Possible Private Medical Coverage Fraud ??

Hi Guys, My 1st post here on ATS...I wanted to post a question here related to a potential coverage fraud issue I experienced while cancelling my personal healthcare coverage. A little background first:

I moved to northern IL to take an IT job with Caterpillar in Dec 2014. I was offered employer sponsored " coverage " that was incredibly horrendous:

- $500 a month premium
- $6000 individual deductible
- $11,000 max out of pocket cost
- %60 co-insurance

The employer was Rose International based out of Missouri who is essentially an IT staffing firm. Clearly after seeing this plan my first reaction was " How is a plan like this even legal? " that quickly shifted to " Well its time to go find an individual plan on the markets." Which clearly seems to be the plan going forward with some employers. That being, ' lets make our plans so horrible they won't want them and force them into individual markets, therefore saving tremendous cost. '

So after looking at the high priced crap plans out there being offered to the public, I found CoventryOne in IL that offered a Silver Plan for about:

- $250 a month in premiums
- $2400 deductible
- $3000 yearly out of pocket max
- 80% co insurance

Not bad, but still not great like benefits used to be back in the 1990s/early 2000s.


The Potential Conspiracy:

As some of you may well know, Caterpillar has gone through a drastic " Restructuring " process to the tune of 2 Billion US dollars which has lead to a lot of job cuts throughout the world. It did not affect me personally but I still chose to leave the company anyways and landed a new job that I'm starting next week. I have employer sponsored benefits and no longer need my CoventryOne plan.

I called CoventryOne to cancel the above plan and to my shock the first person I spoke with told me my plan was never active!!

Coventryone - " How can I Help you ? "

Me - " I'm switching jobs, have employer sponsored healthcare and no longer need my current plan with you. I need to cancel my plan with you"

CoventryOne - "Can I have your Account number on your card? "

Me - " Sure its 1234XXXX "

CoventryOne - " sir I need to place you on hold. I'm having trouble cancelling this plan because I show its inactive and I can't cancel something that's already non active "

Me " That's strange. I have been paying you premiums every month since Jan. How is my plan inactive? "

CoventryOne - " You've been paying us premiums ? How much ? Since when ? "

Me - " 250 a month since Jan ? "

CO - " I need to place you on hold to ask my supervisor how to proceed...can you hold ? "

So they put me on hold, and after he comes back he tells me they are trying pot proceed with cancelling the account but are still having issues. A few mins later the phone call is terminated. Might have been due to cellphone issues on my part but I call back and speak with someone else who tells me yeah your account is active and we go through terminating it again which goes through without a hitch. That call also terminates abruptly before getting to the end of the conversation.

So question for you guys:

Anyone else run into issue where you're being charged for a policy that's not active/ providing you any benefits? Any way to get proof of their fraud without letting them know you're onto them ? In my case its likely too late but for those out there with private insurance like this you may want to check up on your policies and put these vampires on the hook if you can.

Your card has a number for providers to check coverage. Call that number.

Indeed it does and that is exactly what I used to contact them with and provide policy info from....Only card they ever sent me. I did some searching around the internets before posting this to see what I could find and numerous searches resulting in nothing so I wanted to leverage the member experience here to see what people know or if someone else had run into something like this before....I have also considered it was a just a simple PEBCAC issue on their end but I typically like to consider multiple possibilities and see what shakes loose.

a reply to: Iamthatbish

a reply to: wyrmboy12

I know someone who had workmens comp taken out of his check every month...then something happened and he needed it, they never signed him, just pocketed the money

a reply to: wyrmboy12

In my time I've known employers take your money and not pay any of it to insurance until you get sick... and they scramble to pay all your back premiums...so they hope you won't ever makes claim....

I know more than one person whose premiums were paid up but their coverage lapsed because of "clerical error". (And one person to whom this has happened more than once).

They visited the Dr, and insurance denied their claim due to lack of coverage, making it look in the Dr's records as though they were responsible for the routine preventive visit and tests done at that time, even though the policy they carried required only a copay for those services.

In each case, they had to produce records from their bank to show the payments had been withdrawn from their account as scheduled. And it took weeks to get everything lined up. In one case, the physicians billing service had turned the account over to collection by the time the insurance issue was straightened out, so they had to also convince the collector that the debt was satisfied, and also have their credit report annotated to explain the delinquency.

I never considered the possibility that it was deliberate fraud on the part of the insurance company... I suppose it could be. I just thought the companies were completely inept.

and some of y'all still consider private insurance better than single payer? I am lucky, pick up the phone call VA and can be there in 20 minutes. I know it is not like that for all vets, but for a lot of us, the VA is better than any private insurance carrier I have had.

ETA: The last time I used a private carrier was 1996.

