Legal Question in Insurance Law in California

Medical insurance claim overpayment

My husband works for a co bought by a large corp in 2003. In 2004 the medical ins changed to reflect the parent company�s benefits, but we were not notified verbally or in writing of changes. In 2003, I received medical treatment in which 80% of ea claim was covered. I continued this same treatment in 2004. My first two claims in 2004 were paid at 80%.; my remaining claims were not. I was told repeatedly by the ins co to re-mail and re-fax the claims. On Sept 22 I was told that my claims should be processed within �2 more weeks at most�.

In Oct I was told that I had a deductible to pay; that the ins co had updated their files for 2004 coverage info. In Nov, I received my first Overpayment Notice for the two reimbursements I received in 2004. In Dec, I requested a copy of the medical plan docs, and found that my coverage had changed, requiring that I make a call to the ins co before receiving treatment. Otherwise, a deductible was due.

Over a 9+ month period, I was not notified by my husband�s employer nor their ins carrier of a plan change. Am I required to pay the ins co the $ they are requesting? If I don�t pay back the $, what�s their recourse? If I am not required, should they also pay the other 6 claims?


Asked on 1/23/05, 12:42 am

1 Answer from Attorneys
Steven Murray Steven W. Murray, APC

Re: Medical insurance claim overpayment

No, you have a contract w/the insurer. Until you are notified, you were paying (through employer contributions) for a particular contract.

But when you found out about the change, you have the choice of continuing or not, and if you do continue, then whatever the terms are bind you.

If you don't pay back the money, the insurer can sue you, but you can defend against it in court. You might want to check w/your state insurance department about the legality of the insurer's attempt to retroactively penalize you. In California, the employer can be the insurer's agent regarding group insurance, so the employer's mistake in not advising you is the insurer's responsibility, not yours.

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Answered on 1/29/05, 10:45 am


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