Dual medical coverage via tow plans from the same carrier

[ruoli8247]

In Sept. Cigna authorized me to seek physical therapy from a 3rd party via my wifes HMO plan. On the 1st of Oct, a HRA plan with my employeer became active. After the 2nd visit Cigna took claims submitted by the provider and forwarded them so that they were processed against the HRA account with ended up paying $58.00 per visit for the therapy. I was not informed of this until I got a statement from Cigna saying that the account number for the HRA account was being used to pay the provider even-though I was making a co-payment of $45.00 to the provider based upon my wifes HMO policy which had authorized the treatment initially.

Since Cigna is collecting premiums from both me and my wife for dual coverage I believe that they should honor the plan that calls for us to pay the least out-of pocket money and not one where I could end up paying a as much as $5000 out of pocket befoe they pay anything?

Do I have any right to insist that honor both policies and therefore limit my out of pocket expense to lowest amount possible under the 2 policies that I hold with them. Can I force them to refund the preinum if they do not want to honor the conditions of both policies?

 

[army judge]

In Sept. Cigna authorized me to seek physical therapy from a 3rd party via my wifes HMO plan. On the 1st of Oct, a HRA plan with my employeer became active. After the 2nd visit Cigna took claims submitted by the provider and forwarded them so that they were processed against the HRA account with ended up paying $58.00 per visit for the therapy. I was not informed of this until I got a statement from Cigna saying that the account number for the HRA account was being used to pay the provider even-though I was making a co-payment of $45.00 to the provider based upon my wifes HMO policy which had authorized the treatment initially.

Since Cigna is collecting premiums from both me and my wife for dual coverage I believe that they should honor the plan that calls for us to pay the least out-of pocket money and not one where I could end up paying a as much as $5000 out of pocket befoe they pay anything?

Do I have any right to insist that honor both policies and therefore limit my out of pocket expense to lowest amount possible under the 2 policies that I hold with them. Can I force them to refund the preinum if they do not want to honor the conditions of both policies?

This has NOTHING to do with rights, as its at best a contract related dispute or concern.

The answer you seek is buried somewhere in the plan documentation, policy information, or the CONTRACT(S) concerning the plans.

You can discuss, not insist or demand anything.

Why?

Because the provider has determined your policy to be primary, and your wife's secondary. Don't confuse the co-pay with the services provided.
I suspect the medical professional lets you pay $45, rather than another amount because the delta is minimal.
Some people don't quibble over every nickel, dime, or quarter.

People rarely respond to demand or threats well.

So, inquire of the insurers, the employers benefits departments, and read the documents.

In the end, it'll matter very little, as they'll decide and do whatever it is they want to do.

Your belief about what the insurer should do is of no moment, matter, consequence, or import to the insurer.

I suspect it has to do with who is primary,a nd who is secondary.

Both plans are employer based plans, and I suspect YOUR plan is primary, with hers being secondary.

They work out who pays what behind the scenes without consulting either of you.

Its driven by the plan agreements between the employer and the provider.

Its also based on your status as an employee.

As I said, forget rights, this is contract law.

Don't insist on anything, rather ask why and how.

 

[cbg]

Do I have any right to insist that honor both policies and therefore limit my out of pocket expense to lowest amount possible under the 2 policies that I hold with them. Can I force them to refund the premium if they do not want to honor the conditions of both policies?

Absolutely not. The terms of the policies themselves determine which policy is primary, which is secondary, and how the two will coordinate benefits. If these are both employer-sponsored policies then I can guarantee you that for you, the HRA is primary and for your wife, the HMO is. You do not get to decide you want to do it the other way because the other way benefits you more. This is, as AJ indicated, contract law, and you are owed precisely what the contract(s) say you are owed; not one penny more or less.