Exclusion for workers' comp injuries

[Guest Julie]

We have a self-insured medical plan. Currently we have an exclusion in the plan that states that if the injury/illness is due to a work related injury and can (or should be) paid through workers' comp that the health plan will not reimburse the expenses. The provision also excludes reimbursement for any injury incurred while receiving wages or profit.

We're trying to determine if this exclusion is standard, or, what other companies are doing with regard to work related injuries. The reason we're looking into this is because we have many employee spouses enrolled in our plan that are self-employed, i.e. farmers, plumbers, etc. Many of these folks, especially the farmers, are telling us that they cannot get coverage. We don't want to be bad guys but we don't want to be spending money unnecessarily. So we're trying to determine what is the most common practice in this area.

[JanetM]

Our self insured plan has the following language:

Treatment for illness or injury arising out of, or in the course of, any employment for wage or profit , including, but not limited to, employment with the Company, without regard to whether such illness or injury entitles the employee or covered dependant to Worker's Compensation or similar benefits.

From speaking with others that are self funded, this is the norm for just about all.

[Sandra Pearce]

Our self-insured plan excludes:

Treatment due to an injury or illness, which arises out of, or in the course of, employment or occupation for remuneration or profit; or for services covered in whole or in part by Workers Compensation laws and/or services rendered as a result of occupational disease or injury.

[Kirk Maldonado]

My experience has been consistent with that of the prior posters.

[GBurns]

Julie

It looks like you already have wording that is standard, but I get the feeling that your company has not been enforcing it and does not really want to, except for the extra cost. Is that correct?

Not knowing the exact situation, I also feel that many of these employees are working with you partially because of the availability of this spousal coverage. It might really cause a problem if you now started to enforce this wording.

Is it possible to increase the cost of that spousal coverage enough to cover the expense but not enough to force them to have to drop the coverage? Or what about an Occupational Rider, to cover those occupational injuries or even occupations, at a sufficient additional cost since raising the cost of spousal coverage across the board might be bad for other employees?