Texas Paid for PPO and now denied due to birth of child change

[jturboawd]

Jurisdiction

Texas

Hi Forum,

I had a comprehensive PPO medical plan for my family as we had planned a child birth. My daughter was born april 30th. I paid for this PPO through april, which in fact covered through the first 2 weeks of may. My employer allowed me to change medical coverage within a 30 day period after the birth. April 30th I reduced my coverage from a PPO to a HDHC plan. On april 3rd I had paid outright and had no bills due to hospital. Several months after my daughters birth I was notified that my employer removed my covered on April 3rd and reduced it to a HDHC plan. I have since had to pay 8K out of pocket as if I never had a PPO. My employer states that they can go back into the past and delete past coverage and change it to the HDHC plan since thats what I elected to do. This seems very unethical to me. I believe this is a law meant to protect the people, that my employer insufficiently explained, and is not benefiting from. I have called several lawyers and have not found one who handles this type of case. Any advice would be greatly appreciated.

Thank You
Jay

 

[army judge]

Any advice would be greatly appreciated.

Your issue isn't a legal issue.

I suggest you read the plan documents that form the basis for the contract of coverage and your policy with EACH carrier.

You then might wish to peruse documents your employer has given to you, or made available to you about changing health plans when a major life event transpires.

You might then wish to make an appointment to speak to your benefits representative or whoever an employee contacts within your entity when he/she has a question about medical insurance.

You've contacted lawyers and have not found the magic bullet you're seeking.

If I were you, I wouldn't expect much more than you've already received.

 

[ElleMD]

It is a bit hard to follow. What happened on April 3? You had a PPO prior to the birth of your child and you changed your coverage after the birth? And the child was born on April 30th, not 3rd? Was Open enrollment at or around the time you changed coverage?

 

[cbg]

Depending on the exact facts, it is quite possible that your employer not only did not violate any laws, but in fact made the only legal changes possible. However, you are going to need be provide a lot more clarification on not only what happened when, but also what your company plan document says about when policy changes are in effect. If you worked for my employer, the change to the HDHP would have been effective the same day your daughter was born and all of the hospital charges would have been paid through that plan and not the PPO. Are you quite sure that you pay for the coverage in advance? While a significant percentage of the population evidently believes that they pay for the employer-sponsored health coverage in advance, that is actually quite rare and in almost 40 years of administering employer-sponsored benefits, I have yet to see a plan that is paid that way.

 

[ElleMD]

Wouldn't be the first time I had a new parent change their plan following the birth of a child and then get upset that the change was retroactive to the date of the birth. No matter how many times I warn them, some do not seem to understand that the change is not effective the day they turn in the paperwork or some arbitrary day in the future, but becomes effective the day the event that allowed them to make the change occurred (i.e. the birth, marriage, etc.).