denial after paid claims

[lkm]

My insurance company was paying for portions of infertility treatments for six months and then decided it wasn't supposed to be covered by my plan. They are now asking the doctors and hospitals for reimbursement and I am being billed from the hospitals/doctors to pay what the insurance company has taken back. If I had known that some of the procedures they were covering were not covered, we would not have pursued 6 months of them. We will end up now having to pay back around $6000.00. We have gotten NO correspondence from the insurance company regarding these TAKE BACKS. The only correspondence I DO have from the insurance company are statements stating that the claims were paid! I don't feel I should have to call each provider that is now asking for me to pay to ask them why I now owe so much and to hear from them that my insurance company has asked them for an overpayment back. Wanted to know if this is legal for them to do this. Thanks.

 

[lawrat]

I am a law school graduate. What I offer is mere information, not to be construed as forming an attorney client relationship.

It's always important to mention your state. But this is what I have found for you. Please take your time and read. Contractually speaking, I don't think you need to pay for their 6 months of what they deem as a mistake.

I can't stand insurance companies for this reason.

http://www.asrm.com/Patients/insur.html
http://www.fertilityrx.com/insurance/state.htm
http://www.resolve.org/advstlaws.htm
http://www.asrm.com/

 

[lkm]

Thanks for reply

After researching the laws you provided me with,I found that even though Illinois mandates infertility coverage there is an exclusion that my employer met the criteria for. If you are self-insured and have more than 25 employees you are exempt from the mandatory infertility coverage. I am now researching how "recovery of overpayment" applies to my situation. My new employer's benefit booklet states explicitly that they can recover overpayment if they paid for claims and realize they shouldn't have. However, my previous employer's handbook did not have this section. Hoping I still have some hope! Thanks again for the info. Laura

 

[ALawyer]

If the Plan is exempt under ERISA, state insurance law does not govern.

I'd suggest that instead of simply trying to handle this on your own, you have a lawyer write a lawyer's letter to the insurance company for you on.

I'd be careful to try to get your employer on your side, so that it is sympathetic and supportive, or at least not have the employer come after you. Often the employer can influence the insurance company to let matters slide, even though often the employer winds up paying out of its own pocket. Or perhaps you and the insurer/employer can split the difference.

One more thought. Saying you would NOT have started infertility treatments and paid for the treatment on your own is not very believable as most couples do pay, without any expectation of getting insurance to pay. Saying you would have stopped sooner may be far more believeable.