Ethics question

[Rob]

I write a Group Health policy for a business. The husband of the owner of the business neglects to put his children on his policy as per his agreement with his ex-wife.

Per his request I write a letter to him advising that dependents can only be added during open enrollment or if there is a qualifying event such as adoption or loss of group coverage elsewhere.

The ex-wife emails me directly advising she saw the letter and says their divoce settlement requires him to put them on. She asks me does this have any merit (because she doesn't trust him) and says she wants to hear it from me directly.

I am acting as an agent for the Health carrier in this case. I have other P&C lines with his current wife where I act as a broker.

Thoughts?

[Big Dog]

As you're aware of the divorce requirement, you should make your client aware that you've been contacted by his ex to comply with the requirement. His ex's attorney could potentially contact you and/or subpoena you and/or your records with respect to this.

As a side note, is this the type of client you want? You might want to consider advising him to find another broker given the level of his ethics (or lack there of)

[Rob]

As you're aware of the divorce requirement, you should make your client aware that you've been contacted by his ex to comply with the requirement. His ex's attorney could potentially contact you and/or subpoena you and/or your records with respect to this.

As a side note, is this the type of client you want? You might want to consider advising him to find another broker given the level of his ethics (or lack there of)

Well its not as simple as it sounds. His wife wants to keep the kids on her policy and require him to have them on his policy because of coordination of benefits.

The business that I wrote is a veterinary office. He is the husband (that I just met) of the business owner whom I write multiple other lines for. He lost his prior coverage as it was through Cobra and was ending. He didn't think to add his children to their policy because his wife told him she was keeping them on hers but wanted him to put them on his too. That didn't make sense to him (double coverage) and so he didn't do it.

[jctwindad]

Rob,

You said the ex-husband lost his COBRA coverage, so I assume he had been covered under a large group health policy. Are you saying that his 18 months as a terminated employee ran out? What about the kids coverage under COBRA? The kids would have been entitled to 36 months of coverage under COBRA.

[Rob]

Rob,

You said the ex-husband lost his COBRA coverage, so I assume he had been covered under a large group health policy. Are you saying that his 18 months as a terminated employee ran out? What about the kids coverage under COBRA? The kids would have been entitled to 36 months of coverage under COBRA.

I am not sure about that. All I know is the Group came to me for a Group Health policy and they selected the plans. Now the ex is emailing me. So first I'm going to go to him and inform him of the email but the real question, in terms of ethics, is do I email her back and advise I can't discuss, don't email her back, or email her and tell her that it is a qualifying event?

[Big Dog]

OK...this is a much clearer picture. First thought - it's really dumb to have the children covered under both policies.

That being said, if the divorce settlement requires the husband to provide coverage, and he forgot, then that's something that the courts have to deal with.

As to what to do, the ex-husband needs to be aware of the situation. Since he works for the company that you write the group health for, and the ex-wife doesn't, she needs to be advised that you're not in a position to discuss it directly with her. Then, contact the insurance company and find out what can be done to make everyone happy.

[wlunday]

My sister in law and her ex had the same situation. They resolved it by going back to court to ammend the divorce agreement so the ex-husband would be responsible for "out-of-pocket" costs like deductibles, co-pays, and the like. It was still cheaper for him to do this as the kids are very healthy. The mom was assured that she would not be stiffed for any extra out-of-pocket costs.

They should consider this, too.

Swymmer

[Rob]

OK...this is a much clearer picture. First thought - it's really dumb to have the children covered under both policies.

That being said, if the divorce settlement requires the husband to provide coverage, and he forgot, then that's something that the courts have to deal with.

As to what to do, the ex-husband needs to be aware of the situation. Since he works for the company that you write the group health for, and the ex-wife doesn't, she needs to be advised that you're not in a position to discuss it directly with her. Then, contact the insurance company and find out what can be done to make everyone happy.

Well I talked to the husband and he said to go ahead and email her and cc him in and let her know that it was always his intention to try to add them (it was, I just didn't know about the court order) and that we are going forward with putting them on.

She wants them on because of the coordination of benefits. When you say that is a dumb idea, why?

[LadyBroker]

She wants to double-dip...she thinks if she has them on both policies, then they will be able to use both. This is not true. They always ask you on a health intake form if there is other coverage in place....and she is required to answer Yes. So then guess what happens....both carriers are going to fight over who is actually primary....won't that be fun?

I think its silly of her to pay for them on her group health, and then expect her husband to pay for them on his group health. If the court order requires him to cover them, then she should either:
1. Comply completely with the order, and drop her coverage on them, or
2. Tell her husband she will cover them herself, and amend the court order back.

As far as your involvement, you don't have any direct involvment with the wife. The papers she sent to you should have gone to the HR person at the ex husband's company, and they should direct you, not the ex wife of an employee. There are privacy issues involved.

However, you made a statement that dependents can only be added during open enrollment. This is not always true. If you are
a. married,
b. divorced, or
c. born
during a policy year, you can automatically roll on (or in the case of divorce, off) the group health policy at that time, and not have to wait for the open enrollment period. These are called Life Events. You might want to review the policy definition in this particular case and see how it applies.

Good luck!!!

[Rob]

She wants to double-dip...she thinks if she has them on both policies, then they will be able to use both. This is not true. They always ask you on a health intake form if there is other coverage in place....and she is required to answer Yes. So then guess what happens....both carriers are going to fight over who is actually primary....won't that be fun?

I think its silly of her to pay for them on her group health, and then expect her husband to pay for them on his group health. If the court order requires him to cover them, then she should either:
1. Comply completely with the order, and drop her coverage on them, or
2. Tell her husband she will cover them herself, and amend the court order back.

As far as your involvement, you don't have any direct involvment with the wife. The papers she sent to you should have gone to the HR person at the ex husband's company, and they should direct you, not the ex wife of an employee. There are privacy issues involved.

However, you made a statement that dependents can only be added during open enrollment. This is not always true. If you are
a. married,
b. divorced, or
c. born
during a policy year, you can automatically roll on (or in the case of divorce, off) the group health policy at that time, and not have to wait for the open enrollment period. These are called Life Events. You might want to review the policy definition in this particular case and see how it applies.

Good luck!!!

Actually I spoke with a Blue Cross representative and there is coordination of benefits that occur when they are on two policies. One becomes primary, depending on the date of birth of the two subcribers. The other becomes secondary and picks up the difference up to a specified amount. So saying they will fight over who is primary isn't true I don't believe because there are rules which dictate these things.

She didn't send any papers to me, she simply sent me an email.

Also I did mention the other qualifying events in addition to open enrollment in my letter to him.

But it seems that is what they want to do, so forward I go with their request.