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Insurance fraud

strugglingSM's picture

When DH got divorced, he told his ex wife, who was self-employed at the time, that should could stay on his health insurance (to be nice, as he said). It was written into their divorce decree that he would continue to cover her while he was at the job he had when he got divorced. He also provides coverage for the kids.

Shortly after he met me, he got a new job. He told his ex wife he was leaving that job. He told her the kids would be covered under his new plan, but she wouldn't. She had a fit and told him that she would come after him for the amount of money she was going to have to pay for health insurance going forward, that she would request that, that amount be added to his child support payment. I told him that it wasn't his responsibility to pay for her health insurance, so all her threats were just threats.

About six months after, she told him that "your old health insurance still works" and told him she was continuing to put in claims on it.

Fast forward to today - three years later - I'm opening our mail and wondering why DH is getting a notification from the health insurance plan at his own job. Sure enough, BM put in a claim for herself in April. The notice was telling DH that his coverage had been terminated because the payroll office couldn't verify that he worked there anymore.

I'm speechless...I tried logging in to his account to see if I could figure out how many claims she had put in, but was told that the information I had didn't match their records.

Mind you, BM now works for someone else, so should have access to health insurance coverage. She's also "married" (although she and her "husband" never got legally married, for reasons unknown) and her husband is "self-employed", so not sure what he uses for health insurance...maybe nothing.


DaniellaR's picture

This story doesn't make sense. If he changed jobs then that policy should be cancelled. You can't just put random unrelated people on your health insurance. You can't put and ex on your insurance because they are not family. This is your husband?? Read the court orders because he is feeding you some BS.

strugglingSM's picture

She's not on his new insurance, she's still putting claims in on his old insurance. He doesn't work there anymore and hasn't paid any premiums in over three years, but apparently, his large bureaucratic organization did not remove him from the insurance plan, so BM has been taking advantage. She's kept putting claims in on the old plan and they keep getting processed.

lieutenant_dad's picture

I think what she is saying is that, as soon as they were divorced, BM wasn't eligible for his benefits, no matter what was in the CO. Unless his company allowed for domestic partners and he claimed her as such. There is no legal way that I know of that he could keep her after they legally ended it.

notarelative's picture

It's not uncommon here for one person to be required by the court to continue health insurance. However, the decree usually states that it ends when remarriage occurs. Here, your marriage would have nullified the requirement to continue coverage.

DH needs to take both the insurance letter and a copy of his divorce decree to a lawyer. He should be proactive about this. He needs to understand exactly what is likely to happen. Insurance companies tend to want their wrongful payments returned. They are not fussy about who pays. They'll likely go after both him and the ex.

strugglingSM's picture

His decree said he had to continue to keep her on his plan while he was still with the employer in question. No mention of remarriage.

BM had a lawyer during their divorce, DH didn't, so her lawyer added that language.

Just J's picture

This may be what the CO says, but the law states an employer-provided policy can only cover dependents, which BM was not once the divorce was final. A CO doesn't top the law. What it should have said is that he needed to retain coverage for her until the divorce was final, as that is all the insurance company can and will legally do anyway. The mistake your DH made was not dropping her from his policy as soon as the final decree came in. That right there is fraud and he could be on the hook for it. Her lawyer must have been ignorant on health insurance laws because there is no way to cover a former spouse on a company sponsored plan (except for COBRA plans, which cost hundreds more and I can't see that being required unless directly specified by the CO). The fact that his former employer never dropped coverage for either of them after he left the company is an entirely separate issue.

How long was their divorce final before he left that company?

strugglingSM's picture

I told him that an insurance company didn't have to care what was in his decree. Neither he nor his ex wife seem to have a good understanding of what a decree can do and what it can't (and I'm more familiar with the language in the document than either of them are - for my own protection, as well as DH's).

He worked there almost two years after their divorce was final.

twoviewpoints's picture

So BM is running around with an old insurance card, but the claim wasn't paid and company notified policy holder why...because employment with the group insurance was terminated. Correct?

His old employer (as long as he was still employed by them and his premiums were up to date) could have covered BM on his package as before until divorce was final. But then , even if he were still employed there he was obligated to notify the employer's human resource insurance rep and drop BM. To not notify his employer would be just as fraudulent as BM was being.

If he failed to do that, it's on him. Regardless, both BM and DH would have been terminated from the employer's group insurance when he left their employment.

strugglingSM's picture

I've told him that. He said it wouldn't matter because his divorce decree said he had to cover her. I told him that it didn't matter what his decree said, his insurance company could still kick her off.

PaisleyMoonbeam's picture

I work at Anthem BC BS.
Your husband isn't on the hook for those bills that his ex incurred after the policy termed. It would have been up to the past employer to terminate the policy when he left the company, but because she's an adult and because of HIPAA laws, it's all on her. He has no access to her explaination of benefits and because those visits were in her name, it will be her credit that's affected. It's really shady that she did that but it will have no bearing on him. He can't be sued for it.

