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Newborn Complications - Did not add name on insurance!

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emkalmuk

Guest
What is the name of your state? Arizona

Is there any leg to stand on for someone who went in to be induced - ended up having an emergency c-section and then spent 5 days in the hospital with newborn son, who spent 4 days in the NICU - thereby, forgetting to add his name to her husband's existing insurance...? My husband had Cigna PPO - Employee + Family (not + Spouse) at the time our son was born. He left his job a week after our son and I were discharged to care for me and my son. He is now a stay-at-home dad. I enrolled in insurance (Frist Health) with my company and included my husband and son; I have now returned to work. First Health was effective the 12th of the month my son was born. The issue is: Cigna PPO paid for my expenses, but not my son's. We just received a bill from the hospital for $14,000. Since my husband was leaving his job a week after my son was born, we did not think to add his name.

Do we have a leg to stand on with Cigna PPO to pay for our son's expenses, since we had Employee + Family and were covered thru the end of the month he was born? Or, should we submit expenses to First Health and pay the rest ourselves -or- see if Cigna PPO will pay the remaining balance. I am upset because I am not sure what will be covered and we'd need to start over with First Health's deductible and annual out-of-pocket max - which we've already met thru Cigna PPO.

We're not trying to get anything free, but it was an oversight as we were under duress and the trauma we were ensuring distracted us from taking care of the administrative piece of our insurance coverage. Please help!
 
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cbg

I'm a Northern Girl
It is ENTIRELY the responsibility of the insured to add any newborns to the policy. In this age of step-parents, foster parents, open adoptions, second, third and even fourth marriages, and other options for extended families, the insurance carrier has no way of knowing which parent is planning to cover the newborn.

"I'm sorry, it was an oversight because we were in a stressful situation" is NOT going to give you any legal recourse. If you were required to add the newborn within 30 days (which is standard) and you didn't, the insurance carrier does not have any obligation to "forgive and forget" - and incidently, take on $14,000 worth of bills.

I'm sorry I can't give you a different answer, but no, you do not have a leg to stand on.
 

rmet4nzkx

Senior Member
Did you husband apply for FMLA to take care of you and your child?
Did he advise his work of the birth of the child so it could be put on the policy?
 
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emkalmuk

Guest
State: ARIZONA

cbg:
Thanks for the reply. I'm not surprised at the response and will file the claim through First Health (our current insurance, which was effective on my son's birthday). Thank you.

rmet4nzkx:
No my husband did not apply for FMLA. How is that accomplished? Is it too late? We did call the insurance to let them know about the emergency c-section, but no one asked and we did not think to have the child added. We thought with that call, explaining the situation sufficed. He did let his company know, as he took sick and vacation days while we were hospitalized. Please comment. Thank you.
 

rmet4nzkx

Senior Member
It is possible given all the confusion that informing his employer and the insurance company of the birth should have served notice of intent to add the child and set something in place to put the child on the policy, so it is possible that there may be something there to pursue.

Same for FMLA, " Employees are eligible to take FMLA leave if they have worked for their employer for at least 12 months, and have worked for at least 1,250 hours over the previous 12 months, and work at a location where at least 50 employees are employed by the employer within 75 miles."

If your husband qualified and not notified, there may have been no reason to quit and perhaps the child would have routinly added. FMLA allows up to 12 weeks leave which may be unpaid and during which the job is held and insurnace usually contiues, sometime other arrangements may be made in special instances. So it is possible that if your husband was eligible and not informed, that is something to consider.

Here is a link to DOL http://www.dol.gov/esa/whd/fmla/index.htm
29 CFR Part 825 Synopsis of Law
Covered employers must grant an eligible employee up to a total of 12 workweeks of unpaid leave during any 12-month period for one or more of the following reasons:
* for the birth and care of the newborn child of the employee;
* for placement with the employee of a son or daughter for adoption or foster care;
* to care for an immediate family member (spouse, child, or parent) with a serious health condition; or
* to take medical leave when the employee is unable to work because of a serious health condition.
 

cbg

I'm a Northern Girl
"It is possible given all the confusion that informing his employer and the insurance company of the birth should have served notice of intent to add the child and set something in place to put the child on the policy, so it is possible that there may be something there to pursue. "

This is what I do for a living, cupcake. Unless they specifically informed the carrier that they wanted to add the child to the policy, "informing the employer and insurance carrier of the birth" does NOT put them on notice to add the child to the policy. There is nothing to pursue there.

The child would NOT have been routinely added if the father had been on FMLA. FMLA has NOTHING WHATSOEVER to do with the health insurance. FMLA or not, it would STILL have been necessary for them to specify that the child was to be added to the plan.

