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Health Insurance FAQs


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Explanation of Terms and Coverage


Q. My health insurance company is non-renewing my policy. Can they do this?

A. If your policy is not guaranteed renewable, the company may exercise their right to non-renew your policy. It is important that you very carefully read the section of your contract concerning cancellation.m

Q. How long does a company have to pay a medical claim?

A. The insurance company has 45 days to either pay or deny a claim once proof of loss has been received, unless additional information is requested.

Q. I recently had open heart surgery, and the physician's bill was $20,000. I filed a claim with my insurance company, but they say that only $11,000 is reasonable and customary. I do not have $9,000. Can I do anything to get them to pay more on this claim?

A. Reasonable and customary rates, which vary between providers and hospitals and geographical areas, are not regulated by the Alabama Department of Insurance.

The physician can appeal to the company, if the surgery he/she performed was especially difficult or required unusual procedures. The insured can appeal by verifying the customary rates for other physicians in the area, and by asking the company to substantiate how they arrived at the reasonable and customary charges.

Q. The insurance company is delaying paying my hospital claim. They keep telling me they are checking for a pre-existing condition, and want information about all the physicians I have seen in the past five years. I know the condition was not pre-existing, and this is a waste of time. Can you assist in this matter?

A. If the policy is more than two years old, the company should not be conducting a pre-existing condition investigation. If the policy is less than two years old, the company has the right to conduct a pre-existing condition investigation. The consumer should complete a Consumer Complaint Form, and provide us with copies of any correspondence received from the company, as well as a copy of the insurance policy. We will contact the company to find out why they are delaying on paying the claim, and see what can be done to expedite it.

Q. My insurance company has rescinded my health insurance policy. What does this mean?

A. Rescission usually occurs as a result of incomplete or inaccurate information submitted on the application, or an omission of information that is pertinent to the underwriting of the policy. Rescission means that the policy will be null and void from the beginning. All premiums should be refunded to the insured.

Q. What is a PPO plan?

A. A PPO (Preferred Provider Organization) plan is a plan where preferred providers of service (including doctors and hospitals) have a contract with an insurance company or a health plan to offer service for their policyholders. Generally, the preferred service provider agreed to accept an insurance company's usual and customary payment. If you have a PPO contract, and do not use the preferred service providers, you may find yourself paying more for services rendered by the physician or hospital.

Q. I applied for health insurance nearly two months ago, I still have not received a policy. Now they tell me that I am not accepted. I have bills from the doctor and hospital. I paid my premium. Why do they not have to pay these bills?

A. Premiums for a health insurance policy are usually not binding until the application has been approved and the policy is issued.

Q. Are mammograms covered under health insurance?

A. Every policy which provides coverage for surgical services for a mastectomy must provide certain mammography coverage.

Q. My health insurance company is reducing my benefit payment, because I did not pre-certify my hospital stay. Can they do this?

A. It is very important for you to read your policy and look at the section dealing with pre-certification. If your contract states that you must pre-certify a hospital stay, then the company may either reduce or deny benefits, according to the terms of your policy.

Q. How long does it take for a policy to be issued?

A. If you have not received your policy within 60 days from the date you completed the application, file a Request for Assistance, and we will contact the company to find out why the company is delaying your policy.

Q. My employer is changing our group health program to another one with less benefits. Can he do that?

A. Yes. The insurance contract is between the policyholder (the employer) and the insurance company.

Q. Last year, my husband lost his health insurance when he was laid off. Consequently, I listed him on the health insurance plan at my office so that he would have coverage. When he began his current job, I did not notify my personnel office within the allotted time, so I cannot cancel him from the policy until the next enrollment period. When my husband needs to have an exam or some medical work done, is his health insurance coverage through his work considered primary? Can my policy be used to pay the 20% uncovered portion, or is his coverage under my policy useless?

A. If your husband has a claim, his policy will be primary, and yours will be secondary. It would be reversed if you have a claim. If you have any children who are covered by both policies, the primary coverage would be provided by the policy of the parent whose birthday comes first in the calendar year. The other policy would provide secondary coverage.

Q. I want to apply for a conversion policy under my group contract. I have been told I must pay a quarterly premium. I would prefer to pay on a monthly basis. What can I do?

A. Most companies have done away with monthly billing, because it is cost prohibitive. You may want to inquire whether your company will let you pay by monthly bank draft; but,otherwise, premiums will have to be paid in a mode (quarterly, semi-annually, or annually)that is compatible with the company's accounting practices.

Q. I have been covered under my employer's health policy, but now find that my claims are not covered, because my employer failed to pay my premium on time. Is the insurance company obligated to let me know that my premiums have not been paid? What happens to my claim?

A. The company is not required to provide you with updates concerning premiums being paid by your employer. The contract is between the policyholder (the employer), and the insurance company. The insurance company would not be liable for your claim since the premiums have not been paid.

Q. How can I obtain information about the Alabama Health Plan?

A. Please call the Alabama Health Plan Administrator at (800)513-1384 or (334)242-4301.