Don't sweat it.
Deep breath.

strugglingSM's picture

I've read his decree and it says just that "The Respondent will continue to provide coverage for the Petitioner under his plan while he works at (his employer at the time)." Her lawyer added that clause. With the employer name removed that is the direct quote from his decree.

lieutenant_dad's picture

My only question is how??? Most employer-sponsored plans have a very strict set of guidelines on who can and can't be covered. Some plans now won't let you even carry a spouse if they have access to their own insurance. Did his company and the insurer have some sort of arrangement where you could pay the full amount to add a non-qualifying member??? A divorce decree and CO can't just overwrite company policy, can it???

strugglingSM's picture

I asked him all of this. He was under the impression that he was required to continue covering her (thanks to BM and her lawyer) and he was not clear on the fact that an insurance company does not have to follow your divorce decree.

He did notify his job that he was divorced because he changed his deductions, but I'm not sure if he notified his insurance company. He switched jobs two months after we met, so I only found out that his wife was on his insurance because she was sending him threatening messages after he told her that he was leaving that job and she'd have to find her own coverage. I was shocked that she was still on his plan and told him that, but the issue was already finished by the time we were serious.

BM kept using his card after he had provided her with new insurance info for their children and told DH "your old insurance was better and it still works, so I'm going to keep using it." It was at that point that he told her she had to stop and also contacted his old employer. They are large, bureaucratic and very dispersed, so getting them to send any confirmation or any action was a challenge. They also were confused about when his end date was and sent him a check 18 months after he left for a large amount of money that he did not earn, after he left. Even contacting someone about returning that check and getting confirmation that it was confirmed (so they wouldn't come after us for the money later) was a challenge.

DH sent BM a picture of the claim form with her name on it, from her doctor asking her "what is this?!" And she replied "I have no idea". She was not even remotely concerned that her medical info is being sent to my house or even remotely concerned that her claim for $500 worth of medical tests was denied.

I love dogs's picture

She can't just use old insurance because it's better.. What a piece of work. The fact that she pitched a fit about not being on his new plan and threatened to get reimbursement through CS is truly mind boggling. She's his EX-wife!

Why did he agree to continue to carry her on his insurance in the divorce settlement in the first place?

strugglingSM's picture

He told me that he was just trying to be nice. Also, he did not have a lawyer during the process and BM did. I think BM convinced him that he would have to pay more child support if she had to pay for her own coverage. She tries to convince him of those things a lot. I had to tell him that his child support wouldn't change if she just decided to earn less money (as she told him, it would).

strugglingSM's picture

I agree about the COBRA, but I don't even think DH knows what that is.

Also, the ACA had either been passed or was in process when they divorced, so even COBRA was no longer necessary.

I think BM and her lawyer convinced him that he was responsible for her insurance. He didn't have a lawyer and despite the fact that he knew BM was manipulative, he still seemed to take her word for it on that and several other things in their divorce.

I was honestly flabbergasted when I saw that in their decree.

Livingoutloud's picture

The moment she told him (3 years ago????) that old insurance still works and she puts claims on it, he had to tell his old employer. He didn't. So he was ok letting BM to use old insurance that isn't even valid. Makes no sense. She can always say she had no clue about any of it because when she told him it still works, he said nothing to it. I really don't understand how is it even possible. DH knew what she is doing and said nothing? Nice.

strugglingSM's picture

They actually got into a big fight when she told him. He told her to stop using it and he called several people at his old employer to remind them he had left.

Livingoutloud's picture

If he did call his old employer and told them she is still using insurance that needs to terninated, then he should be off the hook. I don't get it though how insurance was processing claims fir three years if he had no policy with them

PaisleyMoonbeam's picture

Once her DH left the company, if the policy wasn't termed, it was the employer's mistake.
Worse case scenerio, if the claims were paid, the funds would be recouped and the provider would let BM know that she owes that money. If she doesn't pay, then it will go to a credit bureau.

Insurance companies have bigger fraud issues to deal with than a few office visits that were submitted under an old card. The fraud unit focuses on the providers that commit Medicare fraud.


moeilijk's picture

Sounds like a few assumptions are being made.

