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P. Simmons
P. Simmons, Attorney
Category: Legal
Satisfied Customers: 26137
Experience:  16 yrs. of trial experience
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My 73 year-old mother is losing her health benefits from the

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My 73 year-old mother is losing her health benefits from the NYC police department due to a state benefits audit.

She cannot provide all the paperwork they want to prove her dependent status to her husband (the NYC officer). Although he wishes her to remain on his policy, they no longer live together or have any shared credit cards, etc.

She can't have anything to do with him, in fact. He has alcoholic dementia and has ruined her credit and has lost all but everything at this point. He is now a dependent of the state and is not altogether part of this reality.

So... unless she can provide something that shows a shared life in addition to her marriage license, they will terminate her health benefits after 30 years. She lives below the poverty income level and has little but has these benefits. Which are important because she's in cancer treatment ongoing.

She has called every number at the police department, the state of new York, and anyone else who will listen. Basically, she has been told nothing can be done.

Without these benefits, she will be hard-pressed to continue the treatment she now receives. Is there anything that can be done to keep her benefits in force? She will lose them September 2oth.

We don't even know what kind of lawyer to talk to in this situation? So any advice is much appreciated. Thanks,

B.D., Chicago
Submitted: 1 year ago.
Category: Legal
Expert:  P. Simmons replied 1 year ago.
Thanks for the chance to help. I am an attorney with over 12 years experience. Hopefully I can help you with your legal question.

This is a difficult circumstance. The police department is free to set rules that limit benefits eligibility...so if the rule is they do not live together, she does not benefits is not a prohibited rule. In fact it is quite common. So it would not likely do any good to try and use legal action against the police department.

Perhaps a better course of action would be to consider a request an order of support from the court.

Can you tell me, has mom filed for divorce against her spouse? Is she considering it?
Customer: replied 1 year ago.


Thank you for your help!


 


No, they have remained friends and have never felt the need to get divorced.


 


Essentially, I think she was staying married for the benefits which she's received for 30 years. They've lived apart for the last 15 I believe.


 


They did have a credit card together (which would work as the secondary identification) up until 1 year ago. But when the state he lives in took over his financial upkeep, they paid off the balance and closed the account.


 


They haven't talked in a long while as his mind is deteriorating. But I don't think there was any talk of divorce. Would divorce help in any way?

Expert:  P. Simmons replied 1 year ago.
The problem she faces is contractual really...it is contract law that governs this insurance program. Basically, the policy that the department uses is to limit benefits to a spouse who is not a "dependent" (however they choose to define dependent) there is not much she can do if she does not meet the definition.

In other words, if the policy defines dependent as someone who shares the same roof the majority of a given year, and she does not meet this definition, then the policy department can rightly deny benefits.

The only way to challenge in this instance would be if you could prove that the department is not following its policy.

Another example, say the policy defines dependent as someone who shares the same roof the majority of a given year. And lets say, for arguments sake, your mom met that definition (she did share the same roof a majority of nights in the past year...again, for arguments sake). In such a case, she could sue to force the department to follow its policy.

But what you describe? It sounds like she is not a dependent as far as the policy goes...

If that is the case? There is nothing under the law she can do to force the department to insure her. Even with her health issues....that is since the department is free to enforce its policy.

Now...I mention divorce since that is one way to force the spouse to help pay for this problem. The divorce court has the power to order support...so the court could, for example, order him to pay her support to help her cover her insurance expenses she will not incur due to loss of this insurance benefit.

But this requires she file for divorce...and find a lawyer to help her in the process.

So it may not be worth the effort (to hire the lawyer and sue for divorce and support).


I am very sorry to have to bear bad news. I wish that there were some legal recourse available against the department, but what you describe, I do not believe that is the case


Please let me know if you have more questions...happy to assist if I can
Customer: replied 1 year ago.


one last question...


 


so the extenuating circumstances of his health and her inability to meet their policy based on his health/state of mind has no bearing?


 


They don't live together because of his alcoholic dementia and they share no ownership of anything because... well, the same.


 


although she is his legal wife, and he wants her to remain on his benefits, it just doesn't matter... the legal matter is just about the contract, their rights to define her status, correct?

Expert:  P. Simmons replied 1 year ago.
The problem she has is that this is a contract issue. It is, in essence, an insurance policy that he is entitled to based on his work in the past. The employer is required to provide the coverage as required by the policy. No more...no less.

So the fact there are extenuating circumstances that force them to live apart? Unless the contract covers this, the extenuating circumstances have no bearing on the analysis

Now...this is not to say what the department is telling her is the ground truth. He can get access to the policy...and he could provide it for her to review.

Since she is not the employee, she has no legal standing to demand a copy of the policy...but as the employee he would.

So it may be he can request the policy and provide it to you or your mom....that may give you some insight into if the policy has a provision that covers this (misconduct by the employee that forces separation). If so? It may be he can demand coverage. If not? Then there is nothing she can do against the department.

Also...if she had to go to court to request support, the facts you describe (his misconduct has forced her to move away) would help her bid for support.


P. Simmons, Attorney
Category: Legal
Satisfied Customers: 26137
Experience: 16 yrs. of trial experience
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