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NewBorn Denied Mother's Insurance Coverage After Leaving Job But While Still Insured

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#1
What is the name of your state? UTAH

I recently left a company to work for another company. My end date was July 13th. My wife was pregnant and due September 4th. She had some complications and they had to deliver the baby on July 23rd. My previous company's insurance extended through the end of July. When I called them to add our newborn on to the plan for the remainder of July, they said I couldn't add dependents to the plan because I was no longer employed at that company (even though we were insured through the end of the month and when the baby was born.) They've advised me to seek a private plan for our newborn (which is silly expensive) or try to qualify for Medicaid (which we won't...) COBRA was able to add him starting August 1 until my new insurance kicks in so it's just from July 23rd to August 1. He's still in the NICU so I can only imagine the costs that are stacking up... I've done some research and there's a federal law under the portability and accountability act of 1996 that says an insurance company has to offer an insured women's newborn coverage if they request it within 30 days. We reached out and requested it within 10 days. Has anyone else ever experienced this? What are my options? Is the insurance company in the wrong and would I have any legal ground to stand on? Thanks in advance for any insights.
 


cbg

I'm a Northern Girl
#2
What does the plan document say about when dependents can be added to the plan? I do NOT mean the employee handbook; I mean the health insurance plan document. You may have to ask them for it.
 
#3
I just reached out to them via their online chat to see if I could get a copy of their insurance plan. They referred me to their benefits website. When I went to the website though, there was a link for a document that when it pulled up said, "More information coming soon!" and that was it....
 

cbg

I'm a Northern Girl
#4
Here's the thing. I know the law you're talking about and it doesn't mean quite what you think it does. It doesn't mean that you have a guaranteed right, no matter what, to add your baby to the plan as long as you do so within 30 days. There used to be, back in the days before HIPAA (the original HIPAA) and the Affordable Care Act (aka Obamacare) whole hosts of restrictions about how long a mother could stay, and getting pre-authorizations, and pre-existing conditions. The law you're talking about was designed to protect new mothers from these restrictions.

But the plan cannot be compelled to enroll a dependent who would otherwise be ineligible.

So it's really important that you find out whether a dependent who is born, or was married, or was adopted, or whatever, to a subscriber after that subscriber has left the employ of that company. That information will be in the plan document and possibly included in the summary plan description. You must be given those on request. I wouldn't bother with the live chat or the website, however. Pick up the phone. Call someone in Benefits or HR. If the plan document expressly states that no new dependents can be added after the last day of work, that's it, that's the ball game. If it does not, you've got some room to argue.
 
#5
I've reached out to have those mailed to me. I couldn't find a plan description (that's supposedly being mailed to me) but I did find a summary plan description. Here's what it says in regards to eligibility and when coverage ends:

"Who Is Eligible? Employees. You are eligible to participate in the Omnicom Group Health and Welfare Benefit Plan as summarized in this document if you are a regular employee of your agency who is scheduled to work 30 or more hours per week. Family members. If you are eligible for coverage, eligible family members generally include your:  children, through the end of the month in which they reach age 26  spouse (as defined under state law in your state of residence or the person named in a valid marriage license issued by any state, US territory or country)  certified same- or opposite-gender domestic partner and their eligible dependents  disabled children over age 26 who depend on you for principal support and are unable to earn their own living due to a mental or physical condition, provided the disability began before age 19 (or prior to age 26 while dependent on you for principal support) and the child continues to meet the Plan’s definition of “disabled.” Expanded eligibility rules under the Patient Protection and Affordable Care Act (“ACA”). If you are not eligible for coverage as described above (i.e., a regular employee of your agency who is scheduled to work 30 or more hours per week), you (and your children) will be eligible for medical plan coverage only if you are hired as a non-regular employee who is scheduled to work more than 30 hours per week. You may also become eligible if you actually work an average of 130 hours a month over certain designated periods defined under the ACA as “measurement periods.” Generally, this is either the 12-month period beginning on the first of the month after your hire date or the 12-month period ending on October 31 of each year. These periods are also called “look-back” periods. If it is determined that you are eligible for medical plan coverage under any of these expanded eligibility rules, the medical plan coverage available to you will be the High Deductible Plan (described below). In all cases, you will be notified if you become eligible for coverage under the Plan.

When Does Coverage End? Coverage generally ends on the last day of the month in which you terminate employment or otherwise become ineligible. Under certain circumstances, some or all of your coverage may continue for a specified period following your active employment (for example, as the result of a layoff). If you become eligible for health plan coverage under the “look-back” provisions, you generally will remain eligible for such coverage for at least one year (provided you are still an active employee). When coverage ends, you will generally be eligible to continue certain benefits under COBRA. COBRA coverage is available at the full cost and you must pay any required premiums to continue coverage. Information will be mailed to your home address on file within the timeframe designated by federal guidelines."

So it says employees are eligible through the end of the month along with their kids. That seems a bit grey and could see that being interpreted differently. Thoughts?
 

Zigner

Senior Member, Non-Attorney
#6
So it says employees are eligible through the end of the month along with their kids. That seems a bit grey and could see that being interpreted differently. Thoughts?
No, it says that eligibility ends on the date of termination. Coverage ends on the last day of the month in which the employee's eligibility ends.
 

cbg

I'm a Northern Girl
#7
You are no longer an employee. You are not working 30 hours or more per week. While I think your former employer is drawing the lines about as tightly as it's possible to draw them, I can see what they're saying.
 

cbg

I'm a Northern Girl
#9
It's worth arguing the point. But they do have a basis for the position they are taking. And just so you know, I do this for a living - if you worked for my employer, I'd be the one you were talking to about this.
 
#10
Thanks - what would your company do in this situation? I talked to the department of labor this afternoon and they sure thought the insurance company was in the wrong... The hospital is saying they think they can work with the COBRA facilitator to get the newborns start date for COBRA to be its birth date but we'll see. It's just frustrating that on top of a complicated delivery (almost lost my wife), I have to deal with all of this..
 

cbg

I'm a Northern Girl
#11
Well, we don't carry you through to the end of the month; with us your coverage ends on your last day of work. So you'd be adding the baby under COBRA with us. I think that both morally and ethically they should allow the addition; I'm just not entirely convinced that they don't have some legal grounds for their position. I'm not entirely convinced they do, either. I absolutely think you should fight it; this is too big an issue not to and I definitely agree there's grey area here.
 
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