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Some questions in regards to health insurance, sorry it's lengthy!

CaveCanem's picture

Hello. I posted in General as well, but realized it's definitely more appropriate here. Thank you to those who directed me here.

Our situation is complicated, because the child was born during our marriage (you can read my post in General or the Bio for more info). We currently have no contact with the child (who is an infant) or the BM for multiple reasons. This may change in the future.

My husband was ordered to provide medical insurance. Since I carry our family's plan thru my employer as it was MUCH cheaper than my husband's employer, the child will be put on my insurance. Currently the child is on state aid because BM doesn't and will not work.

Sorry if this post is more detailed than the post in General; I was posting before with 2 screaming kids in the background and now that 1 of them is asleep, the other one is almost asleep, I can take my time.

Chances are she is going to fight tooth and nail to get the child off of the insurance or to try and have the state cover him, although the judge already told her too bad so sad, if there is an option for private insurance then the state doesn't want him on their aid. Or she won't use the insurance.

A big problem is that WE do not know anything about her (yes, it is sad and embarrassing for both of us to admit this). From what we have learned so far is that she is a manipulative con artist who will lie to try and get her way.


1. I am incredibly concerned with BM having access to our insurance. The child will receive the card soon (I just submitted the paperwork last week). The insurance company and my employer have reassured me that unless I permit it, BM has zero access to the insurance, INCLUDING the child's info. She still has access to his medical records (which we do not as the courts gave her sole legal and physical custody). I do NOT want her to have access and will not permit it unless court ordered to do so; I have no problem mailing her any info such as the EOB as necessary. All claims come to me since I am the policy holder. She will be able to get general information, like which Dr.s are in network, copays, etc. The court order just states that my husband is to provide the insurance, not that we have to allow HER access. Anyone dealt with this?

2. Multi-part questions: She is responsible for the first $250 of "routine uncovered medical expenses" and I'm assuming that means copays for Dr./hospital visits, prescription drugs, etc. It IS her responsibility to keep detailed records, correct? Also, can we demand to see those records prior to paying anything? Finally, once she has paid the first $250, how do we go about paying the other half? My husband wants to directly pay the Dr., which could work; but what about pharmacy? We are incredibly hesitant to send her money that she may not pay the Dr. with, and then still be on the hook to pay.

3. If she chooses not to use the insurance, are we still responsible for medical expenses that could have been avoided if she had just used the insurance?

4. What happens if she is a no-show to an appointment and gets charged a fee for that? Example my Dr. office will charge a $50 no-show fee. Does that count under the "medical expenses"? We are concerned that she will make appts and just no show to try and be a pain in the ass. She made it VERY clear she did NOT want the insurance for the child.

5. If she does not follow directions and constantly goes out of network (this insurance is AMAZING and there are so many doctors there should really be no reason to go out of network) when she COULD go in network, how does that work out?

6. Finally, if she were to actually go and get a job and get insurance (unlikely, but hey you never know), but we were the ones ordered to cover the child and we are, would we be responsible to pay for it? Unfortunately there was no information about that in the order, which was amazingly short and left a lot of questions. Although we don't get a credit (I have a family plan which does not cost me anything extra to add the child) it IS cheaper in the long run for me to provide the plan. I just don't see it making sense if she tries to get insurance and then we get charged/have to pay 1/2 of it when this child will be on one of the best plans in the state at an incredibly affordable rate.

7. Will she have to put me down in the medical record as the policy holder--and if so will I have to provide the Dr./hospital with my SSN? We have taken great measures to make sure she does not get ahold of that information.

She told my husband that the child was sickly and she could not afford the constant paying of copays, however she refused to tell him what was wrong. I think that's why she doesn't want the insurance--we will be able to see which doctors he is going to. If there is something wrong with the child, what rights does he have to know? She has sole legal and physical.

Sorry for the lengthy novel; if you made it this far I just want to say thanks!!!

caregiver1127's picture

I have to say welcome and so sorry for your situation it is very sad - but if I were you I would contact a lawyer and then your insurance company and ask them all of these questions - I too would not want our BM to know our health or any other info and my DH was married to her for over 10 years - so I can understand why you don't want her to know anything - good luck in all of this and am sending prayers your way!! You are a much better and more forgiving woman than I!!

