Not Informed of Benefits for 7 Months
My question involves employment and labor law for the state of: CA
I work for a supermarket chain and am a union employee. I have been at my job for a little over a year and a few months ago started wondering why I hadn't received any information about my medical insurance benefits. I asked my manager and assistant manager when I became eligible and they both told me not to worry that I would be sent the information when I became eligible. So I waited. Another couple of months passed and still no benefit information. I brought the issue up again with my store manager and he told me it "wasn't their thing" and that I needed to contact my union. I did so and was told that they had nothing to do with benefits, contracts only and that the employer was the one responsible for getting this information to me but was told I should get something in the mail soon. Another month or so passes and still nothing. Another round of phone calls and still no answers. Finally a couple of weeks ago I was informed (by the union) that there is a third party trust that distributes the benefits. I contact them and find that I am in their system but they have no address or phone number for me. This is because they have never received the enrollment form that was supposed to be in my "new hire packet" - no mailing address = no benefits information. I called my boss to ask why/how this happened and he acted as puzzled as me claiming it "made no sense" and that he would get right on it. Once he found out that I had already requested the form from the trust he didn't understand what the problem was or why I was upset at missing out on 7 months of medical benefits. Come to find out there are several other employees that have had this happen, according to the union trust. So I bring this up to my asst manager and he pulls the new hire packets out to show me that the enrollment forms should be in there and when he looks, finds they are not in the packet. Today I contacted my union rep and he stated that the forms should indeed be in the packets as he makes them and delivers them. He also stated he had never heard of that happening to anyone and I informed him that the trust has had this happen before with several other employees. He tells me that it is "of no benefit to the employer to do something like that because they have to pay for the benefits anyway". Paying the minimum premiums while incurring no other costs does seem something a big corporation WOULD do, and the evidence points to that being the case. What should I do about being compensated fro the 7 months of benefits I never got? Can I insist on being covered for 7 months going forward even if I will not be employed by them any longer (I am turning my 2 week notice in tomorrow)?
Thank you for any advice/help, I am at a loss as to what my rights are in this situation. It seems like what they are doing is deliberate.
Re: Not Informed of Benefits for 7 Months
I'm asking these questions to help assess your legal situation; I am fully aware that there are additional issues over and above this one. I'll address them, but I need these answers first.
What actual medical expenses have you incurred in the last 7 months? How much have you paid in medical bills that would have been covered by insurance? With the understanding that anyone can walk out into the street and get hit by a bus at any time, what kind of medical bills do you anticipate having going forward?
There is no possible way you can continue to be covered by them once you are no longer employed by them. That is not going to be a viable option, whatever other solutions we may come up with.
Re: Not Informed of Benefits for 7 Months
This is the part 2 of my issue. I am on Transitionary Medi-Cal. I had no idea that I was covered under my job and had a couple of doctor visits (2 of them being work related injuries that I went to the ER for since I have no PCP & that I was asked not to make claims for by my boss). He knew I was on medi-cal and I'm sure he also knew that I qualified for benefits after six months - he would not give me this information after I asked him on multiple occasions. So this has become a major issue for me because now worry I may face trouble with the state for using medi-cal while I was eligible for other benefits. I am unsure as to the amounts of my medical expenses as medi-cal does not send statements, though I can probably request them. I had also been waiting for these benefits to see a specific therapist (for some personal issues) that takes blue sheild insurance but not medi-cal.
Re: Not Informed of Benefits for 7 Months
Understand that you cannot give me exact amounts - can you give me a guesstimate? This information is helping but give me just a little more.
I'm working towards something specific - I"m not just fishing aimlessly. :)
Re: Not Informed of Benefits for 7 Months
I see. Let me call Medi-Cal tomorrow and see if I can get a figure for the last 7 months. As far as the therapy, it would've been $80 - $120 per session (per his site) and the sessions would have been once a week. So were I to see him for 7 months, it would have been ballpark $3000 if I average the session cost.
I will get back about the other costs tomorrow, thank you so much for your help! :)
Re: Not Informed of Benefits for 7 Months
That will help. It doesn't have to be exact - just a general ballpark so I can make an estimate.
Re: Not Informed of Benefits for 7 Months
I just spoke with a supervisor at the Medi-Cal office, he's looking it up and will get back to me soon. I also asked that he mail me a copy as well. If I don't hear back from them by 3, I'll call them again. Thanks again.
Re: Not Informed of Benefits for 7 Months
If you want to PM me the information instead of posting it publically, that's fine. What I'm trying to determine is the most cost-effective solution for you.
Re: Not Informed of Benefits for 7 Months
I should be getting the info tomorrow. Due to hippa laws, they have to go through a specific privacy procedure. I have had to call 6 different numbers to get to the correct dept! I will PM you the claims info as soon as I get it. :)
Re: Not Informed of Benefits for 7 Months
Aw, honey, I don't need the info that much! Thanks so much for being so helpful. Since you've got it, or are getting it, we might as well use it, but I didn't mean for you to go to that much trouble. :)
When you send me the numbers, would you also send me what the insurance would have cost you if you'd had it,, and what you pay for the Medi-Cal. I know what answer I'd give you if you didn't have ongoing medical issues, but I'm concerned about the fact that you have more to come, and I want to give you the best options possible.
Re: Not Informed of Benefits for 7 Months
The employer pays the premiums, there is zero cost to the employee. As far as what my percentage would be, I don't know - they will not give me that information. This is an issue now for several employees so now I want this information for them too. There is a difference between the employer simply paying the premiums and reporting the hours to cover themselves and getting the enrollment forms (as is their responsibility) for their employees to utilize what they're (the employer) paying premiums on to have access to the insurance and claims on the insurance.
