self insured health benefit plans

[Guest Stephen47]

Does Erisa govern the legal standards and language of self insured group health plans? There is a employer sponsored self insured group plan that will not provide any coverage if a covered person was not wearing a seatbelt and sustained injuries during an auto accident. Is this legal? And what governmental resource can I consult to verify the answer? Thank you!

[KIP KRAUS]

To my knowledge, ERISA does not mandate the type of benefits to be covered under any welfare plan, including medical plans.

Most medical plan coverage requirements are mandated by individual states, and insurance companies. One of the reasons for employers to self-insure medical plans is to avoid state madates. Not covering a person for injuries sustained in an auto accident when not wearing a seat belt seems extreem to me. Whether it's legal or not may only depend on whether or not they could when a law suit if challenged.

My question would be, what is the employer's perceived estimated plan savings by eliminating these types of claims, and is it worth a possible law suit?

You may want to contact the DOL or State Insurance Department to see if tthey can provide guidence.