Is there a way to appeal a medical claim after 2 years and the accounts have already gone to collections?

Question

I had surgery back in 2005. I didn't have insurance, so I applied for COBRA. When I asked when the policy would be active, the person taking my information told me she would backdate it to the beginning of THAT day. So, I went to my dr that day and he told me that I needed an ultrasound. The next day, after the ultrasound, I was told I needed to have surgery. A week later, I had the surgery. A month after the surgery, the insurance I got through COBRA sent me a letter telling me that my actual start date on the policy was the day AFTER I called, so they considered my problem to be a pre-existing condition and wouldn't cover the surgery. Also, I wasn't aware that I was still covered under my parents ins. When I found out, I sent them the claim, but they wouldn't pay due to timely filing. All the dr's bills are now in collections. Is there any way to appeal after this length of time? If there is, how would I go about doing this?

Answer 1

More than 2 years is too late for an appeal.

There would have been actions you could have taken at the time all of this intially occurred, and quite likely the issue could have been resolved. However, there is likely not much you can do now. You can always try summarizing the situation for your state's Department of Insurance, but I'd expect that you'll likely get a response advising that they can't help you at this point.

Answer 2

There are many holes in your story, or maybe I'm just confused.

1) I believe your COBRA effective date SHOULD BE the day after your medical coverage terminated. Period. There should have been no lapse in your coverage.

2) Pre-ex shouldn't apply because you should have had credible coverage and under HIPAA regulations, as long as there hadn't been more than a 63 day break in coverage, nothing should be considered pre-existing. And since there shouldn't have been a lapse in coverage, pre-ex seems to be a moot point.

3) You can't be covered by your own insurance AND your parents' insurance. If you're eligible for your own insurance, you wouldn't be eligible to still be covered under your parents' coverage.

4) You may file an appeal with your insurance company, but you'll need to contact them to find out what the procedures are. Procedures vary from carrier to carrier, so it would be impossible for anyone here to tell you how to go about doing that with your particular insurance company.

I'm just not entirely sure you've got all your facts straight, because so much of this doesn't make sense to me.

Answer 3

Probably not. Most insurance plans have a certain length of time for appeals - it usually maxes out after a year. But, your first step would be to call the plan to find out about their appeals process. Primary and secondary plans are a moot point in this case - timely filing is timely filing.

However, expect that you're going to have to pay. You really should have addressed this right away instead of waiting two years and the account being sent to collections.

Answer 4

I don't know of ANY insurance company that will pay a claim filed more than ONE year after the date of service; some are limited to only six months.

It's written into the policy that way - so they're going to deny out of hand, based on the length of time. You're not going to win an appeal on this, sorry.

Answer 5

You have more of an issue of primary carrier. If you were still a valid insured under your parent's insurance policy, that company would be identified as your primary carrier.

The other company would be known as your secondary carrier. To resolve the issue with them you have to demonstrate by some tangible evidence that the agent "verbally agreed" to make the start date effective that day. If you can prove that, then you will be okay.

Either way, this issue can be resolved by seeking intervention from your State Insurance Commissioner's Office or Department. You can file a complaint claiming "bad faith" against both insurance companys. They really take notice and act when they have a claim of bad faith actions lodged against them.

Although this action won't take care of the collections issue, it will get the insurance companies to take you seriously and pay for the coverage you deserve.

In the meantime, negotiate with the collection company regarding a payment plan. This will prevent your credit rating from getting wrecked while this matter is being resolved.

Good luck.

Answer 6

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Answer 7

Dude, COBRA back dates to the last day your terminated health insurance expired. So, either your old health insurance was effective; or your COBRA was effective. There should be no lapse...

Answer 8

After 2 years you're stuck. Normally it's 60 days.