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Coinsurance Questions

Coinsurance is a type of insurance related term that is used to describe a splitting or spreading of risk across many parties. When it comes to coinsurance, generally, this is a type of penalty that is imposed by an insurance carrier on the party who is uninsured and who under reports, under declares, or underinsures their property. Typically, the penalty is based on a percentage stated in the policy. Coinsurance can give rise to many complex questions that can go unanswered. Listed below are a few questions answered by the Experts on coinsurance related issues. .

A person has a policy of $6,000 with an 80% coinsurance agreement. The insured property is worth $10,000, the loss is $800 and the policy has a $500 deductible. In this case, what would be the amount that the insured would collect?

Based on this, the deductible would come off the top and the insured would probably get 80% of the $300 that would amount to $240.

An individual who has insurance was told by their speech therapist that the cost of the therapy would be covered by the insurance. Now the insurance company refuses to cover the costs and the speech therapist is demanding the money. The individual has agreed to pay the coinsurance due. What else can the individual do now?

If the individual can provide proof that they were told that the therapy would be covered, typically, the individual would not have to pay anything other than the co-payments they would have made had the insurance covered the therapy. This would only be the case if the individual did not sign any agreement stating that they would be personally liable for any and all charges regardless of any insurance. In most cases, a doctor’s office will have a patient sign an agreement saying that they will submit the costs to the insurance company but the patient will be responsible for any and all charges that the insurance does not cover. If there is no such agreement in place and the individual has proof stating that the insurance would pay the therapy costs, they may have a strong case.

Under parity law, how can disability insurance pay for disabled people due to addictions?

The Federal Mental Health Parity and Addiction Equity Act of 2008 requires that group health plans of 50 or more employees that generally provide the equal coverage for both medical and surgical benefits as well as the mental health and addictions benefits. This type of coverage includes deductibles, out of pocket expenses, copayments, and any other out of pocket expenses that the person may have.

Can an out of network physician legally wave or reduce the deductible or coinsurance fee for a patient using his/her health insurance in order to make it more financially feasible for the patient to acquire care?

In most cases, if a physician agrees to an individual price for services that are performed for a patient, they have to report the reduced cost to the insurance company and not a higher one.

Coinsurance helps a person to pay their insurance charges but will penalize the provider if they do not report the splitting of costs. There are several rules and laws governing coinsurance. If you have more questions, put them to an Expert now for insights and answers that can help you deal with your case in the best manner possible.

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Recent Coinsurance Questions

  • I live in TN and have a question about health insurance. I

    I live in TN and have a question about health insurance. I provide Cigna medical insurance for my family thru my employer. Our daughter (who turned 18 Aug/2012) moved out of our home in January. We have had no contact with her since that time and provided no assistance to her but she is still on our insurance plan. This month she has incurred several medical bills, obviously with copays due the providers (such as deductibles and coinsurance amounts). I was not aware of this until I received the EOB statements from my insurance company. Although we have no contact with her I would like to keep her on my insurance after this year, but ONLY if we (her parents) are not responsible for any co-pays. Cigna tells me that because she is 18 that the providers should bill her directly and that we are not responsible even though it is our health insurance plan, but told us to check with an attorney to be sure. Is this correct?
  • If a doctor (in California) is out of network with a PPO health

    If a doctor (in California) is out of network with a PPO health insurance company, can they waive the coinsurance and/or deductible amounts owed by the patient?
  • We contracted with a private company for speech therapy, and

    We contracted with a private company for speech therapy, and engaged them to bill our insurer directly. Said company assured us, repeatedly and in writing (emails and attachments) that their services would be covered by our insurance - though their contact asserts that they're not responsible for this assertion or the insurance company's determination. We began services. They failed to submit any claims for nearly three months. When we pressed them to do so, their claims were incorrect and/or incomplete for two more months. Throughout this process they reassured us that the delays and errors were just paperwork glitches, nothing to worry about, etc. We finally became uncomfortable and pressed the matter directly with our insurance company, who determined that the services were not covered and denied all the claims. We immediately discontinued services. The provider now asserts that we're 100% responsible for the services provided as if we were a private payer without insurance. We've offered to pay the coinsurance that the provider told us we'd owe, which is only 30% of their claim. While we understand our obligation to understand our own insurance, we relied on their expertise, and our discovery of their errors was delayed by their failure to file accurate or timely claims. Anyway do we have a leg to stand on, here, as regards XXXXX XXXXX that the provider shares responsibility for the cost of services now in dispute, and we're not accountable for 5 months of services at full cost? Thanks in advance.
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