retroactive cancellation

[joshua ramos]

What is the name of your state? Florida
My wife was layed off from her job. As part of her severance she was given 6 months of medical insurance paid. She was pregnant with pur first child and gave birth about 3 weeks before the insurance was to be cancelled. Everyone involved excluding the hospital was paid. The hospital has now put the debt on our credit reports. when we spoke with aetna the informed us that the hospital had not filled out a pre certification and so the claim was denied. Then my wife's formal employer cancelled the policy and had aetna retroactively cancell the policy back 3 months. So when the hospital agian filed the claim this time with the pre certification, it was denied agian because we did not have insurance. Is it legal for her formal employer to retro act the cancellation? Should the hospital be liable since they did not comply with the rules of the insurance in time? Should the ins. company be held liable no mattr what since it is reasonable to assume that she was going to give birth long before they new about the layoff and cancelation of policy?

 

[cbg]

What kind of a policy was it? HMO, PPO, POS?

Was the hospital in or out of network?

What was the reason the employer gave for retroactively cancelling the insurance?

 

[joshua ramos]

it was an hmo, that covered the pregnancy 100% after co pay which we paid some time in december of 2000. yes the hospital was in network, in fact the date was pre determined and scheduled so that we would be sure that she delivered before the cancellation date. and the company she worked for is no longer owned by loockheed martin they sold to another company and so the new owners say they don't have the files any more they have been purged. so we don't know why.

 

[cbg]

Josh, this is unfortunately not something that can be handled on a message board, but let me give you a couple of things that might help you in moving forward:

1.) Whether or not the hospital has any liability for failing to get the pre-certification properly is going to be based in the insurance contract, not in the law. On some plans, the hospital is solely responsible for seeing that pre-certs are obtained; on other plans, it is YOUR responsibility to see that it is done, although the hospital may be the one that actually does so. Since your plan is an HMO, it was PROBABLY the responsibility of the hospital, not you, but there's no way to say for certain without reading the insurance policy. Either way, your recourse for this aspect of the problem will be found in the policy appeals process.

2.) It is not illegal per se to cancel insurance retroactively; it's done all the time. However, whether it was a contractual violation to do so in your case is something that we are not going to be able to determine in this kind of a forum, particularly since the company is not able to say why it was done. I think for this part of the problem you are going to have to take all associated paperwork, including anything you have which shows that six months of paid insurance was part of the severance package, to a local attorney and have him/her review it.