Legal Question in Insurance Law in Texas

Primary and secondary group health insurance plans

In the absence of any clear written

policy guideline on this matter and

when the following provisions are in

place:

1. A person has a primary and

secondary group medical insurance

coverage; and

2. Both insurance companies have a

coordination of benefits clause; and

3. The medical provider has agreed

to a negotiated rate with EACH of the

insurance carriers and has

contractually agreed NOT to balance

bill the patient for any amount over

the negotiated rate, and

4. Both insurance companies have

assessed their obligations and a

balance is still determined by one or

the other to be patient responsibility.

If the negotiated rates between the

two insurance carriers differ, and if

the primary carrier deems a higher

amount of patient responsibility than

the secondary, does the medical

provider still have a legal and

CONTRACTUAL obligation to follow its

contract with the secondary

insurance carrier in NOT balance

billing the patient for anything over

the negotiated contract amount with

that carrier?

I keep getting all different answers

on this, depending on who I talk to!

1 Answer from Attorneys

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