Insurance denied big expensive claim. I have a question.

[HelpmeHelp]

My young adult son is on our insurance policy until December (Thank you Mr. President.)

He is dual diagnosis psych/alcohol. He just spent two days in a psych unit after drinking rubbing alcohol. The insurance co thinks that is psych problems had nothing to do with it and have completely denied coverage for his stay.

My question is: Does the hospital have the right to come after us, or do they have to try and collect from my son, jobless and near penniless?

[jody]

1. Interesting question. Since your son was dependent on you and used your insurance you could be

liable for his debts.

I look forward to posts by those with legal insight re your your question.

[unblock]

4. insurance provides benefits (well, except when it doesn't) but never liabilities.

whether someone has insurance or not, whether they are part of a group or family coverage or not, whatever, it all has to do with the BENEFIT side of the equation.

any liabilities for medical bills in particular, transfer of the liabilities to someone else, has nothing to do with insurance coverage.



not a lawyer but i can't imagine i wouldn't have run into this before were it the case.

[jody]

6. Understand but could eligibility for insurance imply eligibility or liability for related debts? nt

[unblock]

8. afaik, you're only responsibly for yourself, a spouse, and any children under 18.

[1-Old-Man]

2. If he's an adult its his problem

The hospital is not obliged to pursue an insurance claim that has been denied and it is the adult who received the service who owes for it. If the hospital provided the service they have every right to come after the adult person who got the service. If he had been a minor child, then it would be you who would be on the hook, but he's not. So they go after him, but of course if he's indigent then they aren't going to get anything.

[csziggy]

3. Chances are the hospital will try again to get the insurance to cover it

My insurance company denied the pre-approved hospital stay for my first knee replacement, three months ago. So far I have not received a bill from the hospital and nothing was said when I checked in for the second knee replacement, three weeks ago.

Hospitals are used to insurance companies routinely denying the first, second and sometimes third applications for payment. Of course, all that re-applying just adds to the administrative costs, but the insurance companies don't care.

[sendero]

23. Exactly..

... one denial doesn't mean, it happens all the time. The hospital will re-file and there will eventually be a negotiation.

[cbdo2007]

5. What was the actual denial reason on your sons EOB??

Your coverage should include both medical and mental health benefits so regardless of whether or not he has psych problems the stay itself would be covered under your insurance benefits for that particular issue.

It may be that the hospital just sent it to the wrong place, if you have a separate company who manages the Mental Health portion of the benefits separately from the Medical portion. They may have denied it and the hospital would then send it to the correct part of the plan.

Either way, it sounds like insurance is still "working through" the issue so don't start really freaking out until you actually get the hospital bill. Then, at that time, write in an appeal and send it to your insurance company. If that gets rejected, send in a second appeal.

[WillowTree]

19. Probably doesn't cover self-inflicted injuries.

Most don't.

[NickB79]

7. Do NOT give up. Appeal the hell out of it

My wife had to have robotically-assisted laproscopic surgery to remove large ovarian cysts while she was 4 months pregnant, and the insurance company tried to claim this variation of laproscopic surgery was experimental! It's been used at major hospitals for a decade now, but that just went over their heads apparently. Long story short, they saw the word "robotic" and tried to leave us on the hook for $20K to the hospital.

I appealed every single time they denied the claim, kicking it up the chain of command. Since my insurance was through my job, and my job is unionized, I contacted the head of corporate HR (not just the local HR rep at our plant) and my union representative. They also started making calls on my behalf. I contacted the surgeon that performed the operation and received letters of support from him as well.

Long story short, after 9 months of almost weekly contact with insurance, they finally agreed to cover the entire claim. This was actually very shocking because my reading of our health insurance contract had me pretty sure they could still bill me for $5000 even if they accepted the claim. For whatever reason, they just decided it was easier to just cover the entire thing and never bug me again.

[Bluerthanblue]

9. do you claim him as a dependent on your taxes?

and provide his shelter and living expenses?

I was told that is the deciding factor- If your son is not listed as a 'dependent' on your returns, and he is jobless and without funds, he could apply directly to the hospital for financial assistance. It's worth asking. I wish you well. This is a terrible predicament.

[HelpmeHelp]

18. We couldn't claim him for this past year

because he got paid just enough at the job he had then. We have provided all his food and shelter expenses.

[NNN0LHI]

10. If this is employer paid insurance you need to ask your employer these questions

Because the employer is who tells the insurance company what to pay and what not to pay. The employer is calling the shots here.

