Is this the health insurance board?

I have an interesting issue with health insurance that I'm wondering if anyone here has experience with. My wife has been covering all of our kids under her health insurance, so we were planning to use her health insurance when our baby was born last year since we already reached her out of pocket maximum. We had called my wife's insurance the day our baby was born to get him added.

Well apparently my insurance has this "benefit" where any baby born gets them automatically added to my plan for 31 days. So now my wife's insurance is denying the claims from the birth because the baby was added to my plan automatically. So now if those claims are added to my plan, I'm going to have to pay out of pocket.

My insurance added the baby without my consent. Is there any way around this?

Edit: If I'm the primary insurance and my wife is the secondary insurance, would my out of pocket expenses go to her insurance such that we don't pay any additional out of pocket?

Not too knowledgeable on this but I am a provider who accepts insurance.

Imho, insurance companies seem to be an obstacle between the clients and the insurance company so the insurance company gives the client and the provider a hard time. Last month between being on long hold times and having the call transferred twice, it took me 52 minutes to find the info I needed and be done. That meant three times I had to give a bunch of data about myself and the client. Yep, each new transferred phone call was like starting the process all over again.

Expect a fight. Whoever is the primary holder, their employer should go to bat for you. The employer chose the insurance company (and co-pay can vary with say BCBS because each employer has agreed to different specifics), and they made a promise to the employee who paid for this insurance even if it was subsidized as an employee benefit. The HR department should realize that the insurance company is incorrect.

I wouldn't be surprised if the clerk taking the calls misread the information. I've had many phone calls give me different answers.

Your newborn should absolutely been covered once he/she was born. Your family paid for the insurance and clearly the employer stated in writing what the specifics of the policy were. It might be needed at some point for the head of HR to call a manager or mid-level manager at the insurance company to resolve this issue.

I'm on my wife's group plan which is better and cheaper than I had when I was self-employed. Our children and I are listed as dependants. So we each four have our own out-of-pocket maximum expense before the gravy train, but there is also a FAMILY out-of-pocket maximum expense. This is a guess - your baby will have its own individual out-of-pocket maximum expense payment and if the family out-of-pocket maximum has been met (and naturally that will be higher than the individual) then you should be good to go. I call BS on the "because the child was automatically enrolled" nonsense.

Best of luck!

It's worth asking your wife's HR if the company has an advocacy service. My plan has that service, and I've used it more than once to sort out billing issues. This wouldn't be an employee of your wife's company, but a third party service that comes with the coverage.

Saves you time and frustration, and they should be able to navigate the system better than you can.

Thanks for the advice. I will see if my company has an advocate. Do y'all have any experience when dealing with primary and secondary insurance? If I'm left with a bill to pay the deductible from my primary insurance, would the secondary insurance cover that?

Thunderstruck xx said:

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Thanks for the advice. I will see if my company has an advocate. Do y'all have any experience when dealing with primary and secondary insurance? If I'm left with a bill to pay the deductible from my primary insurance, would the secondary insurance cover that?

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When you say secondary do you mean a true supplemental plan or just having two health insurance plans (intentionally or unintentionally)?

htxag09 said:

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Thunderstruck xx said:

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Thanks for the advice. I will see if my company has an advocate. Do y'all have any experience when dealing with primary and secondary insurance? If I'm left with a bill to pay the deductible from my primary insurance, would the secondary insurance cover that?

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When you say secondary do you mean a true supplemental plan or just having two health insurance plans (intentionally or unintentionally)?

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I have insurance through my employer which they are claiming is the primary for my baby due to some coinsurance rules I've never heard of. They said my wife's insurance through her employer is the secondary insurance due to the same rule. Something about my birthday month being before my wife's, so mine is primary. I never added my baby to my insurance though, but my stupid insurance has some automatic coverage for babies for 31 days from birth.

TRD-Ferguson said:

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Your employer coverage is always primary for you the employee. Same for your wife.

All group plans add newborn children automatically. It may sound stupid and it may be stupid but you would not believe the number of people who forget to add a newborn child.

