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Zachary
Zachary, Attorney
Category: Legal
Satisfied Customers: 4019
Experience:  Lead trial/International commercial attorney licensed 11 yrs
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I have the following situation: 1. I had a health insurance

Resolved Question:

I have the following situation:
1. I had a health insurance with a company Easy Choice Health Plan since 2008
2. In March-April of 2012 I had to use medical services
3. I did not pay insurance bill for March - April 2012
4. On 4/13 I received the letter from Easy Choice saying that I was denied of coverage for non payment, but I can be reinstated if I will pay.
5. I sent a check that was cleared (they accepted a payment)
6. In June 2012 I received bills from medical providers, because Easy Choice denied coverage.
7. I called to Easy Choice (in July 2012) to find out the reason of denied coverage and they admitted that I paid the bill up to 5/1/2012, but they denied coverage.
8. Then the EC rep said, that by manager decision they can reinstate me starting from May 2012, but not for March and April (the medical bills are for March and April services), because i was more than 30 days late to pay. (They received my payment on 4/25).
What should I do in this situation to make them pay the bills, that were forwarded to me because they denied coverage?
Submitted: 2 years ago.
Category: Legal
Expert:  Zachary replied 2 years ago.
Hi,

Thank you for your question. I need some more information in order to answer it.

1. What state are you in?

2. When you say you paid to be reinstated, did you pay the premiums for all the months you had previously missed?

3. Are the medical bills too high to pay now and seek reimbursement from the insurance company, rather causing the medical provider to send you into collections while the insurance dispute is sorted out?

I look forward to hearing back from you.

-ZDN
Customer: replied 2 years ago.
1. New York
2. Yes
3. The medical bills are high (approx $6000), but I can pay them.
Expert:  Zachary replied 2 years ago.
I'm looking at NY law on this. In the meantime, I have some follow up questions.

1. When you paid the overdue premiums, did the insurance company state they are issuing you a new policy, or are they reinstating your old policy with continuous coverage?

2. When you paid, did they send you any sort of letter confirming payment or any sort of document which is a "certificate of coverage"?

Thanks,
ZDN
Customer: replied 2 years ago.
1. no
2. no
Expert:  Zachary replied 2 years ago.
Pursuant to NY law, in your situation, the terms of the policy control the right of the insurance company to terminate. Generally, if you have paid premiums for a certain period, you should be granted coverage for that period.

If the insurance company did not state that they had terminated the policy and were issuing a new policy, and you are still under the old policy, then you are entitled to coverage on the medical bills. On the other hand, if the insurance company terminated the policy and issued a new policy with a new coverage date, you are not covered for the missing time.

In either situation, I believe you have a claim against the insurance company for unfair practices. The first thing you need to do is request a certificate of coverage on your policy which shows the dates of coverage. This is a standard form that all insurance companies issue.

Next, you should check the policy information that they have sent you. Did the policy number change?

After you gather this information, if they tell you that you have the exact same policy as you did before the gap in payment, and your certificate of coverage states that you are covered, you should attempt to file the claim again pointing to your evidence of coverage.

If that is denied, then you should file a claim with the NY Department of Financial Services (the department in charge of insurance regualtions). It will be a "prompt payment complaint" and you can find the form for complaint at: http://www.dfs.ny.gov/consumer/fileacomplaint.htm

You will want to try to resolve this quickly before you medical provider sends you to collections and it affects your credit. They generally give you a decent amount of time before doing this, but you will want to get on the phone with the health insurance company and request the documents I referenced above ASAP.

If the medical provider attempts to send you to collections before the issue with the insurance carrier is resolved, it is wisest to pay the claim and seek reimbursement so as not to negatively affect your credit score.

If all that fails, I believe you have a claim for bad faith and breach of contract against the insurance company. These types of claims are complex and have to be handled by an attorney. Hopefully, you won't get to that point and the Department of FS will force the insurance carrier to pay the claims.

Please let me know if you need clarification or further information.

Best Regards,
ZDN
Zachary, Attorney
Category: Legal
Satisfied Customers: 4019
Experience: Lead trial/International commercial attorney licensed 11 yrs
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