Healthcare Coverage Issue

[Rdp31783]

Oklahoma

My work never officially, via signature or in writing, made me part time at my request. I only worked with my immediate supervisor on a part-time schedule. HR continued providing benefits until six months after the time my schedule changed, due to an error on their end. I believed I was still considered full time until they retroactively removed my healthcare benefits and are now attempting to charge me for all the medical visits, including a necessary life threatening operation from March on. Obviously due to healthcare costs this will be terrible for me, while I’m still recovering from my surgery and the complications I suffered thereafter. At this point it does feel discriminatory towards me due to my health and lack of availability. Do I have a suit against them?

 

[Taxing Matters]

Illegal discrimination would occur if the employer were to treat you differently than other employees because of your race, color, national origin, citizenship, sex, religion, age (if you are at least age 40), disability, or genetic test information under federal law and race, color, religion, sex, national origin, age, genetic information or disability under Oklahoma law. Your post does not indicate that the employer is treating you differently here because of any of the characteristics I listed, so you'd not have a lawsuit against the employer for illegal discrimination.

What health benefits you were entitled to get depends on the terms of the group health insurance policy the employer has. If you had to be full time to get the benefits and you were not full-time it may be that the insurer may deny the benefits and seek repayment from you for the benefits paid. You need to know what the requirements are of the policy the employer has and you need to ensure you meet them. You should be tracking your own hours to ensure your pay is accurate anyway. If you had done that, you would have known you weren't getting the hours you needed to be full-time and could have tried to address that by getting more hours to work or by getting an individual health policy.

You might want to take the terms of the policy and the information you have to an employment law attorney in your state to see if there is any argument you can make that you should still be covered by the policy or that the employer ought to bear responsibility because of negligence.

 

[cbg]

Let's forget official or unofficial for now. Let me make sure I understand.

You requested a change to part time. Part time workers are not considered eligible for benefits. Due to an administrative error, your benefits continued six months past when they should have ended. Do I have that right? If not, what part is wrong?

 

[Rdp31783]

Let's forget official or unofficial for now. Let me make sure I understand.

You requested a change to part time. Part time workers are not considered eligible for benefits. Due to an administrative error, your benefits continued six months past when they should have ended. Do I have that right? If not, what part is wrong?

That is correct.

 

[Rdp31783]

Illegal discrimination would occur if the employer were to treat you differently than other employees because of your race, color, national origin, citizenship, sex, religion, age (if you are at least age 40), disability, or genetic test information under federal law and race, color, religion, sex, national origin, age, genetic information or disability under Oklahoma law. Your post does not indicate that the employer is treating you differently here because of any of the characteristics I listed, so you'd not have a lawsuit against the employer for illegal discrimination.

What health benefits you were entitled to get depends on the terms of the group health insurance policy the employer has. If you had to be full time to get the benefits and you were not full-time it may be that the insurer may deny the benefits and seek repayment from you for the benefits paid. You need to know what the requirements are of the policy the employer has and you need to ensure you meet them. You should be tracking your own hours to ensure your pay is accurate anyway. If you had done that, you would have known you weren't getting the hours you needed to be full-time and could have tried to address that by getting more hours to work or by getting an individual health policy.

You might want to take the terms of the policy and the information you have to an employment law attorney in your state to see if there is any argument you can make that you should still be covered by the policy or that the employer ought to bear responsibility because of negligence.

The only reason I bring discrimination into it is that there was a precedent two years ago where during someone’s transition from full to part time they were allowed to keep their benefits. Even if I had tracked hours I would’ve possibly believed they were doing the same for me. That’s conjecture so I didn’t explain that part. It’s a rather complex issue there and would require me to provide a lot of proof. The last part of your answer is the most important and confirms my suspicion.

 

[cbg]

So you got six months of benefits that you shouldn't have gotten, and you're asking whether you can sue them? It never crossed your mind to ask them if you were supposed to still have the benefits, given that part-timers are not entitled to them? You just assumed that someone else's situation, which you were not privy to and could have been for any number of reasons, automatically meant that you were entitled as well?

I'm going to make two statements here.

1.) Although my employer would eat the benefits you've already gotten and simply cancel your benefits going forward without asking you to repay the benefits you never should have gotten in the first place, I can't think of any law that they are violating. Certainly you don't have anything like enough evidence to support a claim of illegal discrimination.

