Coordination of Health Insurance Benefits

[Eagle Eye]

Wondering if anyone has any insight to this at all.

I moved companies in the new year and my health care provider switched to the same one that my wife has with her employer now.

I feel that now that we are with one insurance provider we are only being treated as one plan instead of 2.

Couple of examples of how treatments would have been delt with before and after my move.

Wife got Orthotics through her Chiro for $549, she sent it to her insurance company and they paid thier maximum of $300, leaving $249 for me to submit to my company. My company paid $200 out of the $249 as this was thier max. So in total we got $500 out of the $549.

This is how it works now that we are with the same insurance company. She submits the $549 to hers and gets paid $300, it automatically gets submitted to mine, but the response is that they had already paid the max of $300 so no more would be available. So only $300 out of $549 is now paid.

Not sure why it is now working this way, but I was wondering if anyone else has run into problems like this. I actually see no reason to have the second set of benefits.

Thanks

[KTrain]

Just give them a call and let them know that you have two separate plans with them. They probably have your names overlapped in their database because of your SIN's.

[Eagle Eye]

Originally Posted by KTrain

Just give them a call and let them know that you have two separate plans with them. They probably have your names overlapped in their database because of your SIN's.

I have been talking with an account representiative at my new insurance company, and they said this is the way that they coordinated benefits and that they dont pay above the maximum.

I am trying to fight it using examples from the past, I was just wondering if anyone had ever delt with a stituation like this?

[KTrain]

But aren't two separate plans being paid for by your employer and your wife's?

[Eagle Eye]

Yup they are completly 2 different plans, and thats our argument, but thier argument is that they are one company. I told my work that I see no need for beniefits if this is the case as I am just paying taxes.

[Eric Vail]

I don't have any answers for you. I wish you luck, however. I hate getting into disputes like this with companies that seems so clear what the answer should be, but whomever you get on the phone just seems to stupid to see what you are getting at.

Fight the good fight.

[Rathji]

I would talk with your HR people and see if they can work it out for you.

Your company (and you) are paying them for a service and they are refusing to provide it.

It really is that simple.

[Northendzone]

Originally Posted by Rathji

Your company (and you) are paying them for a service and they are refusing to provide it. It really is that simple.

i hardly think that the insurance company is refusing to pay for a service.

my guess is that this has something to do with reasonable and customary limits - this means that the insurance company will only pay for a claims based on what they believe the service should cost compared to what was actually charged.

in anycase, with your spouse and you both being covered under policies administered by the same insurer the whole COB issue should be easier.

also sounds like your plan may have some limits on it that perhaps your wife's plan does not.

[Rathji]

Originally Posted by Eagle Eye

Wife got Orthotics through her Chiro for $549, she sent it to her insurance company and they paid thier maximum of $300, leaving $249 for me to submit to my company. My company paid $200 out of the $249 as this was thier max. So in total we got $500 out of the $549.

Originally Posted by Eagle Eye

This is how it works now that we are with the same insurance company. She submits the $549 to hers and gets paid $300, it automatically gets submitted to mine, but the response is that they had already paid the max of $300 so no more would be available. So only $300 out of $549 is now paid.

Originally Posted by Northendzone

i hardly think that the insurance company is refusing to pay for a service.

What would you call not paying out a claim?

Whatever you call it, the insurance company is trying to get out of paying for something the OP are covered for, by a plan that has been paid for. The fact that they are married has nothing to do with it because they are on different plans.

I don't see how this could be any more clear.

[Northendzone]

Originally Posted by Rathji

What would you call not paying out a claim?

Getting paid $0........

If the OP were to provide copies of the relevant insurance booklets and the dates the claims were incurred then I could likely figure out what has gone on.

Just because the orthotics were $549 and he has COB does not necessarily mean the total payout will be $549.......

[Eagle Eye]

Originally Posted by fotze

Is it possible in the first case and you had two plans the fine print says the maximum is $300 no matter the coverage and the only reason you go two payments is because they did not know of the secondary company covereage or had no way to know. Now you are just screwed because they will know.

