Waiting to add spouse to benefits until after child is born?

[Morri082]

What is the name of your state (only U.S. law)? Alabama

My wife was dropped from my company sponsored medical benefits due to not verifying our marriage to the benefits center by the deadline on a letter that I never received. When I contacted the benefits center to inquire about what I needed to do, I mentioned that my wife was pregnant and that was the reason I desperately needed her added back to the benefits. She was originally added when I first got hired at my company. They initially put her on my benefits without needing verification. I had to file an appeal with the benefits center stating my claim as to why they should add her back immediately, rather than waiting until the next yearly update to benefits. Many other employees that I work with had similar issues, and they were all taken care of within a two week time frame. It has now been almost 2 months and I have not received any word from the benefits center regarding the status of my appeal. I believe they are waiting until after the due date of our child to make their decision because they believe that I would not add her to the benefits after the child was here. She is covered by her employer, but we wanted her double covered through mine. Does the benefits center have the right to sit on my appeal until after the due date that I gave them when I first called to find otu what I needed to do to fix the situation?

 

[Zigner]

I don't think they have to do anything with your "appeal" - your option is to sign up (wife) at the next open enrollment.

 

[Morri082]

I don't think they have to do anything with your "appeal" - your option is to sign up (wife) at the next open enrollment.

I appreciate you taking the time to respond, but I am not sure that you understood the point I was trying to make. It may not be very clear from the information I originally stated, but I am claiming that the benefits center wrongfully dropped my wife from my benefits. The benefits center is the one who told me to file the appeal, and now they are wasting time answering it. After following all of their instructions, I have given them an adequate amount of time to generate an action, and they have not done so. I understand that I could re-enroll my wife under my benefits at the next annual enrollment period, but I should not have to wait until next November to do. I believe the benefits center is waiting until the baby is born to make their decision to see if still want her added. This will cause unecessary medical bills due to their failure to act in an appropriate time frame.

 

[cbg]

Federal law limits when an employer can add a dependent, and it is not unusual for an employer to have a requirement that you verify dependent status with a copy of the marriage certificate, birth certificate, or other like proof. If you did not provide the required information within the required period of time, then the dropping of your wife from the policy was not, in fact, wrongful. My employer will add a dependent without the verification but if the verification has not been received within 30 days of the addition and they have not provided a valid reason why not, off they come. Since our plans and policies have been vetted and approved by not one but two of the biggest law firms in the country (and a number of exceedingly prominent lawyers are on our staff) you may rest assured that it is legal.

The Benefits office is not required by any law to allow you an appeal in the first place, so yes, they have a right to sit on it. When the baby is born, that is a legitimate, legally permitted time to add your wife to the policy. Doing it now is legally questionable.

Have you, in fact, provided the needed verification at this time?

(Unless your plan is significantly better than your wife's plan, double coverage is likely to be a waste of money.)

FYI, this is what I do for a living.

 

[Morri082]

Have you, in fact, provided the needed verification at this time?
(Unless your plan is significantly better than your wife's plan, double coverage is likely to be a waste of money.)
FYI, this is what I do for a living.

Thank you for your response cbg!

To answer your question, yes, I have provided them with the needed verification.

Here is a little bit of a timeline:

• December 5th, 2012: Received a letter from benefits center stating I needed to provide verification. The letter stated that the deadline to provide verification was December 3, 2012.
• Contacted benefits center on 12/6/12: Was told my wife was still on my benefits.
• December 17: Was notified that wife had been dropped from benefits due to lack of verification. Was told by benefits center representative to go ahead and send in the verification documents anyway and write a letter stating what benefits I needed her added back to. Was not told that this letter needed to be in the form of an official "appeal".
• January 4, 2013: Received letter stating my "appeal" had been denied. Benefits center claims no administrative error on their part. Interestingly enough, the envelope containing the letter was post marked 1/4/13, but the letter itself was dated November 21, 2012 and referred to events that happened in December.
• January 6, 2013: Submitted my second "official" appeal with their instructions, and have yet to hear a response. They are subsequently also giving our HR Director the run-around when he tries to aquire information on my behalf.

Also interesting, this same circumstance happened to one of my coworkers and the benefits center actually gave him a specific date of January 9th to get all his verification in, and he was fine. They added his wife back immediately. I am curious as to why I was not afforded the same conditions?

Anyway, while I don't necessarily feel that they will do anything before the baby gets here, I just feel that I have been treated by the benefits center in a less than professional manner and their communication has been terrible!

 

[cbg]

Quite possibly true, but not illegal.

As to why your co-worker was allowed to add his wife back on and you weren't, without knowing all the details of his situation I can't say. But without valid and supportable evidence that the reason for the difference in treatment is related to your (or his) race, religion, national origin etc, they are not obligated to treat you identically even if your situations were identical. One thing I often need to remind people is that the employer does have a right to say, Okay, I've been nice about this up to now but it's happening way too much - I'm not making any more exceptions.

 

[Zigner]

When the baby is born, that is a legitimate, legally permitted time to add your wife to the policy. Doing it now is legally questionable.

For clarification...
I understand that the birth of the child is a qualifying event that would allow the child to be added to the policy, but is it a qualifying event to add other dependents at the same time?

 

[cbg]

In the case of adding a spouse at the time of a birth, yes; that is an IRS-defined QE.

