Health Insurance Coverage for Separated Spouse?
November 20, 2012 3:55 PM   Subscribe

I have a question regarding employer's health insurance coverage of a separated spouse. I understand that the information I might (hopefully) be given would be general and not necessarily pertinent in my case but since it's close to a holiday and I cannot get more specific information until next week, I'm hoping that some general info will calm the freakout I feel just around the corner.

This is in NC. There is no legal separation in NC, you are either married or divorced.

I stopped work in February of this year, first covered under short-term disability and then long-term disability. After six months on long-term disability I lost health insurance coverage through my employer (although I was offered and declined COBRA).

My husband and I have been separated for 10+ years but never filed for divorce for various reasons (first because we were raising a young child and wanted each other to receive life insurance benefits if one of us died, then just because of laziness more than anything). When I lost my health insurance through my (now previous) employer, my husband generously offered to carry me on a family plan policy through his employer. (He also carries our now-21-year-old son). We supplied his HR dept a letter from my former HR dept describing my "qualifying event." My former coverage ended on 08/31 and my new coverage under husband's policy began 09/01. Claims have been paid over the last couple of months with no apparent problems.

Last week my prescription refills were refused coverage. My husband learned that my coverage had been denied, ostensibly because we do not live together and are therefore considered separated. As I posted above, NC does not have a "legal separation," only married or divorced.
Today my husband was told to call the HR department again next week, after the holiday, to continue exploring the issue.

Are they allowed to deny me coverage simply because we live separately? Our legal status is married, we own a house jointly (which my husband lives in and pays the mortgage for) and our income tax status has been "married filing separately" for the 10+ years we have been separated.

I recently was awarded SSDI but will not be eligible for Medicare for 24 months. Because disability only pays 60% of my former salary, there is no way I could have afforded the COBRA insurance. My monthly healthcare costs are upwards of $6,000/month (I receive a monthly IV treatment that is $5,000 by itself). This has the potential to be a catastrophic problem for me if I truly lose this health insurance coverage.

To reiterate, I understand that no one can give me a firm and certain answer, I'm just looking for some sort of reassurance to get me through the next week or so until my husband can get more definitive information from his HR department. If we believe that they have unfairly denied my coverage, what would be the next step? Our state insurance commission? An attorney?

Thank you in advance for keeping me from losing my shit.
posted by SweetTeaAndABiscuit to Health & Fitness (9 answers total)
Appeal. Be polite. Assume "innocent mistake" or "misunderstanding" for the time being.

Put everything in writing. Ask if there is a North Carolina team or a special team for handling errors/complaints or some other special somebody who should be looking at your case.

I paid insurance claims for five years. Every single state has "state exceptions" and where you have some oddball thing going on in a particular state, you see more errors. For now, assume that is the issue. And remind them that they paid claims previously, therefore you should be covered. That isn't a hard and fast rule, but it can influence the situation and that's the position you should (politely) take.
posted by Michele in California at 4:15 PM on November 20, 2012 [1 favorite]

Best answer: According to my employer, you are married. Married people get insurance coverage.
posted by jennstra at 4:16 PM on November 20, 2012 [1 favorite]

Best answer: My guess is that you will be required to prove that you are married and in the meantime, the insurance company saves a little money by denying a bunch of shit, allowing them to invest that money for longer before they pay you.
posted by the young rope-rider at 4:18 PM on November 20, 2012 [2 favorites]

Make and bring in copies of those tax returns, the title on the house, marriage certificate. Do not use the word "separated."

"We are married. We live apart because that's what works for us, have for 10 years. We have no intention of divorcing."
posted by amaire at 4:22 PM on November 20, 2012 [10 favorites]

Considering you have to be legally separated a year in North Carolina before you can get divorced, I don't know what you mean-but for the record my daughter lives in NC and her husband whom she has been separated from for two years but is NOT divorced from is able to use his (military) insurance. This may or may not apply to you but I am throwing it out there. As a matter of fact the reason they aren't divorced is he wants her to have insurance as she has an ongoing medical issue.
posted by St. Alia of the Bunnies at 5:38 PM on November 20, 2012

Insurance companies are notorious for disregarding state-specific insurance laws. I don't know if that is the situation you are in. But the company is likely making a big mistake, and it will be sorted out quickly and easily, or you might have to push and push for it to be resolved to your satisfaction. Just don't rely on the HR person to sort it out for you - it's possible that they will just pass on incorrect information from the insurer, and they are not practitioners of insurance law to begin with.

Your next step after HR would definitely be with an attorney, and it should be an attorney experienced in health insurance law in North Carolina. Also worth your time to put in a call to the state insurance commissioner.
posted by stowaway at 8:05 PM on November 20, 2012

If what is going on now still doesn't work after much work, I don't suppose you could "reconcile" and maintain your place as a second vacation home and perhaps somewhere you go to recover (for weeks on end?) after medical treatments.
posted by Chaussette and the Pussy Cats at 10:21 PM on November 20, 2012

If this plan is a self-funded plan, the employer has a lot more leeway on deciding what constitutes physically separated. Employers can exclude physically separated spouses from coverage--does the SPD for the health plan address that?

Do you know if it's a self-funded or fully insured plan? If it's a self-funded plan, the state's insurance commissioner will not be able to do anything for you, as self-funded plans are under ERISA, a federal law.

Bottom line, check the plan documents.
posted by FergieBelle at 5:34 AM on November 21, 2012

Response by poster: It took a lot of phone calls and persistence and some documentation, but my insurance benefits were finally restored and were retroactive to the date they denied me. Now I just have to get all my providers to refile their claims for that period of time!
posted by SweetTeaAndABiscuit at 12:18 PM on December 31, 2012 [1 favorite]

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