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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.
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Q. My insurance company has rescinded my health insurance policy.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. Consumer Complaint Form
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.