Spousal Carve Out

[Guest Tuck]

Self insured health insurance plan provides employee's spouse not eligible for participation in employer # 1's group plan if spouse eligible for medical coverage through spouse's group plan. Employer' # 1's plan required that as a condition to participation, employee deliver a signed form which allowed employer # 1 to contact spouse's employer to confirm whether spouse eligible for group medical coverage. Form completed by employee and / or employee's spouse and returned to employer # 1. Later, from check with spouse's employer, it is learned that the form we were provied was false when provided.

Anyone have thoughts re: 1) ability of employer 1's plan to bring action to recover from employee claims paid which would have not been paid had a correct form been provided, and 2) ability to take disciplinary action against the employee who delivered to employer 1 the false statement pertaining to spouse's medical coverage? Thanks for any thoughts on this.

[J Simmons]

If the statement was false when presented, and it was presented in order to acquire benefits from the employer, it may meet the state's definition of fraud.

It may also constitute theft or embezzlement from an employee benefit plan, 18 USC 664.

[Guest Sieve]

On a practical level, you should be able to recover claims paid since the individual was not eligible for coverage under your plan. I sure hope you have a written plan document and SPD, so you can show the plan's eligibility provisions.