Initial Business Response /* (1000, 6, 2014/10/02) */
We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information.
This consumer purchased a contract for a plan of individual health care benefits from PreferredOne Insurance Company...
("PIC"), which became effective on January 1, 2014.
In January of 2014, PIC began receiving medical claims and information that indicated the presence of a condition that may have resulted from an accident or injury. As a result, information was requested from the consumer in order to ascertain whether their medical condition was the result of an accident or injury in which another insurer may be involved so that PIC could appropriately coordinate benefits under the terms of the individual contract. The consumer responded, stating that their condition resulted from a work related injury; therefore, in accordance with the terms of the individual contract, as these medical claims qualify for primary coverage under workers compensation, the claims were denied as a work related injury and an Explanation of Benefits statement was issued to the consumer notifying them of this determination.
As the consumer has indicated in their complaint to your office, they have since provided their workers compensation insurance information to their medical providers so that these claims can be filed for consideration under that primary policy. Once the workers compensation carrier makes a determination on those claims, those determinations may then be submitted to PIC for reconsideration and coordination of benefits.
PIC then began receiving medical claims for another condition and requested information from the consumer in order to ascertain whether this condition was also a result of an accident or their work related injury. In response, the consumer contacted our office and indicated that it was not, however, information that was provided to PIC by the consumer's physicians office indicated that this condition could be related to the work related injury. As a result, the claims for this condition were denied as a work related injury.
The consumer recently contacted our office regarding this determination. Based on the information provided by the consumer, our customer service representative advised the consumer that they would have these claims reviewed and would follow-up with the consumer. Upon review of the file, the claims and the information provided by the consumer, it was determined that this condition was not related to the work related injury and the claims for this condition were adjusted. Our customer service representative attempted to contact the consumer to advise them of this, however, the telephone number provided was not answered and there was no voicemail on which to leave a message.
On October 1, 2014 our office mailed the consumer a written response to this complaint, which includes information regarding our findings, the outcome of our review and notice of the recent claim adjustments. Following the claim adjustments, the consumer was also issued Explanation of Benefit statements that reflect the payment made on the adjusted claims.
If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at [redacted] or toll free at [redacted].
PreferredOne has again spoke with member and went over the appeal rights and also sent an appeal form. Member also requested the relevant information that was used to make the initial determination which will be sent to the member.
Initial Business Response /* (1000, 6, 2014/10/02) */
We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information.
This consumer purchased a contract for a plan of individual health care benefits from PreferredOne Insurance Company...
("PIC"), which became effective on January 1, 2014.
In January of 2014, PIC began receiving medical claims and information that indicated the presence of a condition that may have resulted from an accident or injury. As a result, information was requested from the consumer in order to ascertain whether their medical condition was the result of an accident or injury in which another insurer may be involved so that PIC could appropriately coordinate benefits under the terms of the individual contract. The consumer responded, stating that their condition resulted from a work related injury; therefore, in accordance with the terms of the individual contract, as these medical claims qualify for primary coverage under workers compensation, the claims were denied as a work related injury and an Explanation of Benefits statement was issued to the consumer notifying them of this determination.
As the consumer has indicated in their complaint to your office, they have since provided their workers compensation insurance information to their medical providers so that these claims can be filed for consideration under that primary policy. Once the workers compensation carrier makes a determination on those claims, those determinations may then be submitted to PIC for reconsideration and coordination of benefits.
PIC then began receiving medical claims for another condition and requested information from the consumer in order to ascertain whether this condition was also a result of an accident or their work related injury. In response, the consumer contacted our office and indicated that it was not, however, information that was provided to PIC by the consumer's physicians office indicated that this condition could be related to the work related injury. As a result, the claims for this condition were denied as a work related injury.
The consumer recently contacted our office regarding this determination. Based on the information provided by the consumer, our customer service representative advised the consumer that they would have these claims reviewed and would follow-up with the consumer. Upon review of the file, the claims and the information provided by the consumer, it was determined that this condition was not related to the work related injury and the claims for this condition were adjusted. Our customer service representative attempted to contact the consumer to advise them of this, however, the telephone number provided was not answered and there was no voicemail on which to leave a message.
On October 1, 2014 our office mailed the consumer a written response to this complaint, which includes information regarding our findings, the outcome of our review and notice of the recent claim adjustments. Following the claim adjustments, the consumer was also issued Explanation of Benefit statements that reflect the payment made on the adjusted claims.
If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at [redacted] or toll free at [redacted].
PreferredOne has again spoke with member and went over the appeal rights and also sent an appeal form. Member also requested the relevant information that was used to make the initial determination which will be sent to the member.