Question
In California, I was covered by my father's insurance company (Seabury and Smith). I was in an accident 7-16-02 and I should have been completely covered by his policy. All information was given at time at the accident and all claims but this last one were taken care of by the insurance company.
A problem at the time (I assume) was that I had recently graduated 6-2-02 and that I would no longer be covered under this policy. Upon a phone call to the insurance company that week, I was assured that there was a grace period into which I was still covered for the next three months.
To my surprise, a bill arrived to my door about 18 months later requesting full payment for 862 dollars. I did not receive this in a timely matter partly (?) based on my move in late August 03. There was a balance forward in October for the remainder amount. This still remains a mystery to me. Obviously due to the tardiness of my response (which I could not avoid due to the delay in receiving this bill) I was unable to respond to the hospital. Therefore, it was turned over to a collection agency and I have been receiving notices ever since.
Upon several phone calls to the insurance company (no answer or disconnected) due to the fact that my father no longer works for the same company that was covered in 02. After reaching an actual person, they found no record of my father's ID or policy number.
I have no means of gaining the insurance information needed by the collection agency to close this claim that should have been taken care of in 02. This information is needed to get the collection agency off of my back.
(What actions should be taken towards either the insurance company or the collection agency?)
Answer
The insurance company telling you they have no record of your father's policy sounds fishy. Even if the claims history is gone there should still be a front screen with your father's name and policy number.
I have worked paying claims for 10 plus years and have never worked for a company that completely cleaned members out of their system. Normally the 3 month grace period you were informed about is usually only in effect if you choose to take your own COBRA policy after your coverage cancelled under your father. Insurance companies go back 3 months and pay retroactively if you pick up COBRA within the timeframe allowed.
You do not mention anything about COBRA but if you did pick it up that is proabably another option you have because a COBRA account would be under your name not your dad's.
Unless the plan benefits booklet specifically shows a 3 month grace period is given for dependants over full time student age you are probably out of luck. Talk to your dad an see if he has an old card or benefit booklet or even an old explanation of benefits from one of the othe claims the company paid during the time of the accident and then call back to the company and ask for a manager.
Depending on what type of insurance it was sometimes when companies move from one insurance company to another they pay the new company to do something called "run in" which means the new company handles any outstanding claims that come in so you may have that option and the new insurance company may pay it for you.
Hope some of this info helps.
Answer
Dspain01,
I’m going to address several things that may help you determine what options you have. Much of the information will be general information as I do not have enough information from your post to give definitive answers. But, right from the start, I’m going to say that I think your best bet is to pay the bill / make payment arrangements. I will explain why I think so. As you read, my answer will sound mean and hateful, but I don't intend it that way. I am only stating the facts. I really understand your position and disagree with much of the managed healthcare system as it exists.
The first thing I want to say is do not ignore the collection attempts. Please address the collection agency in writing and inform them of your attempts to set the matter to rights. Next, have you considered that the outstanding balance could be legitimate patient responsibility amounts such as deductible, coinsurance, or ineligible charges? The provider of the service should be able to validate for you / the collection agency specifically how the charges originated and if any payments or partial payments were applied to the charges. The provider should also be able to provide you with what insurance information was on file at the time of the claim. I also find it bothersome that the person you spoke to (insurance) could find no record of your father’s information after such a relatively short period of time. Are you sure you were in contact with the correct entity? Perhaps you could contact the HR dept. of your father’s previous employer to help you locate the correct contact information.
You mention that you question whether there may have been an issue of your eligibility at the time of the accident because of your recent graduation. I suspect you were eligible. First and foremost because according to your post, other claims were paid. As far as the graduation, you do not mention whether this was high school or college and there is no other indication of your age at the time of the accident, nor is there specific information regarding the eligible dependent provisions of your father’s plan at the time. Therefore, there is no way to determine from your post if you were eligible for sure. But, very generally, most plans have two limiting ages for children as dependents. The first is most commonly age 19. The second from age 23-25. This allows for coverage of full-time students that are financially dependent upon the parent. Between the first limiting age and second limiting age, the insurer will require periodic proof of full-time student status. In most cases it would not be feasible for an insurer to individually track the graduation dates of all its insured dependents. Therefore, there is usually another cut-off point surrounding the limiting ages. Examples would be the actual birthday, the end of the birthday month, or even the end of the calendar year in which the dependent reaches limiting age. I suspect this explains the “three month grace period” mentioned in your post. Not that there is a “three month grace period” for all, rather it was three months from your specific ceasing of eligibility under the plan. This type of information would be found in the summary plan description. If your father has a copy of that former plan description, I suggest looking at it if you want to pursue your position.
