Legality of no coverage for surgery performed by spouse

[traveler2009]

What is the name of your state (only U.S. law)? NE
Hi. Can anyone address the denial of health coverage for medical care provided by a spouse? I recently had shoulder surgery, which my spouse performed. He was the only one in my area I would have gone to, regardless of our relationship, because he specializes in this type of surgery and is the only such specialist in our area. I otherwise would have had to travel 2 hours to the nearest city, and I felt this wasn't an option.

Anyway, not knowing we wouldn't have coverage, I opted for my spouse to perform it. We recently received notice that our insurance company won't cover it b/c he's a relative.

What's the basis for this? Do the insurance companies believe family members will somehow take advantage of the system and go to their relatives for such procedures? That sort of thinking makes no sense to me since I'd imagine there are very few people who'd want to undergo unnecessary surgery, and I can't imagine any surgeon wanting to rack up surgeries on their relatives. So what's the reasoning?

From a fairness perspective......well that's out the window. Basically, the insurance company is not allowing me to choose him as my surgeon --- something every other person covered by this same plan is allowed to do. Is there a winning legal argument to get this sort of practice overturned?

 

[lealea1005]

Your spouse should go back and read his/her BC contract. Most insurance companies have specific exclusions regarding the treatment of family members. They closely follow Medicare's policy of not providing benefits to immediate family members.

 

[Mass_Shyster]

From a fairness perspective......well that's out the window.

If find it disturbing that your spouse would charge you for treatment.

 

[ecmst12]

It is fraudulent to charge insurance for a procedure that the patient wouldn't be directly charged for. They assume that one would not charge an immediate family member for treatment so charging insurance is fraudulent and won't be covered.

Not to mention that surgery on a family member is a conflict of interest and discouraged in the medical community, but that's another story.

Anyway the hospital's charges and the other providers involved should be covered, only your husband's charge won't be.

 

[traveler2009]

Okay, so it seems there's an assumption that my husband would not charge me for the surgery, and that if he had not, then it would not have become an insurance issue. Obviously, if nothing is charged, then insurance would never know about it.

But here's the rub. He's a hospital employee and has no control over whether he charges me or not, unless he were to get his staff to cook the books. All procedures he performs are entered into the system and processed by the finance dept.

Anyway, I'm just wondering what the reasoning if to deny coverage to relatives. Do they fear added liability for violating legal ethics via conflict of interest concerns?

 

[ecmst12]

Your husband should speak to his employer and find out if there's a policy on providing services to family members. I'd be really surprised if there wasn't a policy in place already.

 

[traveler2009]

No, there's no policy. We checked before the surgery. Other surgeons have also done work on their relatives. We're stuck in a small, remote town where there's only one type of surgeon for specialty areas, which is why I imagine legal allows this, which in turn has me wondering about the insurance and the legality of any clause that prohibits it.

Anyway, I'd imagine it's much like legal conflicts of interest. For instance, a client can still choose to enter into a relationship with an attorney as long as the attorney feels any possible conflict will not hinder his/her representation, the client is fully informed and instructed to seek counsel on the issue, and makes an informed decision. Potentially dangerous waters, yes, but still legal.

 

[Zigner]

No, there's no policy. We checked before the surgery. Other surgeons have also done work on their relatives. We're stuck in a small, remote town where there's only one type of surgeon for specialty areas, which is why I imagine legal allows this, which in turn has me wondering about the insurance and the legality of any clause that prohibits it.

Anyway, I'd imagine it's much like legal conflicts of interest. For instance, a client can still choose to enter into a relationship with an attorney as long as the attorney feels any possible conflict will not hinder his/her representation, the client is fully informed and instructed to seek counsel on the issue, and makes an informed decision. Potentially dangerous waters, yes, but still legal.

The clause is legal.

 

[traveler2009]

Zigner, could you expound a bit?

 

[Zigner]

Zigner, could you expound a bit?

Sure.

There is no law prohibiting the clause. Therefor, it is legal.

 

[lealea1005]

Anyway, I'd imagine it's much like legal conflicts of interest. For instance, a client can still choose to enter into a relationship with an attorney as long as the attorney feels any possible conflict will not hinder his/her representation, the client is fully informed and instructed to seek counsel on the issue, and makes an informed decision. Potentially dangerous waters, yes, but still legal.

It is not illegal to treat an immediate family member, but the AMA advises against citing ethics. Here's the link:

AMA - Opinion 8.19 - Self-Treatment or Treatment of Immediate Family Members

But here's the rub. He's a hospital employee and has no control over whether he charges me or not, unless he were to get his staff to cook the books. All procedures he performs are entered into the system and processed by the finance dept.

Is your husband a salaried employee or is he paid fee for service? Either your husband, or one of his staff members, must submit the billing information for his services to the hospital's finance department. Otherwise how would they know what services to bill/submit?

 

[Zigner]

It is not illegal to treat an immediate family member

Correct - but the question is: Is it illegal for the insurance company to exclude services performed by a family member? The answer is "Yes, it's legal for the insurance company to exclude services performed by a family member."

 

[cbg]

Correct - but the question is: Is it illegal for the insurance company to exclude services performed by a family member? The answer is "Yes, it's legal for the insurance company to exclude services performed by a family member."

Well, technically, if the question is, "Is it illegal for the insurance company to exclude services performed by a family member?", the answer is, "No, it's not illegal for the insurance company to exclude services performed by a family member". But that's only if you want to split hairs; it comes to the same thing.