Insurance Demanding 'Overpayment' Money


#1

Hi Everyone! I’m brand new here, though I’m hoping to hear from people who have had experience with my particular issue. If you live in Ontario, Canada, I’m definitely looking to hear from you, though anyone’s experience or expertise would be helpful.

I’m a T1 diabetic living in Toronto, Ontario, and I use the Omnipod and Freestyle Libre. I receive $600 every 3 months in financial assistance from the provincial government to help cover the cost of insulin pumps and supplies, and I also have a group plan with my university. I have been submitting both my government grant info and Omnipod receipts to my insurance company since getting a pump two years ago, and from day 1 they have been paying me the full amount on my Omnipod receipts.

However, today they sent me a letter explaining that they have been overpaying me for two years, because their system glitched out and failed to subtract the grant amount. Their actual policy on my claim statements only says that they pay a max of $2000 every 3 months, so I assumed everything was fine. I assumed they knew what they were doing, but now they want me to pay them back $2400 in overpayments from 2017-18. I am a student with less than $10k annual income, and for them to demand I pay them for their mistakes seems very unjust. They had all of the information necessary, including the amount of the grant, and I don’t think I should be held responsible for their failure to follow their own convoluted policy.

I was wondering if anyone has any experience with something like this? I’m concerned they’ll stop processing my claims if I don’t agree to pay them, but I can’t find any information on whether I am legally obligated to do so, or if they are just trying to bully me into it so they can balance their books.


#2

Welcome to TuDiabetes!

Not in Ontario, just the USA.

A couple of questions to get some more info, please.

  1. Is your insurance designed to actually pay the full amount of your Omnipod, or is there a deductible?

  2. If your $200/month grant is designed to cover your pump and supplies (insulin, test strips?), what amount of the grant did you spend on supplies over and above the Omni?

  3. Conversely, have you effectively been receiving a grant for pump and supplies, but you haven’t had to use the grant money for that purpose because insurance has been covering everything?

Regardless, I might point out to insurance that you are poor, and they can’t get blood form a stone. Could you possibly pay them back on a minimal basis until you are employed full-time? Or could they defer entirely until such time?


#3

Hi Yoga! To answer your questions:

  1. There is no deductible. The insurance company pays for up to $2000 every 3 months, 100% of the cost. I also looked everywhere to find something about them being obligated to deduct government grants. While they are obviously allowed to, my understanding is they don’t have to.

  2. The grant money arrives as a cheque, so it just goes into my account. However, I don’t actually get to save any of it because my CGMs are not covered by insurance, so whatever money I get from the province does go to diabetes supplies.

  3. As above, all money received from the government is spent on diabetes supplies. It may not go directly to the OmniPod itself, but it is certainly used for other things, primarily the CGM. I’m really not pocketing anything I get.

Yes, I think pointing out the poverty issue might be helpful. Thanks in advance for your thoughts!


#4

I would go with your #2 reason when talking with your insurance company.

IOW, your grant is for diabetic supplies, not just the Omni (items covered by insurance). You have spent the grant on those supplies, therefore, there is no grant money available to spend on the items covered by insurance. In other other words (aka IOOW), the inclusion of government grant info to the insurance company was in error.


#5

While I highly disagree with the Ontario government and think the money should be used towards CGMs, it is only supposed to be used for purchasing pump supplies. Does your insurance cover the Libre though? Perhaps if they do, you can argue the overpayment should be used to cover your Libre expenses.