Submitting a claim ten months later

[StressedOutInPA]

What is the name of your state?PA

I have an insurance policy that I guess is similar to AFLAC that I pay for myself every month (not job related insurance) and I have had for almost four years. It covers me for any hospital stay due to an accident or illness. I am supposed to recieve $120.00 a day for every day in the hospital. Now, I had a normal pregnancy which it doesn't pay for so I never filed a claim (I have actually never filed a claim for benefits in the four years I've had it). Recently my policy came up for renewal. While I was talking to the insurance agent he said that my policy covers any newborn child automatically for the first 31 days under the same terms as I am covered and that infant coverage was also part of my policy since I first got this policy. My son was in the hospital for almost a month after he was born and under the terms of my policy he was covered. The problem is he was born almost a year ago and the policy says any claims should be made within 30 days of the admittance date or within a reasonable amount of time. I called them the same day I learned that I should have recieved benefits for his stay. The fact of the matter is he was covered under my policy and met the requirements for me to recieve payment for his stay. Do you think they will just get out of paying me because I didn't realize he was covered?

 

[cbg]

It depends. Most plans have a time limit after which they will not accept a claim. Often it's a year; sometimes a year and a half. But unless your state has a regulation on it (which I don't believe they do but I could be mistaken) there is no legal mandate as to how long it must be. Most plans I am familiar with will still accept a claim after ten months but it will depend upon what the drop-dead date is in the plan. If the claim is sent in within the allowed time frame they'll pay it; if is isn't, they won't.

 

[StressedOutInPA]

I can't find an absolute cut off date for claims. The policy states "Notice of claim must be given within 31 days after a covered loss starts or as soon as possible. The notice can be given to ........... at it's home office in Chicago, Illinois or to a ...........agent." There is nothing that says absolutely no claims after a certain time. One other thing, do they accept my phone call as notice of claim or is it the completed paperwork? The woman I spoke to about the claim said I would recieve the paperwork for my claim in 15 to 20 days and if I add in a day or two to complete paperwork and mailing time back to company and the time it might take them to actually look at my claim I could be close to one year if not a liitle over. I am assuming that since I told the woman the whole situation, they are accepting my call as notice of claim because she said the paperwork was to be sent back as proof of claim.

 

[CIAA]

StressedOutInPA,

Many state courts have interpreted the "notice" provision as being applicable only if (1) notice was unreasonably late, and (2) because of the late notice payment of benefits would be prejudiced or mere guess work.

This protects insurance companies from late claims that can't be verified (ie., doctor and records are gone) or claims that just don't make sense (ie., 12 month disability a sprain).

Sounds like your chances are pretty good.