Did the Insurance Company meet the Legal Requirements to cancel your policy for Non – Payment of Premium?

How might I successfully file an appeal?

Question

 

I got a refund check in the mail the other day. I called BCBS and they said it was a refund because I was late on a payment. I never received a cancellation letterI never received bills from them either so that gave me no indication that my insurance had been cancelled. They said they realized this after they had an audit.

Any suggestions would be appreciated.

Our Reply

The specimen policy on page 39 deals with grace periods. The policy says may terminate, rather than shall. That’s in your favor. Of course, I’m not an attorney and am unauthorized to advise on contract law.

I think you are going to wind up in a he said, she said situation with proving or not proving that late notices and your premium payments were sent or not sent.  Were your checks cashed?

What dates does Blue Cross say they sent you late notices? US Mail or Email?  What proof do they have they sent them.

According to the policy, you lapse 30 days after the late notice, not 30 days after premium was due.

See page 151 for more information on how to file a grievance.  The policy says that you must provide ALL pertinent information and the details and circumstances of your concern or problem.

As an authorized agent, we help our clients with filing appeals, reinstatements, communications problems as a complimentary service as we are paid by the Insurance Companies to consult, enroll and service our clients.  Here’s instructions to appoint us in CA.

***

I just received a notice that my Anthem (non-exchange) policy was terminated because of lack of payment for February.
I filed an appeal based on the fact that I thought that auto-payment had been set up.

Anything else I can do?

Will they reinstate my policy?

What documentation do you have to show that you had cause to think the auto pay was set up? Think of an appeal as a court case in front of an Administrative Law Judge. What evidence do you have? See our appeals page. If Blue Cross says no, do you have enough evidence to take this issue to Department of Managed Health Care?

The Blue Cross manual makes lapsing for non-pay look like a black and white issue of no reinstatements.

What does your Blue Cross Member portal show?

Do you have a copy of the automatic premium payment form that you filled out? Proof that you sent it? Proof Blue Cross rec’d it?

What about the alternate ways to pay premium?

There are always temporary plans.

Do you have an special circumstances to qualify for a special enrollment?

Question

I don’t have any documentation supporting my assertion that I thought I had set up autopay.

I thought I set it up online in the same area where monthly bills are paid.
The tab concerning payments on the Anthem site is not available anymore.Any advise as to whether it is worthwhile to ride out the grievance process or should I move on to other options? One issue with that is I have a number of claims that have now been denied because the termination was effective Feb 1.

Any idea what they look for in an appeal? Is it a mere formality?

Our Reply 

There aren’t really any other options. One plus in Health Care Reform is no medical questions, guaranteed issue and no pre-existing conditions clause. The downside is one can only enroll at certain times.
I’m not an attorney, near as I can tell an appeal is like an informal court case. I suggest you prepare your appeal in the same manner. Here’s the small claims court manual on how to gather the documents you need.When were you notified of the termination? That might get your claims paid?

I requested the Anthem agent to submit the info for my appeal/grievance in hopes of expediting the process. Based on what you have stated I may have been to simplistic in my grievance. Basically I said I thought I was in autopay and received no notice that the payment for February was past due. My first knowledge of the problem was when I received the termination letter. Hopefully they give me an answer within a couple days (they said that is possible)Termination letter was dated March 6. The denied claims are before that date.

Do you mean the customer service representative or your agent, which doesn’t cost anything extra to have?See beginning of this page for information on how and what is needed to file an appeal.

We are talking about February payment right? If it’s January it looks like you’re SOL as the grace period only applies after you’ve made your first payment. Things are really complicated under Health Care Reform. The policy says you shall be informed that you can apply for reinstatement with a new application, BUT they only take applications at Open Enrollment and Special Enrollment. Then it talks about your right to have the cancellation reviewed.

 

Have you received confirmation that they are handling your grievance?

On the other hand, since you don’t seem to have any documentation to prove your case, it appears you’re SOL. You might contact an attorney? Maybe there will be a class action lawsuit somewhere. However, Health Care Reform seems to allow cancellations. It’s the only underwriting left for the Insurance Companies…???

Here’s Kaiser Foundation on late notices…

BC/BS New Mexico

Health Net Cancellation Procedures
Health Net Cancellation Procedures – Click to enlarge 

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10 comments on “Was the cancellation legal? Web Visitor Q & A

  1. I still don’t understand how the Insurance Companies financial mistake on a contract allows them to bill additional – for alleged past due premiums, that were not billed when they were supposed to be.

    (I deal with contracts as a Contractor on a weekly basis and this is not allowed)

    • Please give us a citation where an Insurance Company that due to confusion in the renewal, can’t bill for a month, that wasn’t billed when it was supposed to be.

