Source of Injury exclusion - Applies to Perpetrator?

[Guest calcu]

For purposes of the source of injury rules in DOL Regulation Section 2590.702(b)(2)(iii), if a plan generally provides benefits for a type of injury, the plan cannot deny benefits for treatment of the injury if the injury is a result of an act of domestic violence or a medical condition. Does this rule apply to both the victim and the perpetrator? The regulation does not specifically state that both the victim and the perpetrator must be afforded benefits, but it doesn't state that a plan can deny benefits to the perpetrator as well. Any thoughts and/or insight?

[GBurns]

I do not think that I understand your isssue. Benefits only apply to the plan participant.

If an employee has employee only coverage and inflicts (perpetrates) injury on another person who is not your plan participant, Why would it matter what the law says since you would not be giving any benefits? Why would you be concerned about offering benefits? The person needing the benefits does not participate in your plan and could not get benefits even if you wanted to give it.

If the injury is inflicted on your plan participant, What does it matter what the source was, unless there is no off the job coverage?

[oriecat]

I'm not sure I understand either.

So if A is a Plan Participant, A commits some act of domestic violence and cuts his/her hand in the process, can the treatment for the cut hand be denied because it was received during the course of a crime or would it be required to be treated under the reg you specify? Is that an example of the question?

[Guest calcu]

Sorry for the confusion, but yes Oriecat, you have articulated my question correctly. If A (a participant in the plan) commits an act of domestic violence or commits a felony and in the process is injured, even though A is the perpetrator, do the source of injury regulations mandate that plans provide A benefits? We have a carrier that is saying no. If the participant is the perpetrator of an act of domestic violence or a felony, the carrier will not pay.

[Kirk Maldonado]

Here is the relevant language from the regulation:

If a group health plan or group health insurance coverage generally provides benefits for a type of injury, the plan or issuer may not deny benefits otherwise provided for treatment of the injury if the injury results from an act of domestic violence or a medical condition (including both physical and mental health conditions).

I don't see anything whatsoever in the regulation that supports the position of the insurance company. In fact, I would conclude the exact opposite. If the DOL had intended that the rule not apply to the perpetrator, they would have stated so in the regulation. The absence of any express exclusion here leads me to conclude that the rule applies to the perpetrator as well as the victim.

But I will admit that my involvement in this issue is limited to reading the regulation; I've not researched it at all. So if anybody has really delved into this issue, I'd be very interested in hearing their views.