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Employer did not pay group insurance amongst other things Pennsylvania

Discussion in 'Health Insurance, HMO, HIPAA & Disability' started by Justin White, Jun 15, 2022.

  1. Justin White

    Justin White Law Topic Starter New Member

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    So I was employed by a company that was having some obvious financial trouble towards the end, but were lying about the situation. The last couple of months we were paid out typical net amount in bank/cashiers checks not payroll checks and without statements. The assets (not the business) were being purchased by a customer of the company with plans to continue operating the facility and retain the employees so most of us just hung in there.

    Our last paycheck for the previous employer was not paid. There is no record of taxes, 401k, or health insurance being paid for over 2 months and it's likely that none of it was. The PA DOL was contacted and seemed rather incompetent, and I believe the DA is looking into a criminal case but who knows how any of that is going.

    My current issue aside from the above is that my dentist is billing me for $2k. Now prior to really any of the funny business mentioned above being obvious I had some dental work done, and paid my deductibles on the spot. I contacted the insurance company prior to my visit and was assured I was covered, the plan was fine.

    When the new company took over HR mentioned the previous employer did not pay anything and it would all be rebilled, and I was furious. I again contacted the dental insurance provider and they said "no, we already paid the claim and your coverage never lapsed." which they did pay the dentist. Fast forward another month and the dentist tells me that I will be billed because the insurance company requested a refund.....from the dentist and the dentist had to comply so I would owe the money. So now I can't return to that dentist unless I pay and I'm getting bills.

    So it's pretty obvious that the reason these insurance companies operate this way in the case of non payment from the employer is because of they are subverting some kind of legal responsibilities. Obviously I have no way of knowing the status of a policy unless they tell me, at least when I ask, then there is the whole question of why would they demand a refund from the dentist without making any effort to contact me. It makes no sense, and I see no recourse since MY dispute would be with the insurance company but they have never contacted me nor explained to me a reason for demanding a refund. My dentist can offer me no reasoning or documentation other than attempt to bill me.

    Now I have no doubt that all of this is true, my employer was a scumbag and this happened to others. If I step back 5 feet and look at what I KNOW rather than what someone has told me I know A) I had coverage at the time, and B) the claims were paid. So how can I be billed for something that no one will produce a document for or proof of since I was not the actual party who was responsible to each of these entities. So what is the recourse? I have contacted some labor attorneys who really don't take this serious and bounce the case around to other firms, nobody really wants it likely due to the amount. Do I pay the dentist so I don't have my credit affected even though the dentist can't provide actual documentation about what or why this is happening?
  2. army judge

    army judge Super Moderator

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    If your state DOL is investigating, or won't assist you, contact your state elected officials: Governor, Attorney General, or legislators.

    You could also seek assistance from your federal elected officials as in President, Senators, or Congress members.

    The federal bureaucracies, as in IRS, Social Security, etc... MIGHT be able to help you.

    Otherwise, private internet sites aren't equipped to do anything to ameliorate or rectify your predicament.

    I wish you the best.
  3. adjusterjack

    adjusterjack Super Moderator

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    Yes. Absolutely.

    Then you work it out with the insurance company and/or the employer in whatever fashion works best.

    A word about employer group health insurance. It's not like auto and home insurance. There are no late notices. Premiums are paid on the first of the month for the rest of that month. If no payment was made, there is no coverage. There is likely some lag time between the lapse and notification to the claims department, so if claims were paid when there was no coverage, the insurance company is entitled to a refund.

    You can file a complaint with the Department of Insurance, but I think you will find that the insurance company likely did nothing wrong, and your beef will be with the employer who didn't pay the premiums. Your option then is to sue the employer for the money you have to pay the dentist, money that should have been covered by insurance that wasn't covered because of the employer's non-payment.
    cynthiag and hrforme like this.
  4. cbg

    cbg Super Moderator

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    Just to establish my credentials, I have worked in some form of employer-sponsored benefits/HR since 1979, and have done benefits exclusively since 2008 or thereabouts. I have been the appropriate representative for the employer, the insurance carrier, and the third party administrator. (I told one TPA, when I was working for the employer, "I'm your worst nightmare")

    I would say about 98% of the time, the insurance carrier bills the employer on a monthly basis, using the calendar month. Let's take a specific example. The bill for June will be sent out somewhere between the 15th and the 20th of May. The bill is due on June 1, but the insurance carrier will accept the payment at any time during the month. However, if payment has not been received by the time billing for July goes out somewhere between the 15th and 20th of June, the carrier will remind the employer that June is still outstanding. In my experience, which is considerable from both sides of the desk (yes, we fired the billing analyst who let the insurance lapse), the insurance carrier will wait for June's payment until the end of July. If they've still not received June's payment, they will cancel coverage retroactively back to the date they were last paid for - May 31.

    So now there is no coverage for June or July. We could go on for some paragraphs as to what happens if the employer now pays up, but since that's not what happened we'll leave that for another time. The insurance carrier has now paid out claims for which they have received no premium. No, it's not the fault of the patient/employee, who did nothing wrong and could not have known that this was going on behind the scenes. But it's not the fault of the insurance carrier either; they're the ones who got stiffed. And they have a responsibility to their entire clientele, not just to the one employee or even the one employer. So while some carriers may choose to eat the claims they've paid out, others will go back to the providers (the dentists, in this case) for refunds AND THEY HAVE EVERY LEGAL RIGHT TO DO THIS. This is not any kind of legal subversion, as you put it - it is a guarantee that their contract with the providers grants them this right,

    So now it is the provider (dentist) who hasn't been paid for his work. So of course they're going to come after you. And the bottom line is; YOU received the service - it is ultimately YOUR responsibility to pay.

    Your beef is not with the dentist; nor is it with the insurance carrier. They did nothing they were not entitled to do. Your beef is with the employer. You want to take legal action against them, fine; take it out of their hide. That's as it should be. The employer is the one who screwed up. But it's not the responsibility of the insurance carrier to eat the claims OR to contact you OR to explain what happened. That responsibility lies strictly on the employer.
    cynthiag, hrforme, retic and 2 others like this.
  5. hrforme

    hrforme Active Member

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    1000% agree with cbg although I haven't work in benefits as long LOL..... And unfortunately if said employer has no assets, you can't get blood from a turnip. You might get a judgment but good luck collecting. Instead, I'd work with your dentist to see what they would negotiate. Sometimes they will set up different terms for customers without any insurance.

    I'm sorry this happened, but the first time the employer writes you a check (not through payroll and without any paystubs), know that they are going down this road.

    I too understand that you relied on the insurance company and I am sorry that you ended up in this spot....but in the end that prior employer was very much to blame. And timing bit you in the behind.
    cynthiag likes this.

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