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Secondary insurer rejecting all claims due to my having Primary insurer

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sh999

Junior Member
What is the name of your state (only U.S. law)? California

Hi,

I am added on my spouse's insurance provider (Secondary) as well as through my employer(Primary).
I took entire pregnancy care from a hospital which accepts only my secondary insurance.
The hospital did not ask me if I had any Primary insurance. They just accepted me based on my Secondary insurance.
Towards the end of my pregnancy the Secondary insurance provider asked me if I had any Primary coverage and I said yes.

Now, the Secondary provider is denying all my medical expense claims.
They are asking me to contact Primary insurance provider and if the Primary denies the claims then they will look into it.

Am I liable to pay if both of them reject the claims?

Was it my responsibility to declare my Primary insurance details to the Secondary company.
Was it the hospital's or the Secondary's responsibility to ask my me about my Primary provider?

Thanks
 


I'mTheFather

Senior Member
What is the name of your state (only U.S. law)? California

Hi,

I am added on my spouse's insurance provider (Secondary) as well as through my employer(Primary).
I took entire pregnancy care from a hospital which accepts only my secondary insurance.
The hospital did not ask me if I had any Primary insurance. They just accepted me based on my Secondary insurance.
Towards the end of my pregnancy the Secondary insurance provider asked me if I had any Primary coverage and I said yes.

Now, the Secondary provider is denying all my medical expense claims.
They are asking me to contact Primary insurance provider and if the Primary denies the claims then they will look into it.

Am I liable to pay if both of them reject the claims?

Was it my responsibility to declare my Primary insurance details to the Secondary company.
Was it the hospital's or the Secondary's responsibility to ask my me about my Primary provider?

Thanks
Have you contacted the primary as the secondary suggested? If not, that's where to start before worrying about the rest.

Congratulations on your baby.
 

cbg

I'm a Northern Girl
What they are suggesting is standard protocol. You ALWAYS submit everything to the primary carrier first. THEN you submit to the secondary carrier. ALWAYS.

Yes, it was your responsibility to submit the claims in the proper order.
 

ecmst12

Senior Member
Yes, it was your responsibility to tell your secondary coverage about your primary coverage, as well as making the hospital aware that they have to bill your primary coverage first. Once your primary has processed the claim, the secondary will consider it and will pay based on that policy. But they are not going to pay a penny until they have an EOB from the primary. That is how primary/secondary coverage works.
 

sh999

Junior Member
Thank you all for the quick reply.

The hospital I took medical care doesn't accept my Primary insurance. (Kaiser). Yes we are trying to contact the Primary, but not sure they will approve any of the claims since we have not taken the medical care within their network hospitals.

If the Primary(Kaiser) rejects all the claims , will my secondary approve the claims then?
 

cbg

I'm a Northern Girl
Assuming that the charges are covered under your secondary plan, yes. But it doesn't matter if they're not covered by the primary and you know it; you MUST submit to them first and get the denial before your secondary insurer can go ahead.
 

tranquility

Senior Member
The "assuming" here is quite an assumption. It is quite possible the OP will not be fully compensated for the cost of the choice that was made. Secondary insurance is generally not a good deal. The laws are fuzzy at best and all we have are guidelines. The OP should look to the "coordination of benefits" portion of Kaiser to see what they will pay when a person uses their services by choice when there is a primary coverage at a different place with a different insurance company.

A full denial by the primary will not necessarily allow for coverage by the secondary. Especially in a situation where the primary and secondary have HMO-type coverage, this could be a real problem as the secondary does not want the insured to choose the service they like better. If the primary is a preferred provider insurance, they should still compensate Kaiser to some degree and then the secondary may cover the difference. But, the coordination of benefits clause in the insurance policies (especially the secondary's), will help the OP determine the probable result.
 
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cbg

I'm a Northern Girl
I have a great deal of experience with this, and while I agree that the OP is not guaranteed full coverage by the secondary carrier, there is a better chance than not that there will be at least some coverage. But it's precisely because they don't get to pick which plan they like better that they're required to submit to the primary first, no matter what.

I agree with you also that having secondary coverage is, in most cases, a waste of money.
 

sh999

Junior Member
Thanks much.

yes, the charges are covered under the Secondary plan. The only apprehension I have is what if the secondary says I never informed them about my primary insurance before I took the medical care and tries to deny the claims? Is that a possibility? In that case what are my options?

Thanks.
 

sh999

Junior Member
Ok, I will check the coordination of benefits clause of my Secondary as well as that of my Primary (Kaiser).

Thanks All.
 

cbg

I'm a Northern Girl
I can't say it's completely outside the realm of possibility but it's not likely.

What USUALLY happens is as follows -

You submit the bills to the primary carrier and they make whatever payment is due under their plan.

Then you submit the bills to the secondary carrier. They look at what, if anything, was paid by the primary carrier. They look at what they would have paid if they were the primary carrier. Then they pay the difference.

Please note that is the USUAL method. If your policies say that they will coordinate differently, then the policies rule.

Please also note that they are not obligated to pay a single penny more than the policy says. However, the policy would have to say in so many words that no payment is due if you fail to tell them about a primary carrier, before they could deny claims on that basis.

If they do, then you kick yourself very very hard for not reading the policy and pay the bills.
 

Filius

Junior Member
I can't say it's completely outside the realm of possibility but it's not likely.

What USUALLY happens is as follows -

You submit the bills to the primary carrier and they make whatever payment is due under their plan.

Then you submit the bills to the secondary carrier. They look at what, if anything, was paid by the primary carrier. They look at what they would have paid if they were the primary carrier. Then they pay the difference.
I hope it's OK to piggyback on this thread. I have Blue Cross as primary and Kaiser as secondary. Like the OP, I didn't know that I wasn't allowed to use whichever coverage I want. I have been using Kaiser because its co-payments are lower.

What I'm wondering is, what is the worst that could happen if I keep going to Kaiser doctors? Will they simply bill Blue Cross, and when BC denies coverage, then will Kaiser just pay up?

I realize you can't give me a definitive answer without reading the policies, I'm just asking for your general understanding.

Thanks!
 

TheGeekess

Keeper of the Kraken
I hope it's OK to piggyback on this thread. I have Blue Cross as primary and Kaiser as secondary. Like the OP, I didn't know that I wasn't allowed to use whichever coverage I want. I have been using Kaiser because its co-payments are lower.

What I'm wondering is, what is the worst that could happen if I keep going to Kaiser doctors? Will they simply bill Blue Cross, and when BC denies coverage, then will Kaiser just pay up?

I realize you can't give me a definitive answer without reading the policies, I'm just asking for your general understanding.

Thanks!
No. We prefer you start your own thread. :cool:
 

cbg

I'm a Northern Girl
Kaiser is not going to pay for something that BCBS is responsible for. You can't simply bypass BCBS because you like the Kaiser plan better.

For anything further, please start a new thread. It's confusing for the responders to have two different posters asking questions in the same thread. Piggybacking is discouraged.
 

Filius

Junior Member
Kaiser is not going to pay for something that BCBS is responsible for. You can't simply bypass BCBS because you like the Kaiser plan better.

For anything further, please start a new thread. It's confusing for the responders to have two different posters asking questions in the same thread. Piggybacking is discouraged.
Got it. Thanks and sorry.
 

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