Major health problems can be devastating for families in many ways. If a family member becomes seriously ill, issues such as loss of employment or income, loss of medical insurance, and an inability to pay medical bills all can have a negative impact on the family. Furthermore, the spouse or parent who is caring for an ill family member may experience his or her own issues with taking leave from employment, obtaining medical insurance for the family when insurance coverage has lapsed, and making financial decisions for the family. Finally, healthcare issues involving pregnancy and childbirth can have implications for the family, as well, in terms of medical insurance coverage and taking time off from work.
Your Right to Obtain and Maintain Medical Insurance
If you have access to an employer-sponsored medical insurance plan through your job or your spouse’s job, you have certain legal rights under a federal law called the Employer Retirement Income Security Act of 1974 (“ERISA”). ERISA requires that you be given certain information about your health plan, such as coverage limits, costs, and rules that you must follow. ERISA also provides that you be furnished with information about appealing the denial of claims for medical care that you have submitted for yourself and/or your family member(s).
If you or a family member that is covered by your medical insurance plan becomes seriously ill, such as in the case of a cancer diagnosis, the Health Insurance Portability and Accountability Act (“HIPAA”) prohibits insurance companies from discriminating against you in any way. For example, an insurance coverage may not charge different premiums or rates for a sick person as opposed to a healthy person, deny you coverage for your treatment, or otherwise exclude from coverage. Similarly, an insurance coverage may not prohibit you from enrolling in a medical insurance plan if you are ill or do not meet certain health standards. Likewise, HIPAA requires your health insurance plan to give you an additional opportunity to enroll or obtain coverage under the plan if you have had a certain change in circumstances, such as if you divorced, married, if you gave birth to or adopted a child, if your spouse who provided you with medical insurance coverage passed away, or if you lost other insurance coverage (through a spouse’s job).
HIPAA also gives you certain rights in terms of covered services. HIPAA amended ERISA to impose limitations on the exclusion of preexisting medical conditions, or those medical conditions for which you received some type of treatment during the six-month period prior to enrolling in your employer’s medical insurance plan. Many insurance policies exclude coverage for treatment related to preexisting medical conditions, but HIPAA requires insurance companies to limit their exclusion periods for preexisting medical conditions to 12 months, and to credit you with any periods of other medical insurance coverage that you had during that 12-month period.
If you do lose your medical insurance because you have lost your job, or are unable to work as many hours due to your illness, or the illness of a family member, you do have some rights to maintain your current medical insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”). COBRA applies to all employers who employ 20 or more employees, and requires that you be able to purchase medical insurance through your former employer at the same price for up to 18 months following the loss of your employment. Although maintaining medical coverage under COBRA can be expensive, because you must pay your employer’s share of your health insurance premiums, along with your own share of the premiums, it still will be typically cheaper than attempting to purchase a private heath insurance policy.
Alternatives to Employer-Provided Medical Insurance
There are some alternatives to private medical insurance, if you no longer have access to it through your job. People who are self-employed, for example, or unemployed persons, have no access to employer-sponsored health insurance plans. You can purchase private insurance policies on your own, but they are typically prohibitively expensive, and carry extremely high deductibles. Furthermore, these private insurance policies may not cover some medical conditions, or certain types of treatment, even if necessary.
If you or a family member is suffering from a serious health condition that is expected to last for some time, you may look at programs available in your state for public health insurance coverage. If certain financial eligibility requirements are met, most children are eligible to be covered under state Medicaid programs. Likewise, adults who are disabled may be eligible for medical insurance through state Medicaid disability programs. The requirements for eligibility, as well as the coverage, vary widely from state to state, and are dependent on each state’s laws and regulations that govern these programs.
Likewise, if you or a family member is permanently disabled and/or over the age of 65, you or your family member may be entitled to medical insurance coverage under Medicare, which is a federal public health insurance program. There are no income limits on Medicare coverage, but you will be responsible for some monthly premiums and co-pays, just as if you were covered by a private health insurance policy.
Finally, if you are in need of emergency medical care, and you do not have access to either private or public insurance programs, you still can receive emergency medical care. Under the Emergency Medical Treatment and Active Labor Act (“EMTALA”), all healthcare facilities must evaluate persons who request emergency medical treatment, including pregnant women who are in labor, determine whether an emergency medical condition exists, and take action to stabilize the emergency medical condition. The law states that an emergency medical condition exists when symptoms are so severe that failure to provide or a delay in providing medical treatment would reasonably result in serious harm. While EMTALA requires all healthcare facilities to provide emergency medical treatment if needed, it does not require facilities to provide any medical treatment beyond emergency medical treatment, including necessary follow-up or continuing medical care. However, some for-profit hospitals are required by their own policies to provide some degree of charity medical care, so they may have other programs through which you can receive non-emergency medical treatment at reduced or no cost.
Taking Time Off Work – Your Rights Under the Family and Medical Leave Act
If you become seriously ill and need to take time off from work, or if a family member becomes ill and you need to take time off from work in order to care for your ill family member, you may have a legal right to do so under the Family and Medical Leave Act (“FMLA”). The FMLA may provide you with leave from your job in the event of an illness, so long as you work for a covered employer, you work at or within 50 miles of a location where there are at least 50 employees, and you have worked for your employer for at least 1,250 hours during a period of at least twelve months. If you are covered by FMLA, you are eligible to take up to 12 weeks of unpaid leave, although your employer may require that you use any available sick, personal, or vacation time that you have accrued for the purposes of FMLA leave before you are permitted to take unpaid leave.
Leave is permissible under the FMLA if you or your family member is suffering from a chronic serious health condition that has left you or your family member incapacitated, that continues over an extended period of time, and that requires periodic medical treatment. However, you may take FMLA leave in increments, as needed; your leave time is not required to be taken consecutively.
Pregnancy and Adoption
FMLA coverage is also available for parents who have had a new child, whether it be through birth or adoption. While a mother can take up to 12 weeks of FMLA leave to recover from pregnancy and/or childbirth, and to care for her newborn child, a father is also permitted to take the same amount of leave in order to care for his incapacitated spouse and/or child. Again, this leave is unpaid, and you may be required to exhaust all leave time to which you are entitled before taking unpaid leave under the FMLA.
However, if you choose to take leave from your employer pursuant to the FMLA, your employer can require that you provide certification from a medical professional as to the chronic serious health condition that is affecting you or your family member. Your employer can require you to update this certification at least every six months. While you are not required to disclose your private medical information to your employer under the Health , you do have to provide the requested medical certification to your employer.
Speak to an Experienced Health Insurance Attorney Today
This article is intended to be helpful and informative. But even common legal matters can become complex and stressful. A qualified health insurance lawyer can address your particular legal needs, explain the law, and represent you in court. Take the first step now and contact a local health insurance attorney to discuss your specific legal situation.