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LegalKnowledge, Attorney
Category: Legal
Satisfied Customers: 28007
Experience:  10+ years handling Legal, Real Estate, Criminal Law, Family Law, Traffic matters.
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I am a spouse of an employee with a medical insurance

Customer Question

I am a spouse of an employee with a medical insurance "family" coverage plan. The insurance company has been receiving premiums through my spouse's pay checks without questions. Then after I had a hospital visit and a claim was filed the Insurance company demanded that my spouse and I must send them a copy of our marriage certificate before that claim is honored even though they have been receiving premiums from us under "family plan" without questions. Does a private business, medical insurance company in this case, have a legal right to demand and place my marriage license on their file before honoring my medical claim?
Submitted: 1 year ago.
Category: Legal
Expert:  LegalKnowledge replied 1 year ago.
Good morning. I am sorry to say but Yes, they can. Companies want to make sure no one is trying to trick the benefits system by having an ineligible dependent on their policy. As such, if a claim is filed, they simply want to verify that you are legally married and they have a legal obligation to pay the claim and there is no fraud. After all, when you added her, you simply filled in her name and information and they had no way to verify that you were actually married. Now that a claim is being filed, they want to make sure they have to pay it before they do.
Customer: replied 1 year ago.
Sure. But why doesn't the question of "ineligible dependent" come up prior to the collecting of premiums that include the dependent spouse in the sign up. The company may have the legal right to make requirements within the law but shouldn't such requirements have some consistency? How does the law protect the acceptance of premiums from a consumer whose eligibility is deemed "uncertain"?
Expert:  LegalKnowledge replied 1 year ago.
Certainly. It is because the applicant is making the disclosures. They are enrolling this person and adding them on the plan and signing a document which advising they are telling the truth and not committing fraud or misrepresentation. It would be an additional burden for the insurance company to require and check prior to and if someone is caught lying, they would be forfeiting their premium payments.
Expert:  LegalKnowledge replied 1 year ago.
Please let me know if you have any follow up questions or need any clarification on something which I stated above. Also, remember to rate my service at the top of this page, before exiting the site, so I can receive credit for my help. I hope you found it to be Excellent! Only rate my answer when you are 100% satisfied. If you feel the need to click either of the two lower ratings to the left, please stop and reply to me. I want to make sure your experience with the site was as pleasurable as possible and that you are satisfied with the help I provided.
Customer: replied 1 year ago.
I guess I will just have to live with the fact that the company is spared additional burden at the expense of the consumer's privacy. Our marriage certificate is on file with the government but I don't just like the idea of private organizations keeping our important documents on private files. When my spouse was under my family plan with another insurance company no such ridiculous demand was made before any claim was honored. I can't just help but smell a rat though I just can't identify it. I'm skeptical that this requirement applies across the board among us consumers.
Expert:  LegalKnowledge replied 1 year ago.
I do understand your concern and it is at your discretion to believe the information I provided. Not only am I am attorney but licensed to sell health insurance both on and off the exchange, so I am familiar with what they may request. For those individuals that buy on the exchange, they are required to submit tax returns, pay stubs, immigration cards and anything else to substantiate the claims they make on the application.