. Mom and counsel ignored this request. He has emails and letters to them both dating back to April stating how it all would work out. He asked the judge to write an order in August, but the judge said that the first step was for dad to provide mom with the dental card so that mom could investigate for herself how it would work out. The judge indicated that a consent order could be filed and signed when both parties had the info in front of them.

Mom had her counsel send dad a letter which he received over the weekend which stated that the child had an appointment and could not get her braces because dad refused to sign the agreement - even though dad had already explained to the ortho and the attorney why it was unnecessary for either side to agree to pay out-of-pocket costs.

Additionally, it was brought to my attention outside of this thread that my original post may have made it seem like dad was trying to get out of paying. Dad has no problem paying if that's how it were to work out, but all info shows that with a hair's cooperation, no one would have to pay, and that's why he won't sign at this time. He has lots of experience with mom not cooperating or withholding information, and he is afraid if he signs now, mom will not ever do what might be necessary to comply, just because she can. This is orthodontia to correct an overbite, not an appendix operation, and if it needs to be delayed a few months in order to get all the ducks in a row, it makes more sense for both parties to wait. Mom will have an equally difficult time getting her money back later.

 

[Zephyr]

if dad wants his billed first- why not take his card to the dentist, sign the paper give them the card and request they notify of any charges not covered....then the ball is in mom's court she can use her insurance or not