You're great at posting links and cutting and pasting, but you clearly do not understand what you're linking and cutting and pasting.
 

rmet4nzkx

Senior Member
Cupcake!!!!!

cbg said:
"It is possible given all the confusion that informing his employer and the insurance company of the birth should have served notice of intent to add the child and set something in place to put the child on the policy, so it is possible that there may be something there to pursue. "

This is what I do for a living, cupcake. Unless they specifically informed the carrier that they wanted to add the child to the policy, "informing the employer and insurance carrier of the birth" does NOT put them on notice to add the child to the policy. There is nothing to pursue there.

The child would NOT have been routinely added if the father had been on FMLA. FMLA has NOTHING WHATSOEVER to do with the health insurance. FMLA or not, it would STILL have been necessary for them to specify that the child was to be added to the plan.

You're great at posting links and cutting and pasting, but you clearly do not understand what you're linking and cutting and pasting.
CUPCAKE :eek: :eek: That's Ms. CUPCAKE to you! Where is that number for the EEOC????

All I said was there were some possibilities, neither you nor I know exactly what happened and you didn't even consider that the husband might have had FMLA available and may have made decisions based on that.

What are some of the possibilities?
When our second child was born, all it took was a telephone call to add the child at birth and since there was prenatal care, there was clear intent to deliver a child. In this case they called with the ER C/S and the child was in the NICU so naturally they were focising on their newborn. They may have been lead to believe that all necessary contacts were made, obviously the hospital was providing treatment to the infant and you know their billing offices don't let you in or out without authorization from the insurance or they would have informed the parents before they gave them their bag of newborn freebies that they needed to add the baby to the insurance, or the forms were sitting on the father's desk at work.

The father had contact with work, the exact nature and number of days are uncertain but that he used vacation days during the hospitalization and to care for them after and then employment ended, he didn't know about FMLA or wasn't qualified. Perhaps he come in to pick up his belongings and didn't even get the forms, maybe her never returned and they sent him his check in the mail.

I have seen this happen, they know you are out ill or on disability because they have contact with you but the company fails to forward important things to the person or inform them as required, provide the proper forms, perhaps making a "desk drop" while knowing they are at home unable to travel. All I said is that there are possibilities, they may discover that the forms weren't provided or left on the desk, not sent out or the employee wasn't informed. In this case they were not informed until after the claim was denied that the child was not added on the policy. It is not like they were adopting or a step child with a C/S. Sometimes the business is not in compliance and it is not the fault of the employee. This is why there are complaint and appeal processess that actually work sometimes. Maybe everything is perfect where you work, but I think you are human too and I know what goes on.

All I said was there were some possibilities and we didn't have enough information to give an answer, that is why I asked some questions rather than make assumptions. I am retired now, I used to spend the day solving problems that everyone had given up on, it is a gift more so than a skill, but if this is what you do all day you are going to have one perspective, I try to look at all sides of an issue.
 

cbg

I'm a Northern Girl
Okay, Ms. Cupcake if you prefer.

I think you're making a massive stretch with the FMLA thing, but even if you are 100% correct, it doesn't change the answer about the insurance issue one whit. Being on FMLA or not being on FMLA has nothing whatsoever to do how a new dependent is added to the policy. There is no evidence to suggest that he ONLY gave up his job because FMLA wasn't offered, but if he did that's a whole separate question and a whole different thread. The answer on the insurance issue remains the same.

I'm perfectly willing to accept that they may have thought they'd made all the appropriate notifications, but their belief does not make the insurance carrier liable. It is THEIR responsibility to KNOW what they have to do, not just assume. And if they forget, they suffer the consequences. Neither the employer nor the insurance carrier is legally required to change the rules for them because they were in a stressful situtation.

For the record, I have both as an insurance carrier representative and as an employer fought to get newborns added when the employee did not make the appropriate notifications. Sometimes I was successful, sometimes I wasn't. I can certainly understand how someone would overlook some of the details in the circumstances they describe. But that still does not create any legal liability on the part of either the employer or the carrier. If they want to hold to the bottom line on the rules, they can.

You might also want to consider that IF the insurance plan is under a Section 125 plan (which most group plans are these days) the carrier CANNOT legally add a new dependent once the window has closed. That's Federal law, and violating it could result in the employer losing the right to offer any pre-tax benefits to any employees.
 

rmet4nzkx

Senior Member
Let's see how it pans out, all I said was possibilities. In this case their belief that the child was "covered" if this was based on the breakdown/s in the system somewhere and I am really surprised that the hospital didn't catch it before they left, very unusual. I'm glad to hear you have fought to get newborns on the plan.
 

cbg

I'm a Northern Girl
"In this case their belief that the child was "covered" if this was based on the breakdown/s in the system somewhere"

No, according to the poster's own statement they simply forgot to make the addition. Under the circumstances that may or not be a reasonable thing for them to have forgotten, but it's not a breakdown in the system.

