Question
What is the name of your state? Florida
I recently switched to family health insurance (avmed) with the birth of my daughter. I also added my wife to my policy since it does not increase my premium payment.
My wife still has individual coverage (aetna) through her employer and we would like to keep it because some off her doctors are not included in my insurance plan.
My wife has not made any insurance claims on my policy to date. However, we recently have been receiving letters from primax recoveries incorporated (on behalf of aetna) requesting information on additional health coverage she may have.
My question is: Legally does she have to report that she has coverage under my policy to primax or aetna? and if so can they deny past claims that have already been paid because they want my health insurace company to pay for them?
Additional info: my wife's hospital bills for the birth were paid by her provider while my daughter's bills were paid by my provider.
Thanks for the help,
Joe
Answer
YES you have to report the other coverage. To fail to do so would be insurance fraud and if caught you'd be lucky if the only thing that happened to you was that you were fired.
Aetna is the primary care provider for your wife. They will not be able to request you repay any claims or demand that primax pay them, but they do have a right to know about other coverage, as does primax.
Answer
Legally does she have to report that she has coverage under my policy to primax or aetna? and if so can they deny past claims that have already been paid because they want my health insurace company to pay for them? Additional info: my wife's hospital bills for the birth were paid by her provider while my daughter's bills were paid by my provider.
Absolutely. To fail to report other coverage would be insurance fraud, which is illegal.
Most insurance companies go by the birthday rule in determining which insurer pays first....whichever spouse's birthday comes earliest in the year is primary (regardless of birth year). They may make rules other than that as well, such as the employee's own coverage is primary and spouse's is secondary. I think that's what happened in your case.
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Purple, just as an FYI, the large majority of carriers will declare the husband's policy to be primary for him and the wife's policy to be primary for her; the birthday rule is used to determine which is primary for the children.
Answer
cbg,
Not so in my neck of the woods.
Answer
Must be regional then, because after 20+ years of administering group insurance plans and five years working directly for a national carrier, I have yet to see a plan that wasn't set up as I described.