I know mortgage insurance will not pay out if you have life insurance or some other kind of insurance. Maybe this is the same thing but companies just say "fata it" and don;t try and investigate if you got paid out already.

Either way, having dual coveraghe is costing you or the company money and you should stop paying them that money.

Also, what company is this?

Nope I had to submit the first insurance company's response to what the covered to the other insurance company.

It showed that they only paid $300 of the total amount because that was the maximum. The response from my insurance company showed that $300 was paid by 'another Plan'

[JustAnotherGuy]

Originally Posted by Northendzone

Getting paid $0........

If the OP were to provide copies of the relevant insurance booklets and the dates the claims were incurred then I could likely figure out what has gone on.

Just because the orthotics were $549 and he has COB does not necessarily mean the total payout will be $549.......

You are missing the point. Why are you having attitude? Can I assume you work for one of those insurance companies?

[Eagle Eye]

Originally Posted by Northendzone

Getting paid $0........

If the OP were to provide copies of the relevant insurance booklets and the dates the claims were incurred then I could likely figure out what has gone on.

Just because the orthotics were $549 and he has COB does not necessarily mean the total payout will be $549.......

The orthotics payment occured when I was utilizing 2 different insurance companies (We were paid $300 + $200 out of the $549).

The reason this was discovered was my wife uses an accuputurist (why? I have no clue, lol). She is charged $85 each time she goes (paid $75 through her provider), again the $10 last year would have been covered by my insurance provider, now my new provider is saying that they will only pay $75 and that is it.

[mykalberta]

Originally Posted by Northendzone

Getting paid $0........

If the OP were to provide copies of the relevant insurance booklets and the dates the claims were incurred then I could likely figure out what has gone on.

Just because the orthotics were $549 and he has COB does not necessarily mean the total payout will be $549.......

Its seems obvious (at least to me) what you are describing happened before when they were with separate companies. The "wifes" plan allowed for $300 while the "husbands" plan allowed for $200 hence $500 ($200+$300) being deducted of a $549 cost.

Anyone with a dental plan in Calgary knows this scam - cost is $125, benefit is 80% of $100. I guess it would be cheaper to get my dental work done in rural alberta but they dont pay out mileage so

Now they are not applying the husbands independent policies limits to the balance after the wifes deduction comes off. In essense the husbands plan is now worthless.

***

As another poster has said, talk to HR. Talking to insurance companies directly when you arent paying is a waste of time.

[mykalberta]

oops double post

[Eagle Eye]

Originally Posted by fotze

How do they know what your wife has, to ask for it? What if the limits are $300 each and the cost was $549. Couldn't you try to get $600? Just say she has no coverage. Just never had a wife with coverage and was curious how they get around this?

I am not sure that if you never mentioned that she was covered under a different plan if they would know any different.

But not the point, my new insurance company (same as wife's now) is not treating claims the same way that I would if I had 2 different providers, even though both plans are being paid seperatly as they were before

[Northendzone]

Originally Posted by JustAnotherGuy

You are missing the point. Why are you having attitude? Can I assume you work for one of those insurance companies?

sorry - i did not mean to come off with an attitude - i have worked for insurance companies in the past and i now work for a consulting firm.

insurance companies have this type of situation with lots of plan members - i don't think they are screwing the OP nor do I think they are trying to get out of paying a claim

[Rubicant]

Originally Posted by Eagle Eye

I am not sure that if you never mentioned that she was covered under a different plan if they would know any different.

But not the point, my new insurance company (same as wife's now) is not treating claims the same way that I would if I had 2 different providers, even though both plans are being paid seperatly as they were before

My wife and I have separate plans with the same company and they still give us the benefit of both due to coordinated benefits.

In fact, it's convenient as they have finally figured out how to take a claim submitted to one plan, and walk it down the hall for submission to the second plan. Used to drive me nuts how I had to mail things twice to the same place.

The only thing I can suggest (other than the insurance company being confused) is that you don't have your wife included on your new plan. I pay one premium just to include myself and a higher premium to include my wife.