Illegal Activity
LindaS
1,510 Posts
I'm wondering how many of you out there have wording in your insurance plan that addresses becoming ill or injured while engaged in illegal activity.
For example, our states that participants who become ill or injured as a result of engagement in illegal activity will not have their illness/injury paid.
I have an EE whose son was in an automobile accident several months ago. The accident occurred after he left a party during which he had been drinking. He admitted as much at the hospital and was charged with OWI. She has been very upset at the company for the last several months because the insurance company has held payment of any claims pending the outcome of the criminal proceedings and has been told by her attorney that they have never heard of such a thing and that it may be illegal.
For example, our states that participants who become ill or injured as a result of engagement in illegal activity will not have their illness/injury paid.
I have an EE whose son was in an automobile accident several months ago. The accident occurred after he left a party during which he had been drinking. He admitted as much at the hospital and was charged with OWI. She has been very upset at the company for the last several months because the insurance company has held payment of any claims pending the outcome of the criminal proceedings and has been told by her attorney that they have never heard of such a thing and that it may be illegal.
Comments
"any health care service to diagnose or treat a condition which, directly or indirectly, resulted from or in connection with:
. . .
b) participation in or commission of any act punishable by law as a misdemeanor or felony, or which constitutes a riot or rebellion;
c) engaging in an illegal occupation;
. . ."
We're in Florida, and I'm curious about how your attorney thinks the exclusion might be illegal if its a restriction in benefits, does not have an impact on enrollment to the plan, and the criteria for the exclusion are not a protected characteristic.
thanks,
Thanks
As a result of this issue this EE has become a problem EE with her attitude. She is very angry at the company and feels that after 25+ years of service we owe her son coverage for this accident and that is what she pays insurance premiums for.
Not sure whether you are self insured or underwritten, but I hope you're underwritten. We've had a few touchy issues with out policies, and fortunately, I get to direct workers to the insurance company's grievance process. I did have to tell one of our workers a couple of months ago, who was asking that I have an insurance company denial of benefits waived, that I refused to commit insurance fraud for her or anyone else. I only used used the fraud terminology as a last resort when I was very tired of her screaming at me on the phone. She said that I could probably afford to pay mine if the situation were me. I took her remark as a blow below the belt, told her it was an unfair comment on her part to make about me or anyone else in my role, and suggested that she was trying to get me to violate the law. She calmed very quickly and has left me alone since about the denial. You probably wish your's were that easy. However, if you are underwritten, you could at least point the opposing attorney to the insurance company since the benefits exclusion is really a function of your insurance company. I'm guessing, however, since you have had your company's attorney involved already that you are self insured.(?)
The EE is of the mistaken belief that since she has worked here for the number of years she has that she is owed an exception to the policy and cannot fathom why we will not make an exception for her.
I find it more and more difficult to maintain my "HR face" when talking to her and just want to tell her that she is angry at the wrong person and maybe she needs to deal with the issues with her son first.
best wishes