CaveCanem's picture

Thanks. We are currently "between" lawyers for right now! We have gone thru 3 of them already. The last one totally screwed up our case, and we have a few thousand in arrears to take care of first (not that he didn't want to pay--he understands his financial responisibility, but waiting for the filing and the paternity test took months and the CS was ordered retroactive).

I asked the insurance company and they answered some of the questions, but couldn't really answer much in regards to the specifics of the court order.

hismineandours's picture

Ok-We used to have custody of my ss and he was covered by both bm and dh's insurance BM was considered primary because the court order stated she HAD to cover him. This was a real pain in the a$$. It may not be for you since the infant doesnt live with you. Insurance companies do indeed have privacy laws-to the point in which we had problems with neither of our insuranc companies wanting to pay because they both felt that the other should be primary-we could not even call her insurance company about ss and try to get it straigtened out and she was not willing to. They simply wouldnt talk to us-even though all we wanted to speak about was why they were refusing payment on ss's claims. We had to threaten to sue her to get the bm to make a 5 minute call. So I dont think she will be able to call up your insurance company and get info about you from them. Now, our bm is pretty dumb. I did have a website for the insurance-i was able to log on there, create a profile, and view her entire family's eob's. I cant remember what personal info I had on bm to create this-birthdate I believe and then just the insurance card which her id number was her social security number. She never even knew. She didnt have internet access-but I was able to find out about her substance abuse treatment and her pregnancy/miscarriage and then getting her tubes tied. She will list you as policyholder on doctors' info-since that is what you are.
Your dh is entitled to all of the child's medical records. He is the biological parent and he should be able to get them anytime he wants.
I guess if she wants to use uncovered providers that's up to her, but she will still have to pay that first 250.00 of those visits and then her portion that she and your dh split. What I have always heard is that the custodial parent either pays the whole bill and then submits the receipt to the ncp for payment or just submits the receipt to your dh and he pays his portion and doesnt worry about hers. She will have to be able to provide you with all these recipts-she can't just tell your dh that he owes her hundreds of dollars for medical bills. You should not be on the hook for her share-because she is taking the child to the doctor and she will be the "responsible party". So even if you give her pymt directly your share is done-just keep your own detailed records.
As far as if she gets her own insurance-you should still be considered primary since there is a court order stating that you are have to cover her-or your dh has to. She can add the child on the insurance as well which will help her and your dh as well to reduce uncovered medical expenses. If she wants to be primary, she would have to take it back to court and have it ordered as such. If you both carry insurance with no court order requiring either of you to or it just requires both of you to then primary will be decided based on whose birthday falls first in the year.

CaveCanem's picture

Thank you for the info! So if she wants to be a b**** then she can go to all out of network, which means that $250 will be met REAL quick, and then my husband is still responsible for everything after that despite the awesome amount of available Drs in network? That can be a LOT of money, and he is the type that would pay his own share but what if she doesn't? Also, what if she purposely misses appointments--if she doesn't pay but racks up the bills, it's only $250 of what she pays, or once $250 is met? It just doesn't seem fair to us if she purposely misses appointments and racks up fees--I almost feel those should not count. She has a NEW reliable car (newly purchased with her new CS income :sick: ) and no job, so there would be no reason to miss anything. So far she obviously hasn't done this because we are still waiting on the card, but we know that she will pull something because she made it CRYSTAL clear she did NOT want the insurance and withheld the information we needed to get the insurance. Thank goodness my human resources was able to submit and do everything without the extra info.

I am planning to write her a letter once the card comes, to let her know how to use it and to let her know it is HER responsibility to keep track of everything, keep original receipts, etc. She's not the brightest bulb on the tree (although is VERY well versed on the whole family court thing...makes us wonder if she's done this before...). I have yet to confront or say anything to her; I've been holding off because of all the legal stuff.

Thanks again!

hismineandours's picture

She'd really be screwing herself if she no showed etc-again my guess is that she has to pay these up front and then you reimburse her your half. If she has money to burn I guess she could do this to be vindictive-but she will still have to pay her share

CaveCanem's picture

Oh and I tried to access my info pretending I was someone else accessing the info, and could not access since I already made a profile. My password is very difficult and doesn't match any other password I have for anything. When I call to follow-up on the card tomorrow, I will ask if there is a way to also password protect so if someone calls we are all set.