 

[ecmst12]

Of course, what you SHOULD have done on 12/6 was turn in the verification documents as instructed. If you'd done that, you would NOT be having this problem.

 

[Zigner]

In the case of adding a spouse at the time of a birth, yes; that is an IRS-defined QE.

Thank you.

 

[Morri082]

In the case of adding a spouse at the time of a birth, yes; that is an IRS-defined QE.

cbg, can you post a link to any goverment resource that explains this? I was with Zigner in understanding that the child's birth is a qualifying event, but I can't seem to find anything that affirms what you are claiming about being able to add my wife at the same time as my child. That would be a useful piece of information that I could share with my HR Director/Benefits Center that might get them to understand that they will be adding her in 3-4 weeks regardless or whether or not they won't add her now.

ecmst12: while I appreciate you taking the time to post a response, I find your response irrelevant and merely a misguided opinion, as I had already missed the deadline according the letter I received after the deadline, and after getting the "everything is ok" response from the Benefits center when I called concerned about it.

 

[cbg]

I can try to do that when I get to work tomorrow - that's where my resource book is. Please note: Where I live we are in the path of the newest winter storm. I live on the coast - it is literally a case of "go to the end of my street, turn right, and when you get to the ocean stop". The town immediately north of me has been in the national news with pictures of the waves. The possibility exists that I may be working from home tomorrow if the roads are flooded. (I live JUST far enough from the water so that it's unlikely we'll be evacuated.) If that is the case, it will be Monday before I can provide a reference.

A couple of points for you to ponder:

1.) It is by no means unlikely that your HR Rep will say, "Okay, if we're going to be adding her in three-four weeks anyway, then that's when we'll do it", and use that as a reason to REFUSE to add her now. Remember, since you did not provide the necessary information within the required time, regardless of the reason, (and ecmst12 is right - had you provided the docs as soon as you received the notice, even though it was after the deadline, it's quite possible they'd have simply added her at that time - we would have) they have no legal obligation to add her retroactively.

2.) I don't know what qualifying event you were using to add her to your coverage in the first place (a new job? A recent marriage) but given that the date to provide the verification was in early December, I am going to assume that whatever the event was, it took place in early November. Please be aware that in the event that your HR folk eventually agrees to add your wife to your coverage without waiting for the birth, the ONLY date they may legally use to add her is whatever that date in November was. THEY WOULD BE IN VIOLATION OF THE LAW TO ADD HER ON ANY OTHER DATE. Remember what I said about Federal law limiting when they may allow mid-year changes. You WILL owe past premiums on November, December, January, February and March. Under NO law are they required to waive any premiums. That can add up to a hefty sum.

3.) Once more, I want to bring to your attention the fact that double coverage does not by any stretch of the imagination guarantee that all bills will be covered in full. You will have to see how both polices describe how they manage coordination of benefits but I will describe for you the most common method.

Your wife's policy is primary for her. Your policy is secondary for her. You do not get to change this. (This remains true no matter what the coordination of benefits policies). For ease of arithmetic, let's assume a bill of $100 and that the primary plan pays $80. Your plan, the secondary carrier, will look at the bill and what the primary carrier paid. Then they will determine what they would have paid if they were primary. If they (had they been primary) would have paid $80 or anything less than that, they will not pay anything at all. If they would have paid more than $80, then they will only pay the difference between what they would have paid as the primary carrier, and what has already been paid. (Ex. if they would have paid $90, they will now pay $10). So ONLY if your plan, had it been primary, would have paid
100%, will you not still be left with bills to pay even after paying the premium for two policies.

You might really want to do the math on this one.

 

[ecmst12]

That's not necessarily true, that's how it works with SOME policies but not all. I have double coverage right now. My primary plan pays 80% for some things and 50% for some things (after a deductible). My secondary plan covers office visits with a $20 copay and other services at 90%. So far, all my claims have been office visits, but when they get to my secondary plan, they have been paying 100% of what is not covered by my primary. The only time I have a copay applied was when I had not met my deductible with my primary plan and so they didn't pay ANYTHING. Then they applied the copay. Otherwise, they look at what they would have paid had they been primary, and they pay whatever is left on the bill up to what they would have paid. I didn't know for sure that was going to happen until I finally had some claims that went to both plans after my primary deductible was met last year (which took quite a while), but I was very happy once I finally found out. Having both plans has saved me a LOT of money.

 

[cbg]

No, I know it's not a guarantee, but it's not a guarantee either way. That's why I told him to look at how the policies describe it. But if he's assuming, like so many people do, that a second policy will ALWAYS pay any unpaid balances left, he may be in for an unpleasant surprise. You and I have had this conversation before and while I acknowledge your point, I still maintain that after 30+ years administering health plans, my description is FAR more common than yours.

Could he have one like yours? Sure he could, but it's by no means a given. But before he puts too much effort into alienating the HR and Benefits staff and talking himself into five or more retroactive months of premium payments, he should be sure that what he's getting is actually what he wants. Because there sure as heck ain't no promise either way.

 

[ecmst12]

I agree at this point it makes more sense to just wait until the baby is born and add them both then....because it's not likely to happen before that. And the retro premium will hurt. I know my situation is not the most common, but I don't think it's that rare either. It's just hard to get a straight answer about it either way, even if you read the policy, until the claims are actually in.