Since your kids are already covered under your wife's plan that plan should be primary for the newborn. That would be my argument.

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That's what we tried to argue since we immediately added the baby to my wife's plan the day he was born, but her insurance is denying the claims by saying that somehow the baby already had insurance automatically under my plan despite me not telling my insurance anything about the baby. Not sure how to argue this further with them.

Have you made that argument to your insurance? Would it be possible for them to acknowledge and somehow retroactively remove the baby from your coverage?

I'm going to try calling them again to do this. The first time I called, I got someone who was really unhelpful.

You are in a very unenviable position, and I feel for you. As previously mentioned, an advocacy service, either through your employer our your wife's, should be able to help here. I can be rather skeptical of the value of the advocacy services, but this is the type of situation for which they exist.

One thing to think about here is who is ultimately footing the bill (other than you) for the cost of coverage on your insurance plan. In somewhat simplified terms, if your plan is fully insured, then the incremental claims exposure (cost) for the birth is with your insurance provider. However, if your plan is self insured, then the cost of the birth is carried by your employer. The latter is likely a drop in the bucket, but the former may be significant. Bottom line, I would escalate with the insurance provider or your employer to remove the child from your plan, depending on who is incentivized to not have the claims on their bottom line.

When/if you are able to remove the child's coverage from your plan, you should have less trouble adding the child to your wife's plan and/or having that be the primary coverage for the child. Being said, may run into retroactivity rules at this point. If I am reading it correctly, it does sound like the child is effectively on her coverage as of the date of birth, so that will help with any retroactivity issues.

As much as possible, I would suggest getting everything in writing so that you have a paper trail for all of this. I have a feeling it is likely to linger much longer than you would like for it to, especially when/if the hospital has to re-bill the services.

I hope that this helps in some way and best of luck to you.

Is your birthday earlier in the year than your spouse's? If so, that may be what her coverage is using to shift coverage to your plan. It's the so-called "birthday rule".

That said, on your plan, do you have coverage for yourself only or are you also paying for self & child or self & family. If self only I'd continue the argument and as said above document everything.

TRD-Ferguson said:

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Is your birthday earlier in the year than your spouse's? If so, that may be what her coverage is using to shift coverage to your plan. It's the so-called "birthday rule".

That said, on your plan, do you have coverage for yourself only or are you also paying for self & child or self & family. If self only I'd continue the argument and as said above document everything.

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My birthday month is before my wife's, but she is older. That birthday rule is exactly what they told us for making me primary. My insurance through my employer is for me only. I don't have any family on it. The kids have all be going on my wife's plan.

Age doesn't matter just which b-day occurs first in the year.

I'd fight your wife's plan on this. You have self only coverage. Clearly, no intent to add children as you already have your kids covered under your wife's plan and have paid premiums on that plan for children. The clear intent is that all existing and additional children were expected to be covered under your wife's plan.

I know it's a pain in the ass to deal with. Won't hurt to contact the department of insurance too.

Interesting thread and hope for the best outcome for you op.

It's also making me wonder a little and want to do some research. We are expecting our second child next month. I'm the only one covered through my employer offered insurance. Our 3 yo son and wife covered through her work, mainly to have her pregnancy and the baby's first year on the same plan.

Not sure how, but need to confirm the baby won't be automatically added to my employee only coverage.

Hollar at me if you need some help. I should be able to get you in the right direction on where to look relatively quickly.

I have never seen children "automatically" added to an employer health insurance plan.

It's by choice. If you wanted, you would do a life event change to your insurance and add the child to your health insurance.

Wow OP that's a strange deal!

From what I gather, it is some new feature where they get added automatically for 31 days after the birth since people tend to forget to add newborns. It creeps me out that they just got all the baby's information without me telling them.

I think it's BS because it's really causing a lot of stress for us while we have a newborn. We were responsible and added our baby the day he was born. It may also be a way for insurance companies to somehow screw us over more. Either way I'm fighting this until I get it on my wife's plan. They're the one's delaying the payment. F 'em.