"I am really surprised that the hospital didn't catch it before they left, very unusual."

I'm not surprised, and no, it's not unusual. While if you really stretch it one COULD make an argument for responsibility on the part of either the insurance carrier or the employer (not a good argument, but an argument nonetheless) the hospital has NO responsibility in this matter.

An employee has 30 days to make an addition of a new dependent to the policy. Since the baby was not in the hospital for 30 days, even if anyone there thought to check (which they have NO responsibility to do) it wouldn't mean a thing if there was no coverage at the time they left the hospital - there was still more than two weeks before it legally had to be done.
 
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emkalmuk

Guest
Newborn Complications...Follow-up

Hello - I spoke with both Cigna Customer Service and the HR Director at my husband's company. Neither would budge on this stating it's their policy, from which they cannot deviate, to require the name be added within 31 days. Also, that it's not their (HR's) responsibility to remind an employee to do this.

My main arguement is that we had Employee + Family coverage during the period of these bills. My husband left the company before the 31-day change period was up and also our insurance was terminated before the 31-day period. Who would think to add someone after they were no longer with the company and they were no longer covered.

Here is a snapshot of the timeline: I was pre-certified for my scheduled admission on May 11, my son was born via emergency c-section on May 12, he was discharged from the NICU on May 16, my husband left the company on May 20, and our health insurance was terminated May 31. All this occurred within the 31-day period.

When my husband left there was no contact from HR about any separation paperwork, exit interview or anything. My belief is that they were negligent in not providing guidance/support to their employees.

The HR Benefits Director I spoke with just said we had to file the claim with my insurance company and that it was not their responsibility to do anything at this point.

Is this worth pursuing? Thank you!
 

cbg

I'm a Northern Girl
No. This is not worth pursuing. If they are taking this hard a stand, you will not win. Whether you like it or not, they are correct. YOU are the only one who has any legal responsibility to add dependents to your policy. Neither your employer, your insurance carrier or the hospital has any legal responsibility to remind you. Nor does the insurance carrier have any responsibility to cover dependents who are not on the policy, EVEN IF you have family coverage. PLENTY of people for one reason or other will have different members of the family on different policies. They have no way to know that you want the newborn on the policy if you don't tell them. They don't know what other insurance you might have that you might want to use instead.

The law does not require any separation paperwork on the day of termination. The law does not require any exit interview. Your belief that they were negligent does not make it so.
 

cbg

I'm a Northern Girl
Oh, one other thing. IF your husband's portion of the premium was taken out of his paycheck on a pre-tax basis, then it would be ILLEGAL for them to add the baby after the 31 days was up.
 
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emkalmuk

Guest
Thank you!

Thank you, CBG, for your responses. I truly do understand I was responsible, but I'd hoped under the circumstances they could have made an exception. I can now move forward knowing I did my due diligence in asking my questions. Appreciate your time! Elizabeth
 
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ndb3

Guest
I think this may help...

Hi - I had a similar problem. My wife and I forgot to add our new son to our insurance within the required "life change" time frame. Our insurance company denied all of his claims.

I spoke with a Senior Benefits Advisor for the Employee Benefits Security Administration at the Department of Labor and he confirmed that the information listed below is based on federal law... We called our insurance company and they apologized for their oversite, agreed that federal law required them to cover our newborn's medical bills for 31 days following his birth, and agreed to pay the claims.

Before you call your insurance company with this information, you should probably check with a representative at your local Department of Labor office. Here is the number I called: 866-444-3272


http://www.tdi.state.tx.us/consumer/cbo05.html

16. What does the law say about maternity and newborn coverage?
If your company has 15 or more employees, federal law requires that maternity benefits be included in your group health benefit plan. In addition, state or federal law:

-Prohibits employer health plans from denying benefits because a pregnancy is determined to be a pre-existing condition.
-Requires hearing loss screening for newborns and necessary follow-up screening through a child´s first 24 months.
-Requires* that post-delivery care must be provided if a mother is discharged earlier than 48 hours after an uncomplicated vaginal delivery or 96 hours after an uncomplicated Cesarean birth. Such care must be at the mother´s home, a health provider´s office, a health care facility or "other location determined to be appropriate" by the Commissioner of Insurance.
-Requires* newborn coverage for the first 31 days if the health care plan provides maternity benefits and dependents can be covered. The plan may not exclude or limit initial coverage of a child because of accident or illness - especially congenital medical conditions or premature birth. This includes reconstructive surgery for craniofacial abnormalities for a child younger than 18 who has been continually covered by health benefit plans. To continue newborn coverage beyond the first 31 days after birth, notify the plan/company within the first month that you have a newborn and pay any additional required premiums.

*These laws apply to group and individual coverage if maternity benefits are covered.
 
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