Don

[cbdo2007]

12. the employer doesn't decide on a case-by-case basis....

they buy a certain set of defined benefits from the insurance company. The insurance company is who decides what to pay or not pay based on the definitions in the benefit manual.

[NNN0LHI]

13. My employer does

Any hospital provider has to call an 800 number and speak to a company benefit rep to request pre-approval for any hospital stay. That benefit rep decides what is and is not covered.

Been that way for as long as I can remember.

Don

[WillowTree]

26. Not in all cases.

If this was an emergency admission, which it almost certainly was, the hospital has something like 24 to 48 hours to call for certification. Those lines aren't manned 24/7, by the way. If the hospital called and asked to certify a confinement with a diagnosis of "drank a bottle of rubbing alcohol", the certification nurse would most likely have denied certification.

That could be at least part of the reason why he was discharged from a psych unit after only 2 days.

[Curmudgeoness]

31. Although it is true

that the employer does not decide whether claims are paid or not, they do have an insurance agent who sells them the policy. And that agent can be involved in the appeal.....that is what they are supposed to do. They are paid to do this.

[WillowTree]

22. Only if it's a self-funded plan. If it's an insured plan, that's not the case.

An insured plan will ony cover things that are specifically outlined in the plan at the time when it was written, no matter how much the insured (in this case, the employer) argues. If there is an exclusion of coverage for self-inflicted injuries, and there almost aways is, the denial will almost certainly stand.

[SheilaT]

11. When he was admitted to the psych unit,

paperwork was filled out and signed, and somewhere on that paperwork someone agreed to be the one responsible for anything not covered by insurance. If he agreed, they'll go after him. If you agreed, they'll go after you.

The other thing to possibly look into, since your son is jobless and near penniless, is Medicaid or an indigent fund or some such thing. The hospital should have people who do just that. Sometimes they are connected to the billing office, sometimes they're a stand-alone group.

It may take any number of phone calls to figure out who to even contact in the first place.

Meanwhile, as others have already said, keep on resubmitting the bill, if the hospital isn't already doing it on your behalf.

[Phentex]

14. True, and there is usually only one subscriber or guarantor on the insurance...

that person is the policy holder and the one who has the final responsibility for the bill. Since the OP says the son "is on their policy" then I think which ever of them (parent) is the policy holder is the one who will be on the hook.

[HelpmeHelp]

16. My son signed the "agreement to pay" paper

when he was admitted. His father didn't.

[jody]

15. Thanks SheilaT and Phentex for simple explanations with a ring of truth to laypersons. nt

[SheilaT]

32. I work in a hospital, and I am tangentally

exposed to these things.

[HelpmeHelp]

17. Medicaid isn't an option as long as he's

officially on our policy. And apparently it's next to impossible for an individual to navigate the paperwork to get it. Usually the treating institution gets the account going. They are motivated and big.

[Cleita]

21. Get a lawyer and fight them.

They are in the business of denial. The hospital will probably try to get a collection agency after you if you ignore them. A lawyer might be able to negotiate some kind of deal with the hospital as well if they can't force the insurance to pay.

[forthemiddle]

24. I have worked with medical insurance for 20 years

I have NEVER seen a hospital or clinic place the financial responsibility on the parents if the child is over 18 years of age.

The insurance liability is outside this area. You are not responsible for his bills regardless of being the policy holder. If they try and bill you, immediately remind him that he is over 18 and an adult. The only thing you are responsible for is the insurance premiums, not the bills that the insurance will not pay.

The only thing that could theoretically change this is if you signed financial papers at the hospital (which you said you did not).

[Phentex]

25. I think it's different now....

If he is on their policy after the age of 18. When is it the case that the policy holder is not liable? I don't know the particulars in this case but by law here we have to use what is listed on the insurance card which provides the subscriber's information.

[WillowTree]

27. forthemiddle is absolutely correct. Honestly.

[Bluerthanblue]

28. it is happening to me-

and I'm far from alone in this plight.

[HelpmeHelp]

29. THANK you so much for this forthemiddle!

I had hoped that was the case. I feel a little less panicky.

[1StrongBlackMan]

30. Not my area of expertise; but ...

based on decisions in other areas of law, you are not responsible for the debts of adult off-spring, even if you provide them with 100% support, unless you agree to assume responsibility.

But that said, that does not mean the hospital won't try and have you assume responsibility through intimidation and threats.