Q. My insurance company sent me a check for $200. I ended up returning the glasses. Is it standard for a company to ask for the $200 back? Or is it assumed that because I am allowed $200 in my benefits that I keep it?
A. You should use the money to replace the glasses that you returned. If the new glasses are the same price or more, then no harm no foul. However, you should notify the insurance company if there was a difference in price that would have affected the amount you received.
If this is picked up in a provider audit or claim review (and they do them regularly), then you could see yourself at the other end of a fraud investigation.
It's not okay to just keep the money. Insurance companies take this very seriously, no amount is too little, and they have entire departments to look at claims like this regularly; these people are professionals and aren't necessarily very forgiving. It's not worth the risk for $200.
I hope this helps.
If this is picked up in a provider audit or claim review (and they do them regularly), then you could see yourself at the other end of a fraud investigation.
It's not okay to just keep the money. Insurance companies take this very seriously, no amount is too little, and they have entire departments to look at claims like this regularly; these people are professionals and aren't necessarily very forgiving. It's not worth the risk for $200.
I hope this helps.
How the heck does an insurance company consider a yeast infection a pre-existing condition?
Q. My insurance company is trying to dispute a bill because I had a yeast infection. They're claiming it's a pre-existing condition! WTF!!! A yeast infection? It's not like that is some serious condition that I knew about. I went to the doctor and found out I had one. What a rip off!
A. Here's what you need to know:
When a claim is billed to the insurance company, the doctor's office uses an ICD-9 (diagnosis) code for the claim.
The insurance company flags the claim to investigate whether its pre-existing based on the diagnosis code used. (Some diagnosis codes will flag for possible pre-existing, other diagnosis codes would never be considered possible pre-existing and be processed as normal right through the system.)
They send you and/or the doctor a questionnaire asking if you've ever been treated for that diagnosis code before.
Here's what you need to do/ask:
1) Did you have continuous health insurance coverage prior to this plan? If so, then you should be exempt from a pre-existing clause. Just provide documentation of your previous creditable coverage to your insurer, and you'll never hear a peep about pre-existing conditions again.
2) Did your doctor's office bill the claim with the correct diagnosis code? The code is just a number (for example, a yeast infection diagnosis code would start with 112), and a simple typo in that code can drastically alter a bill - make it seem like you were treated for something totally different.
3) Do you truly have chronic yeast infections, or was this your first one? If its your first one ever (or in a very long time), then its not "pre-existing." You simply need to respond to the questionnaire that you've never been treated for that before. If you do truly have chronic yeast infections and a yeast infection happens to be a diagnosis that your insurance company flags for pre-existing, then there's not much you can do about that.
The first thing I'd do though was provide my evidence of creditable coverage, as that will waive your pre-existing clause. (As long as you had continous insurance before this without a 63 day break in coverage.)
When a claim is billed to the insurance company, the doctor's office uses an ICD-9 (diagnosis) code for the claim.
The insurance company flags the claim to investigate whether its pre-existing based on the diagnosis code used. (Some diagnosis codes will flag for possible pre-existing, other diagnosis codes would never be considered possible pre-existing and be processed as normal right through the system.)
They send you and/or the doctor a questionnaire asking if you've ever been treated for that diagnosis code before.
Here's what you need to do/ask:
1) Did you have continuous health insurance coverage prior to this plan? If so, then you should be exempt from a pre-existing clause. Just provide documentation of your previous creditable coverage to your insurer, and you'll never hear a peep about pre-existing conditions again.
2) Did your doctor's office bill the claim with the correct diagnosis code? The code is just a number (for example, a yeast infection diagnosis code would start with 112), and a simple typo in that code can drastically alter a bill - make it seem like you were treated for something totally different.
3) Do you truly have chronic yeast infections, or was this your first one? If its your first one ever (or in a very long time), then its not "pre-existing." You simply need to respond to the questionnaire that you've never been treated for that before. If you do truly have chronic yeast infections and a yeast infection happens to be a diagnosis that your insurance company flags for pre-existing, then there's not much you can do about that.