2.) While I would never tell anyone not to talk to a local attorney and agree with Tax that it's your best (and probably only) option, I wouldn't hold out a lot of hope that your employer is responsible for anything but beefing up their administration. If they'd cancelled the benefits when they were supposed to, you'd have still had the same bills to pay so it's not as if you've incurred any expenses solely because of their mistake.

 

[Rdp31783]

So you got six months of benefits that you shouldn't have gotten, and you're asking whether you can sue them? It never crossed your mind to ask them if you were supposed to still have the benefits, given that part-timers are not entitled to them? You just assumed that someone else's situation, which you were not privy to and could have been for any number of reasons, automatically meant that you were entitled as well?

I'm going to make two statements here.

1.) Although my employer would eat the benefits you've already gotten and simply cancel your benefits going forward without asking you to repay the benefits you never should have gotten in the first place, I can't think of any law that they are violating. Certainly you don't have anything like enough evidence to support a claim of illegal discrimination.

2.) While I would never tell anyone not to talk to a local attorney and agree with Tax that it's your best (and probably only) option, I wouldn't hold out a lot of hope that your employer is responsible for anything but beefing up their administration. If they'd cancelled the benefits when they were supposed to, you'd have still had the same bills to pay so it's not as if you've incurred any expenses solely because of their mistake.

The issue is that they usually will not remove benefits until they have placed you in another part time position via signature. That has been the way it has always been there. No change was made to my status in the system or in payroll which caused the error. I was still considered full time in the system. Had I known they would retroactively charge me then I could’ve found an alternative provider. I had asked about my status a time or two and did not receive a reply until a month later. I tried calling the provider directly and was told to handle it through my HR prior to their response. As you have mentioned, they are very incompetent. The error was on their end, which they have admitted to in writing. Does that equate to legal culpability in my state? I suppose I will find out. I think Tax’s advice was what I was looking for. Haven’t had many dealings with the law, particularly labor laws, which I consider a good thing.

 

[cbg]

Were you working full time or part time? Not, what was the policy; not, was there a signature, not, what was in the system.

Were you working full time hours or part time hours?

For that matter, were you paying any premiums?

 

[Rdp31783]

Were you working full time or part time? Not, what was the policy; not, was there a signature, not, what was in the system.

Were you working full time hours or part time hours?

I was working 32-33 hours before I had my illness. That tends to be part-time hours there. Elsewhere I’ve worked after 30 you would be considered full-time, but that was elsewhere and not sure that matters in this instance.

 

[cbg]

I added another question. Were you paying any premiums?

 

[Rdp31783]

Yes, I paid premiums during those months. Have up until my last check. I was gravely ill for three months, that is why any of this is hazy to me.

 

[cbg]

Okay, that makes a difference. I had initially understood that you had not.

As Tax said, what matters is what the plan document says. Note that by the plan document, we do not mean the employee handbook or anything that you've been given by the insurance carrier - I mean the official plan document that they have in HR. There is a summary of that, called the Summary Plan Description, that they are required by law to give you on request. (The last time I looked they had 30 days to give it to you, so don't expect them to reach into a box and hand it to you. It's also okay if they say, Here's a link to it on the intranet.) The SPD will tell you who is eligible for benefits and it is Carved. In. Stone. If the SPD says that employees who work 32-33 hours a week are eligible for benefits then they can't do what they're doing. On the other hand, if it says you have to work 35 or 40 hours to be eligible, then they are legal. I could probably even make the position stick that if it says you have to work 40, or 35, or anything more than 32-33 hours a week to be eligible, that they MUST cancel your benefits. It goes without saying that if they cancel your benefits retroactively, they have to return the premiums.

Let me state for the record that I don't think they are handling it well. On the other hand, I don't think you handled it particularly well on your end either. But this is going to be fairly clear; either you were eligible for benefits or you weren't. Incompetence is not illegal. If you weren't entitled to benefits, there isn't any law I know of that's going to force them to cover you anyway. The best you can expect, and I'm not promising you this much, is for a go-forward cancellation and to leave the benefits you've already had alone.

I hope you're feeling better.

 

[PayrollHRGuy]

As an addition to what CBG has written. Since Obamacare went into effect most new plans made 30 hours as the cutoff for part-time and many older plans that were grandfathered in were modified to 30 hours.

