Migliaccio & Rathod LLP is investigating whether certain employer-sponsored health plans improperly issued retroactive health coverage cancellation for an employee’s spouse or child, causing medical claims that had already been paid to be reversed.
Employer health plans sometimes conduct dependent-eligibility audits and ask employees to provide documents showing that a spouse, child, or other dependent remains eligible for coverage. These audits may request marriage certificates, tax returns, birth certificates, or other records.
We are particularly interested in situations where an employee missed an audit deadline or did not provide the requested paperwork on time, and the health plan responded with retroactive health coverage cancellation for dependents —sometimes going back months—and reversing claims for medical care the plan had already covered.
The result can be severe. A doctor, hospital, or pharmacy may suddenly tell a family that insurance payments for old claims were taken back and that the family now owes thousands of dollars for care received when everyone believed the dependent was insured.
You May Be Affected If:
- You receive health insurance through a private-sector employer;
- Your spouse, child, or other dependent was enrolled in your employer health plan;
- Your employer, health plan, or a dependent-verification company asked you to provide documents proving that your dependent was eligible;
- You missed a paperwork deadline or were told that the documents you submitted were insufficient;
- Your dependent’s coverage was canceled retroactively rather than only going forward;
- Medical or prescription claims that had already been paid were later reversed;
- Doctors, hospitals, pharmacies, or other providers began billing you for previously covered care;
- Your dependent was actually eligible for coverage during the period that was later canceled; or
- There was no intentional misrepresentation or fraud concerning your dependent’s eligibility.
We are especially interested in cases where the plan went back in time and erased coverage solely because paperwork was late or missing, even though the spouse or child was otherwise eligible for the plan.
Why Retroactive Cancellation Matters
There is an important difference between terminating coverage going forward and pretending that coverage did not exist during an earlier period.
With retroactive health coverage cancellation, previously paid claims may be reversed. A family that reasonably believed it had insurance can suddenly become responsible for medical expenses incurred months earlier.
Federal law restricts when group health plans may retroactively rescind coverage. Whether a particular cancellation was lawful can depend on why the coverage was terminated, what the plan documents say, whether premiums were paid, and whether there was fraud or an intentional misrepresentation.
Does This Apply to Your Health Plan?
This investigation generally concerns people who receive health insurance through a private-sector employer.
Both self-funded plans and plans purchased from an insurance company may qualify. Government employee plans and certain church plans generally are not governed by ERISA.
If you are unsure whether your plan qualifies, we can generally determine that from documents such as your insurance card, Summary Plan Description, dependent-audit correspondence, termination notice, or Explanation of Benefits.
We Are Interested in Hearing From Employees Who:
- had a spouse or child removed after a dependent-eligibility audit;
- missed a documentation deadline but had an otherwise eligible dependent;
- submitted documents but were told they were insufficient;
- had dependent coverage canceled months back in time;
- saw previously paid claims reversed;
- received new medical bills for previously covered treatment;
- continued having premiums deducted while coverage was later treated as nonexistent;
- successfully proved the dependent was eligible but did not have all prior claims restored; or
- have audit notices, termination letters, EOBs, medical bills, payroll records, or other documents showing what happened.
If your employer issued retroactive health coverage cancellations for your spouse’s or child’s coverage and reversed previously paid medical claims, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.