Because of the above, I doubt, although it is possible, that your graduation date was the actual termination date of your coverage, and I suspect that you were eligible at the time of the accident. Therefore, I think that the problem lies elsewhere. So, now for the very unfavorable information: it is the ultimate responsibility of the insured to see that claims are filed and / or paid timely. Because of today’s managed health care system, many things can and do go wrong in that arena. Yet, the patient is financially responsible for all health care delivered. That having been said, I’ll explain further why I think you will be out of luck getting your claim paid at this point.
First, if the provider did not file the claim timely (insurance plans have set timely filing limits), it still remained your ultimate responsibility to see that it was. The fact that you didn’t know the balance existed doesn’t matter—you were aware that you received services and could have contacted the providers to ensure filing of claims. The next possibility is that the provider did file the claim timely and the insurer did not pay it correctly or at all. Again, it would be your responsibility to see that all claims are filed timely and / or paid correctly. The insurance plan would allow for an appeal period (also defined in the plan description booklet) for any adverse determinations by the insurer. If the claim was not paid / properly paid by the insurer then an appeal should have been filed by you or by the provider on your behalf. After two years, I am certain that this time has likely passed by any standard.
In summary, although I’m sure it smarts, it was your ultimate responsibility to see to the timely filing and payment of claims and to follow appeals processes allowed by the insurer. Although I think your chances of avoiding payment of this balance are miniscule to none, for nearly $900.00, I would do as follows:
1. Determine that you were eligible at the time of the accident by methods suggested above.
2. Contact the provider to request specific validation of the dates of service, type of service, payments by the insurer etc. (i.e. the balance could be legitimate patient responsibility)
3. Ask the provider to provide proof of timely filing of the claim to the insurer.
4. If the provider cannot provide timely filing proof, I would attempt to convince the provider to dismiss the claim for having failed their fiduciary responsibility, especially if they were a contracted provider with the insurance plan. (If you want more info on that statement, just post.)
5. If the provider does have timely filing proof and the claim simply wasn’t paid or was paid incorrectly, I would give up. Again, going back to it being your ultimate financial responsibility to see that claims are filed and paid, the fact you did not ever receive an Explanation of Benefits form from the insurer would in itself be the grounds for an appeal to the insurer. The thing that really sucks here is that since this was your father’s plan, likely all correspondence from the insurer was addressed to him (2002 being before new HIPAA privacy regs).
Just FYI, if the balance owing is not legitimate patient responsibility under the insurance plan at the time, I think your situation is a ‘poster-child’ for just a small part of the problems with managed health care as it is. My gut and experience tell me that the provider in your situation is the primary problem in this situation. Even if the provider did file the claim timely, they failed to inform you of the status and / or appeal to insurance on your behalf in a timely manner. Although as I have said numerous times, it is your ultimate responsibility to see to proper claims filing, I believe that by accepting ‘assignment of benefits’ the provider should be held to a standard. They should have to inform both the insured and the insurer, on a regular basis, of their actions in claims filing attempts as well as having knowledge of the benefits of the plan to which they file—at a minimum. Unfortunately, that is not the case. Providers are simply more interested in the status of claims they have filed rather than those they have not.
Do what you can, but do not wreck your credit history over this thing. Pay the claim if you must, even if you feel it is not just. Best to you, lkc15507.
Answer
In response to your very informative reply I would like to post the following information.
I have been in contact with the collection agency on several occasions, both in writing and verbally. I have tried to explain the situation, but obviously to know avail. They have put a hold on the account for right now due to the fact that I had expressed the need for further information from the insurance company.
My eligibility was in fact valid for full-time college students and also valid because I was 21 at the time of the claim.
You did mention several times that it was my ultimate responsibility to ensure proper filings of claims with provider. But as you mentioned, the minimum was provided to me as far as information that the claim had been denied, awaiting further information from me to the insurer.
I have recently filed a claim with California State Insurance Commision on my behalf. I simply filled out there claim form and mailed in duplicates of all contacts that I have had with the collection agency as well as the service invoice from the provider which was dated 4-1-04 for services on 7-16-02. Along with this information, a brief summary of the situation.
But I have decided to not risk the disaster that might entail with credit reports in the future, and pay the balance and seek retribution through the uncooperative insurance company.
Answer
I certainly think that you are doing what you should. Your credit history is all important in this situation and although I do think you had some possible, although slim, chances of fighting this, bending is sometimes the best option. I will point out, that even if you do pay the collection agency for the balance owing, there is nothing that precludes you from continuing to pursue the matter with the providers and insurers. (Sorry so long to return post, but my connection capabilities these days really stink!) I do hope my info helps you and others in similar situations. As I always say regarding health insurance-----READ THOSE PLAN BOOKS AND BE KNOWLEDGEABLE! KNOWLEDGE IS POWER WHEN IT COMES TO YOUR HEALTH PLAN!!! Best to you again, LKC15507