Who do you contact about an insurance company paying claims on an individual who isn't even a member?

Question

This is a case of mistaken identity and I have contacted the insurance co. but they think I'm nuts.

This is health insurance.

Answer 1

"Mrsfloridalady" is 100% correct. ALL state insurance departments in the U.S. require insurers to have "anti-fraud plans." These plans must be filed with (and approved by) the insurance commissioner's office. In the event an insurer is lax about enforcing its anti-fraud plan, the insurance commissioner will become involved.

Also, each insurance commission in the U.S. operate the state's insurance fraud investigative unit. Insurers are required to report cases of suspected fraud to this unit so the state can investigate. Therefore, a police report will not be fruitful, since the police lack jurisdictional authority to investigate insurance fraud.

If this is a true case of insurance fraud, the LAST THING you should do is tip off the health care provider's office! Please keep this to yourself and let the pros take over.

So yes, I support "Mrsfloridalady's" suggestion that you write to your state insurance deparment. Simply write a letter describing the problem and attach photocopies of any documents you have (such as EOBs). Send your complaint to the attention of the Insurance Fraud Division.

Here's a link to a map of all insurance commissioner's offices; simply click on your state, and you'll be directed to the appropriate office:

http://www.naic.org/state_web_map.htm

Answer 2

Well if the insurer wouldn't take your word that they (the insurer) are paying claims on a person who doesn't even have a policy with them, then they are the fools for wasting their money.

You don't need to call the state....the state would not care if the insurer was paying claims of a person who did NOT have a policy, but they would very much care if the insurer was NOT paying claims of a person who DID have a policy with them.

But a mistaken identity case where the insurer cares not who they are paying for is not going to draw a state investigation into claims practices.

It would be better to call the insurer again and ask for a claims supervisor....or better yet, the Vice President (or equivalent) of Claims.

Tell them that there is a person who is making a claim for benefits with the company that is not entitled to them.

If the Head of Claims continues to not care....then I'd just chalk it up to a very stupid business practice.

And, if you know your insurer is paying claims it shouldn't....then it means they are charging you premiums you shouldn't have to pay.....time to start shopping for a better, more efficient company.

Answer 3

You should contact the providers office and have them call the insurance company and explain what hap pended. They need to tell the insurance company to send them a request for a refund. Insurance companies have no problem doing that! Once they receive the request the provider should refund them within 30 days or the insurance can recoup the money from their future checks.

Answer 4

Insurance is regulated by each state. Your state will have an Insurance commissioner's office, Dept. of Insurance or State Financial Office. You can contact them and they will investigate it and force the insurance company to get involved and handle it after you file a complaint.

Answer 5

first you need to file a police report. take an explanation of benefits showing that this person isn't a family member..... isn't family member... they won't prosecute unless it is proven identity theft.. But the only way your ins. Co is going to take you seriously is if you can produce the police report. then they will research it and stop billing your the remainder balance..

I had the same thing happen..

Make sure you tell them that you want all claims to be reprocessed. All the way back to when they accused you of insanity.. lol