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I have COBRA Insurance and have more then met my maximum co

Customer Question

I have COBRA Insurance and have more then met my maximum co pay for the year. My husband turned 65 and was forced off the policy and into Medicare in Sept. They have assigned me a new card number now that he is not on it. The coverage remains the same and I've been on it since it started. Can they reset my copay to charge me another 2900 out of pocket in the same year only because it's a new CIGNA internal policy number?
Submitted: 1 year ago.
Category: Business Law
Expert:  John replied 1 year ago.
Hi, thanks for submitting your question today. My name is XXXXX XXXXX I’m happy to assist you with your question today.


This specific scenario is covered by the Treasury Regulations that cover COBRA coverage. Specifically, they state that where a change in coverage by way of changing the coverage group (i.e., going from self plus spouse to self coverage) the employee must be given credit for amounts contributed to deductibles and co-pays for the current plan year. An important distinction here though is that coverage can be broken down per person if the plan tracked your co-pays in that manner. Thus, if this co-pay was solely under your husband's patient name, the plan could now charge you a copay. So you'd have to figure out 1) how much of the $2900 co-pay was contributable to you and 2) what is the required co-pay for single coverage. Subtract the amount contributable to you in copays from the amount required for single coverage co-pay, then you'll have what, if any, co-pay you can be charged for the remainder of the plan year.


I believe this answers your question. However, if you need clarification or have follow-up questions regarding this matter, I will be happy to continue our conversation – simply reply to this answer. If you are otherwise satisfied with my response, please leave a positive rating as it is the only way I am able to get credit for my answers. Thank you, XXXXX XXXXX wish you all the best with this matter.

John, Attorney
Category: Business Law
Satisfied Customers: 3132
Experience: Licensed and practicing attorney helping businesses achieve their legal and practical goals.
John and 4 other Business Law Specialists are ready to help you
Expert:  John replied 1 year ago.
Hello Connie,

I am sending you this follow-up to determine if you require further assistance with your matter. I believe I have answered your question to the best of my abilities. I truly enjoy helping others with my knowledge and experience, and I believe I provide a valuable service. If you agree that my response was of value to you, please support my endeavor to share my knowledge by providing a positive rating; these allow me to continue to serve customers. Providing a positive rating will not cost you any additional charge, but it will permit the website to credit me with answering your question. Otherwise, the website does not credit me with answering your question. Thanks.
Customer: replied 1 year ago.

Hi, sent a long expert reply to you asking at what point all that Cigna does to disallow my treatments becomes fraud or what to call it.


 


As stated in more detail in my 3:30 reply, they have held my transferred and cashed electronic payments for which I had payment confirmation numbers from ADP (their COBRA billing company) and bank copies confirming they had the money for up to 3 months while telling me that was not proof of payment - internally they need their billing company (ADP) to force the records to them in their nightly download - it cleared my bank 7-28-13 and did not credit and reactive my coverage until 10-10-13. And the promised forced transfer took 7 instead of the promised 1 day, another 6 day delay.


 


They've delayed, required above and beyond repeated certifications and refused to acknowledge the validity of the prescriptions my doctors provided, claimed we had other insurance as confirmed by a secret confidential source we couldn't know about etc., to delay my care and save the cost of 5 treatment because they took so long to confirm coverage that they could no longer be scheduled. I'm to have one every 2 weeks and they turn it into one every 4 weeks by refusing to confirm coverage.


 


I've sent 4-7 hours 8 days in the last 2 weeks to get them to finally acknowledged they have been paid at least a month before it is due for the coverage thru December 1, 2013 and then found that they still reported that my coverage ended the end of July, the end of Aug to my care providers in Aug, Sept and October, thus saving them the cost of another treatment, delaying eye surgery and created a real billing mess with all of my providers.



When does this become fraud and are they in any way accountable for the damage created by the delays?

Expert:  John replied 1 year ago.
Connie,

I did not receive a 3:30 reply from you and, as you can see by reviewing this thread it never posted to the thread. In any event if you are being falsely denied coverage despite your clear payment of the deductibles, that would be a violation of COBRA. In that case I'd recommend you go ahead and contact the Department of Labor to file a claim against CIGNA. You can in fact do that from the Department's website here.


Hope this helps.

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