CaveCanem's picture

Thank you. I am such a die-hard planner I guess I'm just trying to prepare myself for every angle, because everything I thought we were prepared for I found out we weren't. So I guess I'm almost a little paranoid now! And yes, it is all eating me up alive, and yes this is hell on Earth for me, and would've been if I had stayed or left. I've been trying my best to try and stay 2 steps ahead of everyone (including my husband) because I'll be DAMNED if I get screwed anymore than I have. Although we are working on our marriage, you better believe I'm not only still heated, I'm still hurt and upset.

skylarksms's picture

My H is COed to provide medical insurance and pay for half of any uninsured medical costs.

BM has used this clause to rake H over the coals often in the years I have been around.

CO says that BM has 6 months to supply the bills and then H has 30 days to pay his half. She saves them up to nail us all at once.

One thing I would have fought for in the beginning was to pay the 1/2 TO THE PROVIDERS rather than BM. There is nothing stopping her from collecting the $$ from H and then filing bankruptcy on the medical bills.

If the BM is vindictive enough, she won't care if it is costing HER extra in her quest to take as much money as possible from the bio-dad.

DaizyDuke's picture

I think everyone pretty much answered your insurance questions, but I just wanted to say that you are an incredibly strong person for dealing with this crappy hand that has been dealt to you.

Not only do you have to deal with your H having an affair, he father's a child with an unstable, non-working piece of trash and YOU have to put this child on your insurance. You are way stronger than I could ever be and I give you alot of credit. You must really love your husband and I hope that all your efforts to keep your family together pay off.

The first person I thought of when I read your post was Elizabeth Edwards. What an amazing woman she was!

NavyChiefWife's picture

The BM is allowed to contact your insurance company to get information related to her child (unless the CO states otherwise). Your insurance company is NOT allowed to give out your info or your DH's info.
BM also must have the information needed to give the doctors offices to have the child use your insurance. That includes the policy holder's ss#. You need to keep a close eye on your credit once she knows your ss# so you can catch her if she uses it.

If she is not taking the child to the network doctors that your insurance company lists then you will need to notify the courts of this. You should send her a letter/email with the list of the approved networked doctors and let her know she is to use one of those. If you notify the courts that she is not using them then she may be forced to pay for the entire out-of-pocket expenses that were incurred. If she refuses to use your insurance at all then you can notify the courts and should not have to pay any out-of-pocket medical expenses. She would be violating the CO.

Any bills that your DH pays for the child can be payed directly to the doctor's office unless the CO states he must pay BM. Keep receipts for anything paid. Notify BM when you pay. Routine uncovered medical is usually office visits or procedures. Some courts will also consider prescriptions routine as well. With this you will need to ask an attorney to clarify for you. With my situation we do not have to pay for any prescriptions because there is a military base where the BM can get them for free at. If there were no bases around then we would have to pay for half of the uncovered prescription costs. We have a 30/30 clause in the CO for any uncovered medical expenses. BM has 30 days to notify DH of an uncovered medical bill and he has 30 days to pay his half. If BM pays for the bill in full she is to provide DH with a copy of the bill as well as a copy of the proof that she paid it in full. Then DH sends his half of the payment to her.

DH can also have access to any information regarding his child unless the CO specifically state he can't. He has a right to this information. Just as the BM has a right to it (unless the CO states otherwise).

I hope this helped...

CaveCanem's picture

Thanks! I will be DAMNED if my SSN is used; they will either have to put it in a private file or not have it at all. I'm sure with the circumstances of our situation they would understand and be willing to work something out. I have a contact number and email so the clinic of her choosing can just directly contact me.

I did call my insurance company today, and unless she is on my policy (which will never happen), then she cannot contact them or get any info, even on the child. I have 1 of the best insurances in our state and they have serious lockdown/security. There is a way that I can allow her to only get the info on the claims for the child; however it would require her to work with me on filling out a special form, and she has avoided me like the plague so I doubt that will happen too. NO way am I signing something and then mailing it to her to sign. When she decided to mess with my husband she automatically signed up to deal with me, so she can kiss my ass at this point. It would just be easier to mail her the EOBs.

The CO was incredibly vagued; just stated that he is to provide the health insurance (or thru me) and he is responsible for half of expenses after $250. That really is it. She is taking him back to court for arrears (which were caused by the delay time in filing, paternity, etc.) because she is asking for $2000 more than what she is entitled, partly due to her incapcity to read/comprehend and partly due to her lack of math skills. At that time we will try to get clarity. If we cannot we are filing for joint legal and clarifications anyway down the line.