Thank you so much for your help, I really felt lost because I got the run-around from my employer and the union. They are acting like this never happens and that they don't see what the big deal is because I am now enrolled. They are not admitting any fault, nor are they realizing the value that the benefits would have been to the employee during the period they were not provided. It's frustrating. I know they want me to just let it go and forget about it, but it seems purposeful based on the fact that the enrollment forms are not in the new hire packet, so all employees have their benefits delayed for indefinite periods until they investigate for themselves.
Re: Not Informed of Benefits for 7 Months
I should have thought of this sooner. Do you have a copy of the plan document?
Just to be sure I understand, the employer pays 100% of the cost and there is no cost to the employee at any time; no payroll deduction?
Did you give your notice?
Re: Not Informed of Benefits for 7 Months
I am waiting on the plan docs and insurance cards, etc. It's been almost a month now and I still haven't gotten anything from the insurance co. I pay union dues but the union claims that it has nothing to do with benefits. No payroll deduction as far as premiums but I'm still unsure about my portion of cost - one of my co-workers says she has gotten a bill every time she has gone, I just wonder if it's informational or an actual bill. Another issue I was waiting on my insurance for is my feet (constant pain on the sides of my feet. I'm pretty sure it's plantar fasciitis and that it's work related but we get pressured into using our insurance and saying it's not job related). The reason is that once you go to a Dr. for something before your company insurance kicks in, it is considered a "previous condition" and will not be covered. Since I couldn't get an answer from anyone on whether I was covered or not I just waited. Now that I am enrolled I want to go, but am nervous about the work comp thing. This whole thing is ridiculous.
Re: Not Informed of Benefits for 7 Months
There's a difference between your employer paying the cost of the insurance, and your paying a co-pay or co-insurance when you use it. Right now, I am only concerned with who pays for the insurance itself, not whether you pay a portion of the bill when you have medical treatment.
It is exactly because of the pre-ex that I am concerned about this.
I'm traveling today and they're calling my flight so I'll have to go more into detail later.
Re: Not Informed of Benefits for 7 Months
Okay, sorry about that. I didn't have internet access for the rest of the day. I"m back now.
Workers comp claims do not get submitted under your personal health insurance. If you have a workers comp claim, there is a special policy your employer has that covers that. I understand that your employer doesn't want you to use the workers comp insurance but it's illegal for him to refuse to let you.
There are rules about when a condition can be considered pre-ex and when it can't. Unfortunately, because of this gap of 7 months it is *possible* for a condition to be considered pre-ex. That's why we're going through this exercise in the first place. :) Not all policies include a pre-ex clause, however. Do you know for an absolute fact that your employer's policy does, or are you assuming it? (That's a real question I need you to answer.) If you know, how do you know? Is it because you've seen the wording yourself or because someone told you? Again, I'm working on something specific here.
Re: Not Informed of Benefits for 7 Months
I was told by a co-worker that the insurance we get does not cover pre-ex conditions. And I'm 99.9% sure that the employer pays 100%. There is a big deal with this right now in SoCal because the grocery stores are trying to make the employees pay for their benefits and the workers are set to strike in 72 hours if there is not an agreement made otherwise. I will get on the phone and have the insurance co explain what my policy is regarding pre-ex and whether I pay anything just to be totally sure I'm giving you the proper info.
https://www.blueshieldca.com/bsc/fin...arn/faqs.jhtml
^ Explains the PPO's pre-ex policy.
I have Blue Sheild PPO, employer pays all premiums.
Re: Not Informed of Benefits for 7 Months
The insurance company will not know if you pay any part of the premium. That's a matter strictly between the employer and the employee.
If you are certain that the employer pays all premiums, we'll take that and go from there. There is no such thing as an insurance policy that pays 100% of everything so we will assume that you pay the occasional co-pay or coinsurance.
The pre-ex clause in that link you've posted is pretty standard, assuming that it applies for your specific policy.
Re: Not Informed of Benefits for 7 Months
I have $35 copay, $600 deductible and am responsible to pay 30% up to a certain amount (I believe it was around $12,000 in network).
Per the union trust, employer pays 100% of the premiums.
Re: Not Informed of Benefits for 7 Months
You have a 30% coinsurance and a $12,000 stop loss IN network?
Either you have a really crappy policy or that's not right. I could believe that out of network, but that's a HORRIBLE in network plan design.
Which makes it that much more important that we have an idea how much you've had to pay out in claims that would have fallen under the policy. I'm still concerned about pre-ex, especially if you are planning on leaving. Depending on the plan design of your new employer, that might solve your problem altogether or compound it.
Re: Not Informed of Benefits for 7 Months
The lady that was explaining it to me was speaking very fast and since I am pretty unfamiliar with some of the terms, it is very possible I mixed up the numbers on the stop loss. One number she quoted was $12,000 the other was $7,000. But for sure I am responsible for 30% with a $600 deduct. As far as seeing what I would have paid if I used this insurance, I still can't say because I've not heard back from Medi-Cal regarding my claims with them. And I didn't go for things I would have because I was waiting, unsure when I qualified. I have decided to just stay with Medi-Cal though. My new job is only part time and I would make little enough to still qualify. The plan my new job offers is probably pretty close to the one I should have had at my old job but they don't even pay the premiums. Knowing how much I would have had to pay, I probably wouldn't have gone.
I'm officially putting my 2 weeks in today.
Re: Not Informed of Benefits for 7 Months
Let me ask you a question, and you may not know the answers right now. But given what we've learned, this is really the only point that's important right now.
What is the pre-ex policy on your new employer's policy, and when are you eligible for coverage under it?
Just FYI, despite what you may be seeing in the news about the potential union strike, nationally very, very, very few employers pay 100% of the premiums.