 

[Rdp31783]

Okay, that makes a difference. I had initially understood that you had not.

As Tax said, what matters is what the plan document says. Note that by the plan document, we do not mean the employee handbook or anything that you've been given by the insurance carrier - I mean the official plan document that they have in HR. There is a summary of that, called the Summary Plan Description, that they are required by law to give you on request. (The last time I looked they had 30 days to give it to you, so don't expect them to reach into a box and hand it to you. It's also okay if they say, Here's a link to it on the intranet.) The SPD will tell you who is eligible for benefits and it is Carved. In. Stone. If the SPD says that employees who work 32-33 hours a week are eligible for benefits then they can't do what they're doing. On the other hand, if it says you have to work 35 or 40 hours to be eligible, then they are legal. I could probably even make the position stick that if it says you have to work 40, or 35, or anything more than 32-33 hours a week to be eligible, that they MUST cancel your benefits. It goes without saying that if they cancel your benefits retroactively, they have to return the premiums.

Let me state for the record that I don't think they are handling it well. On the other hand, I don't think you handled it particularly well on your end either. But this is going to be fairly clear; either you were eligible for benefits or you weren't. Incompetence is not illegal. If you weren't entitled to benefits, there isn't any law I know of that's going to force them to cover you anyway. The best you can expect, and I'm not promising you this much, is for a go-forward cancellation and to leave the benefits you've already had alone.

I hope you're feeling better.

If you saw the incompetence at this place you’d consider it criminal, just a joke. There are some mitigating factors on my cognition but those are personal things and I know the law won’t care either way. I will accept my responsibility. What you said makes sense. I suppose that we will see how it pans out and lesson learned on my end. I’ll request the SPD from them. The immediate concern is I won’t work for them given their incompetence in handling this matter and others. If it goes against me I suppose I’ll have debt. Returning to school, so student loans amongst other things leveraged will kill my credit anyway. It seems shady that employers not only can do this sort of thing without recourse but are required to. It doesn’t seem in keeping with regormi Suppose we shall see. Thanks for your time.

Okay, that makes a difference. I had initially understood that you had not.

As Tax said, what matters is what the plan document says. Note that by the plan document, we do not mean the employee handbook or anything that you've been given by the insurance carrier - I mean the official plan document that they have in HR. There is a summary of that, called the Summary Plan Description, that they are required by law to give you on request. (The last time I looked they had 30 days to give it to you, so don't expect them to reach into a box and hand it to you. It's also okay if they say, Here's a link to it on the intranet.) The SPD will tell you who is eligible for benefits and it is Carved. In. Stone. If the SPD says that employees who work 32-33 hours a week are eligible for benefits then they can't do what they're doing. On the other hand, if it says you have to work 35 or 40 hours to be eligible, then they are legal. I could probably even make the position stick that if it says you have to work 40, or 35, or anything more than 32-33 hours a week to be eligible, that they MUST cancel your benefits. It goes without saying that if they cancel your benefits retroactively, they have to return the premiums.

Let me state for the record that I don't think they are handling it well. On the other hand, I don't think you handled it particularly well on your end either. But this is going to be fairly clear; either you were eligible for benefits or you weren't. Incompetence is not illegal. If you weren't entitled to benefits, there isn't any law I know of that's going to force them to cover you anyway. The best you can expect, and I'm not promising you this much, is for a go-forward cancellation and to leave the benefits you've already had alone.

I hope you're feeling better.

I do have some mitigating mental health factors on my end and as you can imagine stress only exacerbated that. Doubt the law will take any of that into consideration since this isn’t a criminal case of any kind. I certainly don’t deny my responsibility but it seems morally wrong given the situation. Doubt the law cares about morality in this instance.

My immediate concern is I won’t work for a company this incompetent anymore. Lesson learned the hard way on coverage and I will ask for the SPD. If I’m culpable, then the hospitals will be waiting a while. All I can say on that end. Thanks for all the help and the well wishes. Hopefully it doesn’t come back.

 

[Rdp31783]

As an addition to what CBG has written. Since Obamacare went into effect most new plans made 30 hours as the cutoff for part-time and many older plans that were grandfathered in were modified to 30 hours.

That’s good info to know. Maybe for once the Affordable Healthcare Act will benefit me.