1. Did DH do something sketchy to keep BM on his insurance, or was there a provision via his employer/insurance that this was allowed.
2. Did DH do something sketchy by keeping BM on his old employer's insurance, or was it up to the employer to terminate the plan once DH left.
3. Did BM do something sketchy by using insurance that was made available to her, or was it up to her to stop using it once DH's circumstances changed.

strugglingSM's picture

For #1, I don't know if he was alllowed to keep her on his insurance. I know he told his employer he was divorced because he changed his tax deductions, but I don't know if he specifically notified his insurance company or what their policy terms were. DH left this job two months after we met, so I only heard about the issue because his ex wife kept threatening to ask the courts to give her more child support because she now had to pay for her own insurance (DH still covers his children) and I told him that he wasn't responsible for the costs of her coverages

For #2, DH was told by his employer that his plan was terminated. He even got supplementary coverage for his children while he was waiting for his new insurance to start.

For #3, BM knew that DH was no longer enrolled (or was not supposed to be enrolled) in his old employer's plan. She knew that her children's insurance provider had changed and she also sent DH a bunch of threatening messages indicating she was angry that her coverage was terminated. She then tried to use DH's old insurance anyway and discovered it still worked. She told DH she was still using it and he told her to stop immediately. He also called his old employer to make sure the coverage had been terminated.

PaisleyMoonbeam's picture

We have people calling every day, trying to remove dependents. We refer them back to their HR, who then sends us weekly feeds that update eligibility. I have seen members who still carry their former spouses without a COBRA policy, but it's all according to the guidelines set forth by the employer. Once that term date is in the system, the claims recycle back through the system and anything processed in error after that term date are recouped through the provider, who would contact the expired card holder for updated insurance information or payment arrangements.

Your DH did nothing wrong.
Call your carrier on Monday and they can explain it to you.

twoviewpoints's picture

But so far, there is nothing to report. All OP knows is something was submitted for April and that she has no coverage. It wasn't an attempt to recover or a 'we are coming to get you'.

One thing I am wondering about is tax season deadline is April. Insurance is mandatory on federal or a fine due. I'm wondering if she tried to use her old insurance info. Which in turn would be not verifiable and declined.

I fail to believe any employer and a insurance company had this major 'oops', not just one year but three. No employer pays 100% of a employed person's spouse's premium (the rare creature if it does). No premium, no paycheck to pull it from. Light bulb moment. Employers also usually go benefit year to year by calendar year (some do fiscal year). BM could not have reenrolled herself as the non-employee and the ex DH (the past employee) wasn't employed there to have done so.

At most, he may have failed to notify his employer's group insurance representative while he still worked there. BM might have been able to file claims and had coverage (since he didn't notify), but that would have ceased upon his own leaving of employer's employment and termination of his own policy. She had to be merely listed as 'spouse' (even if lied about being divorced) to be on his policy. She would not be deemed eligible for coverage and could not have re-upped her enrollment by herself (either through paper work or online enrollment). Again, no one to pay premium and no paycheck to draw from. A employer does not get away with paying premiums for 300 people but 'oops' expecting to get coverage for 301 people.

Between payroll (no deduction for premium), auditing books (routine) and having to reenroll yearly it is ridiculous to think BOTH the past employer AND the insurance company totally missed the woman not being on the premium paid and on contract for coverage.

There is nothing in the letter stating the insurance paid anything out at any time since the policy holder (ex DH) terminated from past employer. No one is accusing or pursuing Dh for anything. The letter merely states coverage could not be verified. Yeah, the woman may have tried to use the old card, but obviously was not successful. It says nothing about any claims ever having been paid out in the last three years.

Except for perhaps coverage (with any claims made or not is questionable at this time) during the time the man was policy holder, she was still listed as spouse and a premium being paid through his paycheck NO ONE from past employer or the insurance carrier is currently telling this guy anything is wrong or been done wrong . It appears to be no more than a 'hey, buddy, who we use to insure, your wife (meaning BM) doesn't have insurance through us, in fact their is no payroll deduction to say she should have, whatever she is trying to claim from April, isn't going to happen'.

Chances are this is not more than a nut BM running around with an invalid insurance card trying to say she has insurance coverage (when she doesn't) or a nut BM trying dumb enough to think a provider will give her services without checking on her status as having a effective coverage.

And yes, it is the employer who must notify the carrier. And it is unrealistic to think this woman has been using and enjoying the benefits of this old insurance for three years undetected by both the past employer's payroll (which the man isn't on) nor the insurance company ( who even with current coverage makes clients jump through hoops and swear up their first born to get a dime from...just kidding, kind of, lol)

I love dogs's picture

What a brat she is. She knew he changed employers and what was in the divorce decree but still even attempted to use an old card even though she knew it shouldn't have worked? The nerve of some people.

still learning's picture

Funny how if we were Canadians this wouldn't be an issue. America w/all it's health care woes.

notsobad's picture

Actually it would still be a problem.
We have health insurance that we pay for. It's to cover the things that universal health care doesn't cover. Prescriptions, dental care, phyiso, other various things.

Our universal health care is great and means I can walk into any hospital and be taken care of without question but there are still things I'd have to pay for.