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My husband's insurance covers his daughter as the primary but her mom carries dental for her now her insurance is refusing to cover her orthodontia due to the fact they are secondary- is this legal?
Wiki User
∙ 12y ago
You do not say what state you are in and the exact answer could be a function of the insurance law for coordination of benefits in your state. However there also could be a specific provision in the Mom's policy--usually titled non-duplication of benefits--that says it does not pay if other insurance exists.
Without a non-duplication provision, in general if the primary insurance company covers orthodontia, it will pay first and then the secondary insurance will pay some additional portion. There can be differences state to state but in general it works this way:
The primary carrier pays the claims as if there is no other insurance involved. The COB law requires the secondary carrier to calculate what the benefit would have been for the claim if there were no other carrier involved, but allows the secondary carrier to deduct the amount paid on the claim by the primary carrier from its payment. The secondary carrier then pays the claim up to 100% of the allowable expense if the benefit contained in the policy is great enough. So, if the dentist's charge for ortho is $1000, but the allowable expense is $800; the claim will be paid based on $800 being the maximum that can be paid.
There are two exceptions to this general rule. First if the primary carrier is a DHMO and the patient does not use a DHMO provider, the secondary carrier must pay the claim as if it were a primary carrier. As well, self-funded and collectively bargained employer groups operate under federal law and do not have to follow state COB laws. These groups often utilize "non-duplication" provisions to lower premiums. These provisions provide that that the insurer will not pay for benefits that are reimbursed by other insurance. Where these provisions are present in the patient's policy, there may not be any payment from the secondary carrier.
An allowable expense is the usual and customary or maximum allowable expense for the dental service when the item is covered at least in part under any of the plans involved. When a covered person is covered by two or more carriers which determine benefits on the basis of usual and customary fees or maximum allowable expense, any amount in excess of the highest usual and customary or maximum allowable is not an allowable expense. When a covered person is covered by two or more carriers, which determine benefits on the basis of contracted fees, any fee in excess of the highest contracted fee is not an allowable expense.
You might want to contact the consumer representative in your state Department of Insurance to help sort out your policy provisions.
Wiki User
∙ 12y ago
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Which insurance is primary for the husband when the husband and wife each have insurance through their jobs and husband is covered by the wifes insurance as well?
The husbands own insurance would be primary, and his wife's would be secondary.
What if your husbands dental insurance doesn't cover crowns and you can get dental insurance through your company does he have to drop you from his?
Absolutely not. However your husbands policy would become your secondary insurance and you would hold your own primary insurance. Make sure you check with each insurance company to verify that the offer coordination of benefits on what is considered major work!
Can a wifes maternity expenses be covered by the husbands insurance if her insurance does not have coverage?
If you both have coverage the wife's policy will be primary, and the husband's will be secondary - provided the wife is covered under the husband's policy. Submit the unpaid claims to the secondary carrier.
When husband is working and his wife collects SSI can she still be covered under her husbands employee health insurance?
Yes! If she has a state-funded insurance also, the husband's coverage will be secondary.
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Can your husbands company require Medicare to be your primary provider?
they can't actually "require" it but any insurance can contract with Medicare to be secondary, provided both parties agree
What is the definition of primary coverage in regard to medical insurance?
Often, a person will have "primary" insurance and "secondary" insurance. For example, if you have insurance through your job, and your husband has insurance through his job, then your primary insurance will be the one through your job, and your secondary insurance will be the one through your husband's job. Also, your husband's insurance through his job will be his primary, and yours through your job will be his secondary. There can be some exceptions to this though. For example, if you were married, had a child, then divorced and remarried (retaining custody of the child), and both your ex and current husbands have insurance through work, then the one who's birthday is first is considered the "primary" insurance, and the other is the "secondary" insurance. But there will still be a deductible with each one that has to be met before either one will pay.
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