I Thought He Was Covered By My Insurance

On the last day of school when my son was in first grade he was in the after-school program playing on the playground waiting for his dad, my ex-husband, to pick him up after work. Only moments before my ex arrived at the school, my little boy cut his knee open, and the injury was very serious. The after-school program coordinator told him there was a hospital only two blocks from the school, so my ex scooped up my son and rushed him off to the emergency room. I got a call at work to meet my son and his dad at the hospital, and I left work right away.

What a great emergency room staff! They comforted my scared son and calmed down an equally scared dad. By the time I got to the hospital, my son was stitched up and ready to leave. They told us how to take care of him at home, and we left the hospital. When we got home and calmed down, I asked my ex how the trip to the emergency room was paid for. Our son was covered by my insurance, and my ex didn't have a copy of my insurance card, so I expected the hospital staff would have wanted to see my card. But they never asked to see it, and I forgot all about it when they said we could leave. My ex told me it didn't occur to him that our son was covered by my insurance, and he gave the hospital his insurance card without thinking. I figured I could just call the hospital the in the morning and give them my insurance information.

The next day at work I was telling my boss what had happened and told him I would have to call the hospital and straighten out the insurance information. My boss asked me if I was covered by the HMO plan or the other insurance the company offered. I had the HMO plan. He told me he thought there might be a problem because with the HMO plan I could only use specific doctors and hospitals or they wouldn't cover the expenses unless there was an life-threatening emergency and/or the doctors or hospitals on their plan weren't available. To use someone out of the plan, Id have to have permission first.

Unfortunately, when I called the insurance company he was correct. Only a few blocks away from the hospital was another hospital which was on the HMO plan. I told them how panicked my ex was and explained everything to them, but they told me the expenses wouldn't be covered. They did tell me, however, I could appeal the decision in writing.

In a very nice letter to my HMO I detailed how serious the injury to my sons knee was, how panicked my ex was when he saw the bloody cut on his little boys knee, how it was a simple mistake that he forgot our son was covered by my insurance and not his, and how the hospital accepted his insurance. I asked them that because of these circumstances, would they please make an exception in our case and pay the expenses. I got back a very nice letter saying our request was denied. Without any doubt we had to fork it out all ourselves.

An HMO could be a very good plan to have. There are many doctors to choose from, many hospitals and they generally cover pre-existing conditions. But if you're going to use an HMO, you have to follow all of their rules or they wont pay.