Health Insurance Exclusions and Refusal to Pay.

[AllyandJack]

I am the benefits administrator where I work, and have a copy of the insurance certificate which is sent to every employee when they enroll. The certificate is pretty clear regarding exclusions and limitations. Yes, exclusion for alcohol-related injuries is something a subscriber may not expect, but the exclusion was there at the inception of coverage. How much hand-holding do we need to do for people? Where do you draw the line?

Denae

I agree with this for the most part. The problem I have is that the care was given under emergency circumstances.

Plus, it took me about 3 months to get my contract. BCBS does their mailings every 90 days, so when I called and asked for it, they sent me a letter telling me it would go out in the next mailing - that was 60 days away. I called them before I did anything, but if it was an emergency, I wouldn't have that option.

Also, some things are NOT in that contract. I had a test done and got a bill for a co-payment. My contract says I have no co-payment for radiology. I called and was told that this test involved the injection of dye, so I had the co-payment. That is nowhere in my contract.

 

[KelNottAt]

Can anyone explain why the health insurance was primary in this case and not the auto insurance?

I know many health insurers have a "coordination of benefits" staff to determine who pays when car crashes are involved. Usually it's the auto insurer. That's the point of personal injury protection on auto insurance policies, I thought.