      Here’s the reference material we’ve found on this topic:

      One must read a contract, law, statue, rule or regulation 3 times. Then when you think you understand it, read it again.
      https://healthlaw.healthreformquotes.com/plain-meaning-rule/

      Guide to Contract Interpretation
      https://files.reedsmith.com/files/uploads/miscellany/A_Guide_to_Contract_Interpretation__July_2014_.pdf

      Excerpt of Group Agreement
      Due Date and Payment of Premiums

      The payment due date for each enrollment unit associated with Group will be reflected on the monthly membership invoice if applicable to Group (if not applicable, then as specified in writing by Health Plan). If Group does not pay Full Premiums by the first of the coverage month, the Premiums may include an additional administrative charge upon renewal. “Full Premiums” means 100 percent of monthly Premiums for all of the coverage issued to each enrolled Member, as set forth under “Calculating Premiums” in this “Premiums” section.

      Can the Insurance Company send a Invoice several months late?

      Well in short the answer is yes, unless more than six years have passed. The only regulations placing a time limit on collecting a genuine debt is the Limitation Act 1980.
      Although you have the right to invoice, where the invoice is over 6 months old we would recommend to include a covering letter apologising for the delay or simply calling your customer beforehand to discuss the matter. This is especially true if the invoice is for a large amount and could cause difficulties at their end when it finally appears!
      If they have been prudent then they should have accrued for this bill in their accounts, especially if it is a large amount. However for many businesses a late invoice may come as a shock when they receive the invoice. I do grant, this law is from England. If you have a better citation, let us know. https://www.mycreditcontrollers.co.uk/Articles/how-late-is-an-invoice-still-valid.html

  2. What if my Covered CA bill has my spouses name, but it’s ONLY me that’s covered?

    *********************************************************

    On Exchange records displays the name of the Responsible Party instead of the main applicant. The Responsible Party is the person who set up the Covered CA application and indicated that they are responsible for the payment and oversight of the account. Before the binder payment is processed, the Responsible Party name will show up on the Individual List Bill (ILB), but the SSN and DOB will show as the main applicant. The main applicant is different from the Responsible Party. This will typically happen when the Responsible Party applies for a dependent or a spouse through On Exchange Covered California plans. All correspondence sent out will be addressed to the Responsible Party, including the initial binder payment letter. Once the binder payment is processed, the main applicant and additional dependents will be visible. Blue Shield Email Dated 1.13.2013

  3. I have battled Anthem over a wrongful cancellation. I paid my premiums on time, sent certified mail so I know it was received, but Anthem apparently decided not to cash one and claimed that I owe it.

    According to Black’s law dictionary, payment is “The performance of a duty, promise, or obligation, or discharge of a debt or liability, by the delivery of money or other value. Also the money or other thing so delivered.” This means that the check doesn’t need to be cashed in order for the payment to be made; it means that the payment (check, money order, etc) only needs to be delivered. This makes sense. Your mortgage company couldn’t repossess your home by refusing to accept your payment.

    Further, the Uniform Commercial Code (Article 3) states that if you give someone a payment, and they refuse to accept it, your debt to that person is reduced by the amount of your payment. (paraphrased)

    Last but not least is the concept of good faith and fair dealing. In contract law, the implied covenant of good faith and fair dealing is a general presumption that the parties to a contract will deal with each other honestly, fairly, and in good faith, so as to not destroy the right of the other party or parties to receive the benefits of the contract. (Wikipedia). When I sent my payment and Anthem didn’t cash it, Anthem appeared to be acting in bad faith by denying me the benefits of having the insurance I had paid for (see point #1)

    Just a few thoughts on what’s happening……..

  4. Found your name on website of anthem…..We have lost our coverage due to exceeding grace period time frame…..DEVASTATING….Anthem is going through process of reinstatement application but informed me it does not look good. Is their any hope? My husband and I are 61 years of age. what can we do? We pay $1,980.00 monthly in premiums.

    • Thank you for our conversation by phone this a.m. Please e-mail me whatever documents that may be able to assist me in getting reinstated with Anthem Healthkeepers Gold Richmond VA under Blue Cross Blue Shield

    • Do you qualify for any special enrollment periods?

      How about a temporary plan? The time periods for coverage have become very limited though.

      Didn’t you get a late notice?

      Personally, I don’t like submitting appeals and grievances over the phone. You don’t know if the person taking the grievance really knows what they are doing or are looking out for your best interests. I suggest you put everything you have together and file your own grievance. Then if you get denied, you are all ready to give it to your attorney or the appropriate state agency to help you.

      So, basically, read everthing I have and follow the links in this section of the website and put together your best argument.

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