Health Coverage Denied B/c Legal Separation

[HOTRODMKVIII]

What is the name of your state? Virginia
The company that I just started working for has it's health coverage self insured and administrated by a third party. My wife and i are separated but not divorced (and may not divorce). The insurance administrators are denying coverage to my wife on the grounds that she is not eligible because we are "legally separated". Is this legal?? I can find no definition of "legal separtation" in any VA code.

 

[Beth3]

So are you legally separated as opposed to one of you simply having moved out?

 

[HOTRODMKVIII]

As I understand the law, there is no such thing as a "legal" separation. Yes, we live apart. Yes, we have an agreement that outlines child support terms and division of property IF we do not reconcile and end up divorcing. HOWEVER, if one of us sleeps with someone else, it is still adultery. We cannot file taxes as single, but must file as married filing separate. The law does not provide for any status other than single, married, or divorced.

 

[Beth3]

This is a tricky situation and I can see both sides of the argument.

What I think the decisive issue will be is the language in your employer's group health plan document that defines what a "dependent" is. If you can get your hands on a copy of that, please post back and share exactly what it says as the definition of a dependent.

You should have been given a plan doc and/or insurance booklet with all the legal mumbo-jumbo when you joined the plan. Definitions of who qualifies as an eligible participant is typically right up front.

 

[HOTRODMKVIII]

"THE PARTICIPANT'S LEGAL SPOUSE WHICH IS A RESIDENT OF THE SAME COUNTRY IN WHICH THE PARTICIPANT RESIDES. SUCH SPOUSE MUST HAVE MET ALL REQUIREMENTS OF A VALID MARRIAGE CONTRACT OF THE STATE IN WHICH THE MARRIAGE OF SUCH PARTIES WAS PERFORMED."

"THOSE SITUATIONS SPECIFICALLY EXCLUDED FROM THE DEFINITION OF A DEPENDENT ARE:
1. A SPOUSE WHI IS LEGALLY SEPARATED OR DIVORCED FROM THE PARTICIPANT"

So, as you see, the question here is whether "legally" separated is an actual legal term, and what defines "legal" from simply living apart.

 

[CIAA]

Hotrod, we are not attorneys and do not give legal advise. It would seem that you could get a free consultation with a family law attorney in Virginia to answer your question. Having said that, it sounds as if you are "legally seperated" as that term is generally used. In interpreting insurance contracts, undefined terms are to be used in their common ordinary meaning. I believe that, in this case, it would mean a court approved (legal) seperation agreement. I suppose it could also mean a seperation agreement that comports with generally acceptable legal requirements within your state (ie. addresses, support, proberty use, no-cohabitation, etc.). However, I would expect that it should have been approved by the court.

 

[Beth3]

At this point, I also agree you'll have to consult with an attorney as the issue now becomes one of family law in your State.

In my layman's opinion, you and your wife are living apart, filing separate tax returns, and have a legal document which stipulates the terms of your separation and financial obligations to one another - to me, that's a legal separation. Whether that meets the exact legal criteria in your State as to what constitues a legal separation and whether the carrier is bound by your State's family law on this, only an attorney can tell you.

You can file an appeal with the insurance carrier at no cost and see what happens though. Info on how to do that will be in the back of your insurance book. If they don't see things your way, then your next option is to go to your State's Insurance Commission.

 

[ALawyer]

Yours would seems to be a "legal separation" as that term is commonly understood -- it is formal, of indefinite to permanent duration, and you are fining separate tax returns -- presumably not as married filing separately. Also, my guess is the cost of fighting it would outweight the benefits, if all that is at stake is lack of insurance or an ordinary small claim. As it is a self-insured employer plan, under ERISA the state insurance department has no say in the matter.