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Insurance claims issue. Not sure where to start. Georgia

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  • Insurance claims issue. Not sure where to start. Georgia

    Howdy folks, not sure if this is the correct place to post this question, but I'm hoping someone may be able to point me in the right direction.

    So, here's the issue. My wife and I moved from North Carolina to Georgia in September of 2015. While in NC my wife was employed and received health care benefits through her employer. When we moved to GA, she decided she would like to be a stay at home mom, so that's what we did. I placed her on my insurance policy through my employer along with my son, both receiving routine medical care without any issues. A few months later, we find out my wife is pregnant. Fast forward, she received standard prenatal care throughout the pregnancy, has an uncomplicated delivery, stays 48 hours in the hospital, comes home. Everything is fine and dandy. Then I get an email... Its her OB stating I owe them several thousand dollars. After calling and speaking to there billing department, we find out that her ex-employer from NC never notified the insurance company up there that my wife was no longer an employee. Our current insurance company finds this out and recalls ALL the payments they have made toward her prenatal care, delivery and hospital stay. They stat that she has another primary insurance and they are not going to pay anything, the 'other' insurance has to pay. We contact the other insurance company and they tell us she is not covered, obviously, because she hasn't been employed with the previous company in over a year, on top of being in another state. I'm totally at a loss of what to do or where to begin. We are now been told we owe upwards of 20k for all the different services provided during her pregnancy, and more payments are still being recalled. Is there anything I can do?!

    Thank you for any information.

  • #2
    You may need to go back to the respective HR's for this information.

    Forget the history for a moment. Right this minute, today, what is the effective date of coverage for your current policy? What is the effective date of the termination of your former policy?

    We'll start there.
    The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.


    • #3
      Our current policy too effect on Dec. 3, 2015. The termination of her policy, as I understand it, should have been the last day of employment, which was Sep. 20, 2015.

      Found out she was pregnant near the end of March 2016, prenatal care began at that time.


      • #4
        I'm less concerned with when it should have been, as when it was. If this was discovered in a routine audit, which is what it sounds like, they may have made the effective date something later, and simply eaten the extra premiums since it was their mistake. It is a very important point in figuring out who is responsible for the charges. As I said, you (or she) may need to have to go back to her old HR or Benefits office for this information.

        Just to be sure it's clear, because I just read my post over and realized it could be taken two ways, I'm not looking for the date that they said, "Oops, we're still covering Judy and she left here in September of 2015" but the date that would complete this sentence: Dear Insurance Carrier - please terminate Judy Smith's coverage with an effective date of xx/xx/20xx".
        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.


        • #5
          In other words, you need to contact the previous insurer and/or her former employer's HR department and find out the answer to cbg's question. Then come back and we can help you further.


          • #6
            If she received a COBRA letter to continue coverage after leaving her last employer, that might help. The letter should have the date she was last covered.
            I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.


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