Hip Replacement Covered by Std?

[Boardwoman]

Please bear with me,,I am a newbie. Here is the question,,,and story to explain question. I am on a board that runs a very small company. We only have 2 employees, with one seasonal employee. One of the workers wants to have a hip replacement done, not hurt on the job, they bought DI just for this worker,,what kind or type I am not sure. Are elective surgries covered? if so, how many times can the same person have electives done? The worker had one hip done already, before I was on the board, and workers relative got on our board to make sure worker was safe from getting fired. This was stated by board member as to why they were on the borad to begin with. I do not want to begrudge the worker from any benefits they may have coming. I just want to be sure we are not doing anything that our taxpayers(PPT is our operating budget) may object to.

 

[Norwayguy]

Please bear with me,,I am a newbie. Here is the question,,,and story to explain question. I am on a board that runs a very small company. We only have 2 employees, with one seasonal employee. One of the workers wants to have a hip replacement done, not hurt on the job, they bought DI just for this worker,,what kind or type I am not sure. Are elective surgries covered? if so, how many times can the same person have electives done? The worker had one hip done already, before I was on the board, and workers relative got on our board to make sure worker was safe from getting fired. This was stated by board member as to why they were on the borad to begin with. I do not want to begrudge the worker from any benefits they may have coming. I just want to be sure we are not doing anything that our taxpayers(PPT is our operating budget) may object to.

A Disability Policy (DI) provides weekly or monthly check while the insured is unable to work...It will not pay for a surgery a major medical policy would do that. You might want to get ahold of the policy to verify what type of coverage exists, It is also possible since it sould like this policy was taken out anticipating this surgury that this might be a Pre-existing condition exluded by the policy.

 

[LGilmore]

trouble on the horizon I fear. Pre-existing is the biggest issue. Please find out more (what company is the coverage through, Is the coverage through a company or are you folks creating a sick leave plan?)

It is also very dangerous to put policies in place for one employee, simply because it can lead to discrimination suits.

Please find out more about the situation and come back.

 

[Mark]

I just had to look at this. My brain was thinking something else.

Like how does a S.T.D. cause your hip to go out...HMM

 

[arnguy]

I just had to look at this. My brain was thinking something else.

Like how does a S.T.D. cause your hip to go out...HMM

You just had a major brain fart, Mark. In this instance, STD stands for Short Term Disability. Of course, you may have been joking, but the act itself could cause a hip to go out of joint!

 

[Boardwoman]

Thank you guys,,,and first off,,,LOL!!! on th S T D causing the hip replacement!! Finally something about this situation to laugh about. I will get as much info as I can get my hands on,,,and re-post what I find out. I thought it sounded a bit,,,,lets say....hanky. The policy is not to pay for the surgry,,,but to pay him money while he is off work,,and unable to perform his duties.

Would it be ok to get a hold of the agent and ask them what is what? This is a very small town and it is run by a bunch of "good ole boys",,,,I have been verbally threatened to mind my own business,,while at a meeting to discuss this very matter. Knowledge is my best bet,,,to get this figured out and put on the right path.

Thank you so much for taking the time to answer,,,,

 

[LGilmore]

It is OK to pay "time off", that in itself is not wrong. BUT how are they doing it? Is it in writing, is it available to all employees, is it self funded or through an insurance contract. You can do it, but the how you do it is where the problems can be.

It could be paid as sick pay, but is there a policy (not just insurance, but company policy for it?)

I used to run a youth soccer region with a full time and part time employees. It was really hard to get understanding that "non profit" does not mean do or treat employees in any manner or in any way you want at the momment. Non profits have to structure policy the same way a for profit would.

I have a feeling this is being set up as a classic example of how not to do it that can be used as an example in future DI sales.

 

[somarco]

Might want to read about ad hoc disability plans and Chism Ice Cream. This is a somewhat famous case about what can happen when disability payments are made without a formal plan in place.

Ad Hoc Payments

 

[COInsguy]

Thank you guys,,,and first off,,,LOL!!! on th S T D causing the hip replacement!! Finally something about this situation to laugh about. I will get as much info as I can get my hands on,,,and re-post what I find out. I thought it sounded a bit,,,,lets say....hanky. The policy is not to pay for the surgry,,,but to pay him money while he is off work,,and unable to perform his duties.

Would it be ok to get a hold of the agent and ask them what is what? This is a very small town and it is run by a bunch of "good ole boys",,,,I have been verbally threatened to mind my own business,,while at a meeting to discuss this very matter. Knowledge is my best bet,,,to get this figured out and put on the right path.

Thank you so much for taking the time to answer,,,,

After you get this problem solved I would pull in an agent from outta' town to handle your business so you can get some real help, like someone who will come sit & talk through this problem. Not that you won't find help here but those situations are easier handled by someone closer to the transaction. Hopefully you get straightened out!

 

[scagnt83]

After laughing at the title, I never even opened this thread until today (I thought they wanted a DI policy to cover the cost of the surgery), there is more to this than whats on the surface.


I do a good bit of DI in business settings, and this sounds like a ticking time bomb to me!

First, of course you need to know what the benefit amount, elimination period, and benefit period are.

But more importantly, is it an "Own Occupation" or "Any Occupation" policy?
Own Oc pays if you cant do your current job.
Any Oc pays only if you cant do "any" job.... at all. Meaning that if he can type on a computer and do Medical Transcription then they could easily deny the claim.
So that is the first question to ask.
(if its own oc, then for how long; some only do own oc for part of the benefit period)


After figuring that out; how long has the policy been in force? how long has the employee known that they need the surgery? has the surgery been recommended by a doctor?

Most any DI app will have a health questionnaire, and I have never seen one that did not ask about joint problems or reccomendations by a doctor that have not been performed.

If this guy knew about the problem at time of the app and it was not disclosed (companies would not insure someone needing a hip replacement for DI), then the claim would be denied.



And ditto to having a formal plan in place, you are looking at a world of trouble and headaches without it (the last people you want investigating you is the IRS!).

Also, the agent that sold the policy should be more than happy to sit down with you and answer any and every question. If they are not you need to find a new agent!