The first thing I'd do though was provide my evidence of creditable coverage, as that will waive your pre-existing clause. (As long as you had continous insurance before this without a 63 day break in coverage.)
How do you know if your insurance company is also insuring the party who caused you the damage in a claim?
Q. If your insurance company pays you a small amount for a large loss and you then sue the party who caused the loss, what complications can there be for you? Are there conflicts of interest sometimes which prevent an insurance company from pursuing subrogation? If they do pursue subrogation, do they share in paying the legal fees.? If they are also insuring those who caused the loss, will they pay out under those people's insurance?
A. I'm not sure we have the whole story here, but here goes. This is assuming that both you and the other party are insured by the same company.
I don't understand why you have collected from your insurance company for the loss under your policy, and then plan on suing the other party. Generally you either collect from your policy and let the insurer go after the other party, or go after the other party and leave your insurer out of it. We aren't talking an uninsured motorist here, so what type of claim could you be making? You can't collect twice for the same damage. Either way, unless your exhausted the other party's policy limits, you will have to reimburse them.
There is little chance that the insurance company will bother with subrogation against itself. And subrogation rarely requires legal fees, especially when the parties are insured and liability is clear.
Finally, as to the conflict of interests, if there is an issue regarding this, the claims department will appoint different adjusters, usually having them report to different supervisors, to handle the claim. In some states this is a requirement, both even without the law, most companies consider this protection against getting sued for bad faith claims handling.
I don't understand why you have collected from your insurance company for the loss under your policy, and then plan on suing the other party. Generally you either collect from your policy and let the insurer go after the other party, or go after the other party and leave your insurer out of it. We aren't talking an uninsured motorist here, so what type of claim could you be making? You can't collect twice for the same damage. Either way, unless your exhausted the other party's policy limits, you will have to reimburse them.
There is little chance that the insurance company will bother with subrogation against itself. And subrogation rarely requires legal fees, especially when the parties are insured and liability is clear.
Finally, as to the conflict of interests, if there is an issue regarding this, the claims department will appoint different adjusters, usually having them report to different supervisors, to handle the claim. In some states this is a requirement, both even without the law, most companies consider this protection against getting sued for bad faith claims handling.
Can an insurance company dictate how many hours you work a week?
Q. My insurance company states that if I drop the insurance, I can work no more than 25 hours a week, can they do this?
A. I think what is happening is this:
The Insurance Company has participation requirements. Your employer may need to have 75% of all eligible employees enrolled in their insurance plan. Waivers for those with coverage through their spouse do not count against them. So, let's say that there are 50 eligible employees and if you were to waive coverage because it is too expensive, you don't feel you need it, or any reason other than you have coverage through your spouse, it puts the group below the 75% requirement. Your election puts the whole group's coverage in jeopardy. The easiest fix is to make you ineligible - cut your hours to below the threshold of a full-time employee.
Bottom line, your employer is trying to protect the integrity of the group health plan for the good of the company and its employees. They can cut your hours anytime they feel it is necessary for the fiscal well-being of the company. I think this qualifies.
The Insurance Company has participation requirements. Your employer may need to have 75% of all eligible employees enrolled in their insurance plan. Waivers for those with coverage through their spouse do not count against them. So, let's say that there are 50 eligible employees and if you were to waive coverage because it is too expensive, you don't feel you need it, or any reason other than you have coverage through your spouse, it puts the group below the 75% requirement. Your election puts the whole group's coverage in jeopardy. The easiest fix is to make you ineligible - cut your hours to below the threshold of a full-time employee.
Bottom line, your employer is trying to protect the integrity of the group health plan for the good of the company and its employees. They can cut your hours anytime they feel it is necessary for the fiscal well-being of the company. I think this qualifies.
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