State Farm, carrier of my mother's car insurance and homeowner's insurance, committed fraud. My elderly mother broke her back in Sept 2010. She was recovering from surgery but still in considerable pain when in Dec of 2010 she was involved in a very minor, "bump" I hesitate to call it a fender bender as that implies great damage. As a precaution and at the urging of my concerned father, she went to the hospital to be checked out.
It was discovered that she had three more broken vertebrae, which were not likely caused by the accident. The driver who "bumped" them was uninsured so my parent's uninsured motorist coverage kicked in.
She had surgery to repair the three broken vertebrae which resulted in a punctured lung and ongoing care for several more months.
A report was made to State Farm, details given and permission to obtain medical records was given TWICE.
In April of 2011, Medicare, who automatically covered the medical expenses, as a conditional payment until liability could be sorted out, sent State Farm a conditional payment letter, stating that they were owed $13,000 unless State Farm disputed these charges and sent proof as to why Medicare should bare the expense. State Farm had 30 days to respond.
Well....at the same time (early April 2011) State Farm did two things.....sent Mom a check for $4800 saying she had requested the payment so she could settle the matter herself...not true...they also sent a "request for conditional payment letter" to Medicare.
Mom did not cash the check and continued to urge State Farm to settle the claim.
I have just learned, January 2012, that ANY DOCUMENT sent to Medicare relating to the same claim number would constitute a dispute and thus stop the demand process for payment of the $13,000.
The initial letter sent to State Farm, from Medicare insisted they dispute within 30 days or a demand letter would be sent.
Well, I believe State Farm knew *** well, that sending the request would halt the demand against them, which is precisely why they took the action to send the request at the same time as they attempted to "settle" the matter with my mother. Medicare stated that the two documents, the conditional payment letter and the request for a conditional payment letter, must have passed in the mail.
From April till November my Mother made several calls trying to compel State Farm to settle the $1700 bill she was receiving for the emergency room visit the night of the "bump", which State Farm was liable for.
There was always an excuse as to why the bill hadn't been paid and in August the claims adjuster even sent a letter to the hospital stating my mother wasn't covered and they should seek payment from her directly.
This gets better.
At the end on November, the hospital bill remained unresolved and my mother, who has always paid her debts, grew concerned that the unpaid bill would have lasting effects on her supplemental insurance or the balance would become hers to pay. We made another call to the claims adjuster and agreed to accept the settlement of $4800 to pay the hospital bill. We were told the balance was for "pain and suffering".
Well, the other shoe falls when my mother receives a conditional payment letter from Medicare stating that they had been informed by State Farm that my mother had accepted a settlement and she would need to dispute or receive a demand for $13,000.
So, I call the claims adjuster for assistance. No return call.
I then spent 49 minutes, the precise number of minutes I am told my wait time would be, waiting to speak with someone in the Medical Payment Recovery Dept with Medicare.
I was told that my mother was now the debtor as she had accepted a settlement.
Let me stop and say that Medicare sends one letter...and only one letter. Never, ever did my mother receive an update or further correspondence regarding the unpaid balance of $13,000. After all, she knew that State Farm had 30 days to settle or dispute and naturally since they had permission to request her medical records, they had taken care of this matter and Medicare was satisfied.
But she was now the debtor.
I was informed by the Medicare rep that:
They only sent the one letter to State Farm which my mother was copied on...
One document sent referencing the claim number indefinitely suspends the "demand" for payment from State Farm...
Finally, I was informed that State Farm did only two things regarding my mother's claim where Medicare was concerned....they sent the "request for conditional payment" in April of 2011 and they sent the notice of Settlement in November of 2011. Never did they send a dispute, never did they provide Medicare with the medical record information they had the permission to collect to dispute the claim.
Why is this fraud?
1) They intended to deceive my mother by taking no action to settle the conditional payment matter with Medicare, they merely stopped the demand process.
2) They withheld pertinent information from my mother. In other words, they KNEW the $13,000 demand was out there and still sought to settle the matter with my mother for $4800.
3) My mother was led to believe that the only outstanding debt was the emergency room care. She therefore relied on the information or lack thereof from State Farm.
4) She was harmed in excess of $8,000.
Now it is up to my mother to dispute this herself, of course it will be me driving the process. My mother not only broke her back a year and a half ago but she is 73 years old, has COPD and MDS (pre-leukemia) in addition to suffering from a punctured lung during her last back surgery that nearly killed her and subsequently has had to have her gallbladder removed and has lost 4 inches and 50 pounds.
Who holds State Farm accountable?