Legal Question re: Health Insurance Coverage?

Question

Long Story = Bottom Line... I had coverage through my employer (as an hourly temporary employee - I paid the full premium - the employer just provided access to group rates) When I had a baby, I did not work but continued to pay premiums (the company was set up for this arrangement as they have a "missed premiums" dept. that you send your payments to. Apparently, this can only be done for a maximum of 4 weeks. I was never informed of the time limit and the company that I worked for never informed the carrier when my last assignment was. However, I continued to make payments and was never late nor missed a single payment. The carrier has totally fouled up my coverage and now that I am trying to have them straighten it out, they are telling me I should never have been able to make those payments for so long and they recently sent me a COBRA form. However, the coverage is a mess. They keep cashing my checks and paying (some of) my claims so what rights do I have?

Answer 1

I suspect the REAL culprit here is your employer, not the insurer. In a group policy situation, the insurer goes by what the employer tells them. So if you employer continued to remit premiums as if you were still working and failed to send you the COBRA information, they are at fault, not the insurer.

I would suggest you write a letter of complaint to the insurance commissioner in the state where you worked. Provide copies of the cashed checks and request assistance getting this sorted out. An investigator will contact your insurer (who should also contact your employer) and make certain this is fixed.

Answer 2

Suzanne is correct. I've worked in insurance/healthcare, specifically in and legal/compliance for a long time. It really does sound like its up to your employer. You need to make your COBRA premiums payment ASAP. Most likely, they will be paying the claims the group insurance plan denied. From what you said above, it would appear as though you DO have coverage... Its just that your group health plan, and COBRA need to get their ducks in a row. Ask your former employer for help. They are legally obligated to send your cobra paperwork to you within a certain amount of time... Then you have another window to enroll in... Cobra will backdate to the date your policy ended; provided all of the time frames were met.

You're taking the long way around going though the insurance company.... Speak with HR, or the benefit administraor @ the company. They ultimately have all the control.

Answer 3

You do have rights, but it may take awhile to sort out. My advice is to go ahead and apply for COBRA and pay your first premium. Then, they can't cancel you. Then look in your plan materials, an SPD...it should tell you where to file an appeal. Write a letter to that address and tell them you are filing an official appeal to protest the fact that you paid premiums and have been denied coverage. Copy your company Benefits Administrator on the letter.

Answer 4

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Answer 5

Hello,
Well here is the deal. I would suggest signing up for the Cobra... however it is probably quite expensive. I would call your insurance company and ask for the claims Manager and begin discussing the claims you show have not been paid. If that does not get things going in the right direction send your complaint in writing.
Good Luck.

Answer 6

If your premiums are paid on time, and the company is cashing the checks (make sure you have copies of the cancelled checks) then you have every right to assume you have coverage, therefore, your claims should be paid.

Answer 7

You should immediatelly contact the Federal Dept. of Labor in your area to act as intermediary. Don't bother fighting with your employer or the health insurance company, let the D.O.L. do it. They will listen to a Federal Agency.