Health Insurance Expert Forum
Paid on part of claim but says we aren't covered
About This Forum:

This forum is for questions and support regarding health insurance issues such as Medicare, Medicaid, Long-term health insurance, COBRA, insurance portability.

Font Size:
A
A
A
Background:
Blank
Blank
Blank
This expert forum is not accepting new questions. Please post your question in one of our medical support communities.
Blank Blank

Paid on part of claim but says we aren't covered

Our insurance was supposed to end on March 31st and Cobra was to begin on April 1st.  We had an emergency surgery on March 31st.  The insurance has paid some of the claims for the 31st, but is denying all others saying that we no longer had insurance and that it ended on March 30th.  We did not select Cobra, realizing that we would have to pay for a hospital stay for one day on April 1st.  We do not understand why they chose to pay some of the claims and deny paying  others because "we were not covered".  We are either told that we were "just not covered" or that had we enacted Cobra, we would have had to not have any insurance for one day, that day being March 31st.  We do not understand why some claims were paid, as they are saying we were not covered.  We specifically did not take out Cobra because they said we were covered and the Cobra would not start until the 1st of April.  We feel they are choosing to not pay because the wording is "tricky" and because it is an emergency surgery.  We don't know what to do.  
Related Discussions
282113_tn?1388163349
Rose071498,

Most health insurance claims are filed based on the date on which services were rendered. It does get more tricky when it comes to services that were billed through hospital, given that the exact time of the services may not be documented preperly, which may be why some of your claims got denied. Unfortunately there isn’t much you can do about the unpaid claims now, but you could have enrolled just the one member who had the claims for one additional month on the COBRA which would have paid the claims.

I am curious though as to why they are only covering services that were rendered until 03/30 & denying those that are dated 03/31. Have you tried to find out what they base that decision on? If you had coverage in the month of March, you should typically be covered for all covered benefits until 12 midnight of 03/31!

Sincerely,

Amir Mostafaie
2 Comments
Blank
Avatar_f_tn
I agree!  We understood that we would be responsible for the hospital stay on April 1st, since Cobra would start on that day and we already knew we had insurance lined up to begin on April 15th.

When I called the insurance company, the lady I spoke to said A) benefits were to end on the 31st and we were just lucky that some of the claims got paid by accident B) had we enacted Cobra, we would not been covered on the 31st not matter what because our benefits had ended.

We fill strongly that the benefits for the 31st should be paid and anything done after March 31st, 11:59 p.m. should not be paid.  We would be responsible for that.  I don't understand how we are paid through a month, but the end of the month does not include the last day?  No one can explain this to us.  We have saved the screen shot of the benefits that were paid and have asked for these claims in paper form just to be told they are "not available".

The way we see it, the fact that they did choose to pay claims on the 31st sets some sort of precedence that we were in fact covered on that day.  We are not sure if we need to hire an attorney to point this out, or if we just keep climbing the ladder.  They deny every appeal saying we were not covered on that day.

Thank you
Blank
MedHelp Health Answers
Blank
Weight Tracker
Weight Tracker
Start Tracking Now
RSS Expert Activity
242532_tn?1269553979
Blank
Emotional Eating Control: How to St...
16 hrs ago by Roger Gould, M.D.Blank
233488_tn?1310696703
Blank
New Cannabis Article from NORTH Mag...
Jul 20 by John C Hagan III, MD, FACS, FAAOBlank
242532_tn?1269553979
Blank
3 Reasons Why You are Still Binge E...
Jul 14 by Roger Gould, M.D.Blank