Health Ins. Plan language vs policy language

Wandra

My question deals with which language prevails - health insurance policy language or policy handbook language. If the health insurance policy states that an employee must work "30 hours to be eligible for coverage" but the policy handbook states that an employee is considered part-time if they do not work 37.50 hrs per week and part-time employees are not eligible for health insurance benefits, which language prevails? I have heard that the health ins. plan language prevails but have also been told by an attorney that the policy handbook language would prevail. I thought that I knew the answer to this question but now I am totally confused. Please help!!

marc

Our handbook specifically states that the Plan language prevails.

Wandra

But what happens when the handbook does not specifically state that the Plan language prevails? Or is it in your handbook because there is something in ERISA that I have missed (I have been trying to find something specific about this but my research has not come up with specific language in ERISA yet - but I have not given up the research). Thanks for your help!

irenesmsaclaims

Regardless of what your handbook says about full-time and part-time and the definitions of each, the policy is a contract between your company and the insurance company, and the insuror will only cover employees working a certain specified number of hours. This is agreed upon when the employer applies for the policy, and signs the application with the number of hours worked on the application, which becomes part of the policy/contract.

You wouldn't want to put something in your handbook that allows or implies eligibility for the medical plan if it conflicts with the contract with the insurance company.

Plan language will prevail over a handbook written by the employer; but you need to be completely consistent with both so you won't have to research ERISA to avoid problems.