Is anyone else aware that the benefits of a health plan can be different for the enrolled employee versus the dependent? How is this even legal in any state? And disclosure is not required either. This was a work-related injury.
Fuming and Hurt
Dear Fuming and Hurt,
I think what you have found is that a dependent’s work-related injuries are not covered by the parent’s (or spouse’s) health insurance. This is standard language for health insurance contracts, though some insurers are not diligent about refusing to pay these claims.
With the right wording, the insurer could refuse to pay the claim even if the dependent did not have workers compensation coverage from the employer. Thus, a self-employed person who does not have to have workers compensation coverage could be left to pay for his/her own injury.
The disclosure would be in the certificate of coverage, though they may or may not refer to workers compensation specifically. They would simply state that the plan would not cover care that could be covered by another liable party (such as an employer).