No no no... I mean call as of you were a PROVIDER and verify the dates that way. They get the start of service and other pertinent info.

originally posted by: wyrmboy12
Indeed it does and that is exactly what I used to contact them with and provide policy info from....Only card they ever sent me. I did some searching around the internets before posting this to see what I could find and numerous searches resulting in nothing so I wanted to leverage the member experience here to see what people know or if someone else had run into something like this before....I have also considered it was a just a simple PEBCAC issue on their end but I typically like to consider multiple possibilities and see what shakes loose.

a reply to: Iamthatbish

originally posted by: research100
a reply to: wyrmboy12

I know someone who had workmens comp taken out of his check every month...then something happened and he needed it, they never signed him, just pocketed the money

Employees don't pay WC. That's something only the employer pays, so if it was being taken out of his check, he was being screwed.

a reply to: wyrmboy12

I'm gonna guess you are from the armpit of Illinois; Rockford. I used to live there once upon a time and worked at the Airport for UPS over the holidays. Illinois is notoriously corrupt, but chances are this is not fraud; At best, it is likely to be breach of contract. Be advised, I am not an attorney and I encourage you to speak to one after you do your own research. Empirical experience in filing many small claims is where I speak from, but I will lend my perspective based on what you provided.

Under the ACA, any cancellation requires 30 days notice. Your insurance was active if they accepted your payments and your payments were within the effective dates of the policy, provided you did not receive a cancellation. That would have been a different court case had you filed an insurance claim for a doctors visit, and were declined. At that point I would just chalk it up as a clerical error by Coventry.

If Coventry did in fact cancel your policy and you never realized it, then immediately gather documentation of the policy, cancellation notice , reason and date. The penalty for not carrying insurance would be worth it to me to recover everything owed. It would be fraudulent for you at that point to file your taxes and claim coverage when you had none. If the policy was never active, then there is quite a bit to consider.

Given the origin of the claim, a breach of contract for pre-tax wages, any part of the judgement relating to the wages would be taxed the same as income before you received your settlement. Other damages awarded may or may not be taxable. The implication here is that a refund on a pre-tax deduction from your income may very well negatively affect your taxes and even put you in a higher bracket. It is not free money to buy a PS4. The IRS will know because the employer would need to pay employment taxes on those wages, so don't think you would sneak one by.

You are a party to your insurance contract but have no say in negotiating the terms; this is what they call an Adhesion Contract, similar to renting an apartment. Any ambiguity in that contract will always favor you in court. Moreover you are legally obligated to carry insurance which would weigh even more heavily in your favor. You will not be able to convince anyone this is fraud if its an isolated incident. That doesn't mean you are not individually entitled to any form of reimbursement for a breach of contract if you wanted to pursue it. You could name both your employer and Coventry as defendants in a claim, but I would want to know for my argument if Coventry even received payments for your policy from your employer.

Don't fight it yourself if the employer kept your wages but never paid Coventry. Chances are they never paid employment taxes on those wages, and that is tax evasion. I'd contact the Illinois Wage and Hour Division to start my complaint. They would audit the employer and possibly find other instances of this happening. Then the employer will be forced to reimburse your wages and probably see tons of other fines.

Despite that Illinois is so corrupt, my gut instinct is still that it was merely a clerical error by Conventry tho.

Let us know if anything comes of this!

thx
-d

originally posted by: queenofswords

originally posted by: research100
a reply to: wyrmboy12

I know someone who had workmens comp taken out of his check every month...then something happened and he needed it, they never signed him, just pocketed the money

Employees don't pay WC. That's something only the employer pays, so if it was being taken out of his check, he was being screwed.[/quot

you bringing that up, made me remember the employer was taking it out of his checks, came time when it was needed, turned out they never paid...

I remember someone who had a similar problem years ago. The person who signed up the family for health insurance did not do it right and when they had their first claim a few months later they did not pay. After a bunch of phone calls and checking the insurance company returned their premiums and did not pay the hospital bill. That was years ago, they had only had their insurance for a few months when the accident occured so they wound up with a pretty high hospital bill. It wasn't nearly as expensive back then but neither were the monthly premiums. I don't know if they had a deductible or not or any particulars about their policy.

Never thought of doing that...Will have to add that to the dirty bastard bag of tricks...

Dirty bastard trick# 211 going down in the book. Thanks for the good idear a reply to: Iamthatbish

I'm in East Peoria until next week...Then back to Milwaukee to start the new job...The premiums were also not paid directly out of a paycheck. I paid directly as I had my own personal policy...CoventryOne drafted my bank account every month... a reply to: drewlander

a reply to: wyrmboy12

Boooo! I have stuck wage and hour division on an employer before. It's like having a free attorney. I guess I'd still try to determine if you had coverage or not then so you can CYA on the taxes side of things.

check this info out to see why

If they don't report you as having coverage and you sign a tax return that says you had coverage it could trigger an audit because you would be committing tax fraud. If you didn't have coverage, then collect your premiums from their subrogation department so you can pay the penalty.

a link to their evidence of coverage documentation

Coventry is a terrible company in my experience. I was a subscriber years back and basically felt I was giving my money away for no coverage. Stick the screws to them or at least file a complaint with the attorneys general consumer complaint division. It's free and if a lot of people complain the AG will investigate them.