Other Waiving of waiting period for maternity benefits

Folks this is a bit of a read but I would appreciate some feedback.

Do you think I have grounds for legal action?

As some of you may know there is a waiting period of 52 weeks before a woman can avail of maternity benefits. Aswith all companies the authority to change policy is an arbitrary one.

I am with my insurer 10 years and seldom make a claim. My partner was with them 48 weeks and was told no she was not covered. I argued that it was irrelavent who was having the baby, I had 10 years service with them and wanted my child to be delivered in a private capacity. They said but you are not having the baby, I argued so what?! Whats the difference, if I could I would but I cant, does this deny my right to have my child to be born in private care? We both created the child!? Long story short we went public and sat on average 4hrs in waiting areas to be seen and the experience could have been better (mildly put)

One of their agents came into our company and gave a presentation on what was covered under our policy and he said we were coverd for everything. I said "you missed something there, you never told anyone about the watining period of 1 year", to which he replied thats waved for your company as there are over 200 members... I almost fell off my chair. I contacted the girl (via email) to explain to me why she didn't know this. She wrote back to say, "sorry you should have been covered it wont happen again, I trust this to your satisfaction...".
I went through their complaints procedure and they denied compensation. They initially told us no we were not covered, then verbally we were, followed by confirmation in writing we were only to be told verbally again that we were not, followed by a mail to say we were not! They said the waiting period was only waved for the policy holder! Which litereally translate to

FEMALE:- If she joins the company and is the policy holder, the waiting period is waved for this benefit if she becomes pregnant.
MALE:- If he joins the company and is the policy holder, the waiting period is not waved for your partner even though she is also listed on the policy (before she was even pregnant).

This is written now where by the way.

I recieved what is referred to as the "final notice" from our insurer with a copy of the terms and conditions of the contract which in all fairness does state the waiting period. However, this issue surrounding the waving of the wating period is written nowhere.

I have since submitted a complaint to the ombudsman who advised mediation which I have declined.

Should I stop this David and Goliath battle.

Zen

Should I stop this David and Goliath battle

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That is up to you... It's frustrating, annoying, etc etc... but insurance companies seldom live up to what promote as their ideals ,with health insurers "looking after you"... typical example in your case...

In your case & the fact that you have in writing that you should have been covered, I would continue to "argue the case"... Some health care employees are not fully aware of specific company coverages, but no harm in contacting the "rep" again to have a chat & see where it's written down - could even be a memo from HR ... keep everything formal & try not to take things too personally if you do keep "fighting the fight"... just keep smiling & send another letter...

Tks for the words of encouragement Jazz01. The wheels are in motion. I'll be sure to post the outcome. Our own HR dept dont know or really care, they have a very inapropriate passive interest in the matter. This ambiguity is affecting over 200 staff policies! You would think that this would need clarity. But then again, we are in Ireland. Sometimes its better not to ask questions....

zen said:

Should I stop this David and Goliath battle.

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What do want as an outcome to your battle?

If it is fairness for your co-workers who may be in this situation in the future, then yes, it's probably worth continuing so that there is clarity and fairness for future potential claimants.

If it's compensation for yourself/partner, your problem is that there is nothing to compensate you directly for. If you had been denied but then gone ahead and gone private, paying several thousand to do so, I could see you having a case for getting this amount back. But you went public and your 'costs' were in time and inconvenience - which it's difficult to put a fair value on.

Are there any of your colleagues interested in this situation or would they offer some support. Surely this needs written clarification at least.
As the policy holder is the policy payer it sounds odd to me that terms & conditions re waiting times would be different for the partner of that policy holder.

If it were me I'd follow it like a dog with a bone but you must make your decision

orka
I'm looking to be compensated for the years of paying for a policy when I was denied the services that I was paying for. Or for the excess they should have paid to a private institution along with free health insurance.
I still have the argument that it is irrelavent who is having the baby as long as one of the co-creaters of the baby is insured. Its all about having the baby, there is nothing in it for the woman except pain. So you see my initial arguement, I wanted the child to be looked after privately. This arguement got me nowhere, I gave up, we went public till I discovered the waving of waiting period issue.

Bare in mind folks, if you forget so much as to dot an "i" or cross a "t" on your policy you'll see what insurance companies are capable of. The shoe is on the other foot and I aint going without a fight! grrrr

BlackSheep
Thanks for the words of encouragement. I would imagine there are lots of men here who are not aware of this but I was hoping that the HR dept would take a lead on this and actually tell employees. I'll be sure to let you all know how I get on.

zen, I think you have three separate issues combining which should probably be looked at individually:

1. A man’s health policy should cover the private care of the mother for the birth of his child. This has never been the case and no health insurer provides this interpretation. Each per-person premium can only cover one person. Trying to argue the case on this would be very difficult. You didn’t pay for years only to be denied services you paid for – as a male, your premiums were never going to provide maternity cover for you personally. Your child can be covered without a waiting period from the time it is born but not before.

2. There is a discrimination/unfairness in the treatment of new female employees (no waiting period) vs. female partners of male employees (52 week waiting period). I’ve thought about this again and I don’t actually agree that there is discrimination. The concession is given to the employee only, not to all those covered under the policy.

3. Your girlfriend was treated unfairly in not being covered despite being 48 weeks into a 52 week period. I do think this was very harshly applied. As your scheme has over 200 employees and is presumably of importance to the health insurer, you could maybe try appealing via your HR department or whoever decides which health insurer gets to be your company one. Denying a claim 48 weeks into a 52 week waiting period when pregnancy is only 40 weeks long is harsh – if your HR department could take up your case with the insurer (pointing out that they expect better treatment of their employees’ families and maybe implying that the incumbent health insurer might be changed), they might get a better outcome. What date did your girlfreind join the scheme vs. the expected due date? And how long before that did you start enquiring about the possibility and cost of adding her to the policy? If you started the process of getting her added a few weeks before she was actually added, that would be nearly 52 weeks which might help your case.

Although again, I'm not sure what positive outcome can be got here except maybe an ex-gratia payment or a reduction in your premium for a year as compensation - as you don't have an actual monetary loss to claim for - and in fact, you are financially better off as going privately would have cost you personally a few thousand...

Update:....

Thanks Orka but I think it might be time to challange that. It shouldn't matter which of the two co-creaters of the child is. The female is not being "cared for" she's be used as a vessle to bring a child into the world. The males insurance should be sufficient to profide the capacity to do so.

Late reply I know but I have trolled through the insurers internal complaints dept to the Ombudsman to the final notice of the insurer that there would be no compensation or consideration. However,,,. since I had it in writing that I was covered and they changed their story they have since offered 500eur for “for the distress caused due to this mis-information.”

This dismisses the entire reason for me doing this

Essentially I want to take a case against VHI under the Equal Status Act for denial of equal treatment of a service on the grounds of gender under their normal terms and conditions.
Secondly for the waving of a waiting period which I see as indirect denial of treatment which favours only famale policy holders within our organisation.
The insurer should compensate for the amount that should have been spent on private care.
The insurer should make clear the specific terms in their correspondences regarding the waiving of waiting periods for certain clients. i.e. you must be female and you must be the policy holder otherwise the normal terms and conditions apply.


I must embark on this path separately with the Equality Tribunal and continue with the adjudication of the settlement with the Ombudsman case.

I haven't yet decided....

zen said:

One of their agents came into our company and gave a presentation on what was covered under our policy and he said we were coverd for everything.

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Hope you don't mind me asking but what type of policy does this refer to? Is it one of the Company Plans?