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Dwayne B.
Dwayne B., Lawyer
Category: Employment Law
Satisfied Customers: 32154
Experience:  Employment Law Expert
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I went to a get prescription filled recently and learned

Customer Question

Hi,I went to a get prescription filled recently and learned that I do not have medical coverage through my employer. My employer has an enrollment period that ends Nov. 30th and according to their records I waived coverage.I am wondering if change of residence would qualify as life event for special enrollment? HR is saying otherwise: "Because you’re currently in waived status for medical, moving to another state […] will not open up an enrollment window." Does change of residence always qualify as life event, or are the limitations and discretions for my company and their insurance?Also, are there any avenues for me if I did not intend to waive coverage? For example, I do have dental (why would I have that and not medical), and I am single, ( so why did sign up process not flag or warn about waiving coverage).From the "Summary Plan Description" it says that the following apply.
Qualifying life events
Special enrollment events
These special enrollment events include:
· Increase/decrease employee life insurance coverage
Other life events
If you experience any of the following life events, you may be eligible to make limited benefit changes for yourself or your eligible dependents.
· […]
A change in employment for you or your spouse/domestic partner, even if this change does not affect your eligibility for coverage (gain or loss of job, change in hours worked, taking or returning from unpaid leave)
· A change of residence for you or your eligible dependent (for example, an interstate transfer that results in a change of eligibility for a medical plan)
Submitted: 7 months ago.
Category: Employment Law
Expert:  Dwayne B. replied 7 months ago.

Hello and thank you for contacting us. This is Dwayne B. and I’m an expert here and looking forward to assisting you today. If at any point any of my answers aren’t clear please don’t hesitate to ask for clarification. Also, I can only answer the questions you specifically ask and based on the facts that you give so please be sure that you ask the questions you want to ask and provide all necessary facts.

Your questions were:
I am wondering if change of residence would qualify as life event for special enrollment? and

Also, are there any avenues for me if I did not intend to waive coverage?

Unfortunately, to get a definitive answer to these you are going to need more information than you have here and it may be that you even have to file a lawsuit.

The problem you're having is that the term is vague and the insurance company and HR are choosing one definition that excludes you from coverage.

Using the language you cite, it does sounds like a change of residence could qualify as a special enrollment event but the issue is that the language from that section states "may be eligible" as opposed to "shall be eligible".

If you want to force them to add you then my suggestion is to hire a local lawyer that does either civil litigation or consumer law and let them get involved. The first thing they are going to have to determine is if it is the employer being difficult or the insurance company. If it is the insurance company then your chances of getting it changed are much better since there are a number of steps you can take that will cause problems for them whereas if it is the employer there are few options.

In addition, this may end up being an ERISA issue which make sit even more difficult.

Finally, the lawyer will also want to look into whether you actually did waive coverage or whether something else happened and they just don't want to admit it. In the cases I've seen where similar claims were made by the employers it was always an issue where the employer had made a mistake and the employee had never actually waived coverage.

Customer: replied 7 months ago.
Great thank you Dwayne,Q1: Can you clarify how this might end up being an ERISA issue, and how this makes things more difficult?HR has pointed me to "An individual loses eligibility for coverage under a group health plan or other health insurance coverage (such as an employee and his/her dependents’ loss of coverage under the spouse’s plan) or when an employer terminates contributions toward health coverage"And they are saying that:
• "when an employee moves between states, the employee only gets an enrollment opportunity if the option they’re currently enrolled in is not available in the new state"
• "If a member is in the HSP and moves to another state with the HSP […] they aren’t offered a special enrollment window." (implying all states offer Health Savings Plan)
• "Similarly, if a participant is in waived medical coverage status at the time they move, it doesn’t open up a special enrollment event.  They’ve not had a loss of eligibility for coverage under a group health plan as a result of the move."Implication of moving to a different state can apparently be interpreted in different ways. Because according to web site, and conversation when I called their 800 number, if I move to another state, this opens up special enrollment period (no qualification): Or, their web site and 800 number were not accurate.
Q2: Is this open to interpretation?Also, as a non-lawyer reading HPIAA it does not say anything about waiving coverage. And I could interpret that fact that my company is not allowing me to get coverage because I waived coverage as a loss of eligibility. Don't know if that has any legal must however.
Q3: Any legal possibilities here?
Expert:  Dwayne B. replied 7 months ago.

Q1: Can you clarify how this might end up being an ERISA issue, and how this makes things more difficult?

The courts have interpreted ERISA so broadly that almost everything that involves benefits from an employer ends up being covered by that even though the statutory language doesn't appear to do so.

ERISA makes things more difficult because it can only be handled in federal court and only under ERISA law so all of the other laws that would normally apply, don't. You can still try and argue that 1) ERISA doesn't apply and 2) that you need to be able to pursue alternative theories of recovery and some courts will allow you to do that but others will say that you can only pursue ERISA claims.

Q2: Is this open to interpretation?
Yes, but the issue is where do you interpret it? really the only forum where interpretation comes into play is in court. The good part is that when a contract (which this is at its core) is ambiguous and subject to more than one interpretation then any reasonable interpretation offered by the party that did not draft the language (in this case, you) must be accepted by the court even if the interpretation offered by the other party is more reasonable.

Q3: Any legal possibilities here?

Not sure what you mean by this. I think I've pretty well set out the possibilities already.