Weird Group Clause

Jun 27, 2007

  1. BKrocko
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    I was given a referral for a guy that is a house painter (sole proprietor - no employees). Colorado does not require Workman's Comp. for owners. He is currently covered under a group policy (Great West) from his wife's job.

    There is a clause in the policy that states he is not covered if he is injured while engaging in a "for profit" business. He will fax me the exact wording but for now, that is the way it was explained to me. He wants a HD plan that will cover him while working but they also want to keep the group plan = low deductible, benefit rich, better coverage for illness. I still need to find out how much they are paying for him to be on the group.

    Anyway, I have never run into this before - is that a normal clause? I called Aetna and inquired as to how the coordination of benefits would work if he had both individual and group coverage - they did not know and will call me back. He would only need individual if he had an accident while at work - if he gets sick, they want the group benefits.

    Obviously, I do not want to see someone have "double coverage". It seems to go against principle. I think the proper answer is for him to take out workman comp. ins - but I have been told that it is expensive and he would be better off on an individual plan. Thoughts???
     
    Last edited: Jun 27, 2007
    BKrocko, Jun 27, 2007
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  2. somarco
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    somarco That Medicare Expert Guy

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    I don't recall seeing a group plan that will pay for on the job injury. Not saying it doesn't exist, just haven't seen it.

    As for the double coverage, I believe the group is primary and his plan is secondary . . . which means they will probably pay nothing.

    I have never seen a justification for double coverage.
     
    somarco, Jun 27, 2007
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  3. BKrocko
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    Thanks Bob,
    I think there are a lot of blue collar sole proprietors out there that are on the spouse's group plan. I bet they have no idea that they are not covered for an injury while on the job. If they are NOT required to carry Workman's Comp (Colorado) - then they are up a creek without a paddle!

    I thought it would be the other way around - If they carry WC, then WC will cover the costs but if they don't, then whatever insurance they have in place should cover it. Looks like another reason we can give them to consider individual coverage when they say "I'm covered under my spouse's group plan". GoldDoor could use this answer to his recent post pertaining to that subject.
     
    BKrocko, Jun 27, 2007
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  4. somarco
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    It's actually a great pitch line I had never thought of before. Just to be safe I am going to check with a few group carriers & see what they say about on the job injury. My guess is all have that exclusion but I would like to be sure before using it on someone.
     
    somarco, Jun 28, 2007
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  5. somarco
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    Just to make sure, I have polled my group carriers to see if ANY would cover a spouse in a work related injury.

    So far here is what I have

    KP, Time, IAC, Allied have responded with a definitive no.

    Still waiting to hear from Aetna, UHC and a few others. I don't see the answer changing.
     
    somarco, Jun 28, 2007
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  6. salpro22
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    Reminds me of the pitches MEGA used to train their agents to say.
     
    salpro22, Jun 28, 2007
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  7. James
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    Maybe so but it is a good line. In fact I'm sitting here and saying "Duh", as I know several this would effect big time.
     
    James, Jun 28, 2007
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  8. salpro22
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    I agree. I'm going to check with the group carriers....
     
    salpro22, Jun 28, 2007
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  9. somarco
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    somarco That Medicare Expert Guy

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    The light bulb went on in Atlanta too . . .

    Realtors come to mind right off the bat.

    They are 1099 so not even eligible for WC. Spend all day (and night and weekends) in the car going to, coming from a showing or closing. Basically "on the job" 24/7.

    Walking around new construction, old houses. Lot's of things can happen.

    "Yeah, but I am covered under my husbands/wifes policy."

    "I have auto insurance and that covers me."

    No, you are not.
     
    somarco, Jun 28, 2007
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  10. James
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    Or contractors that work on houses, on those ladders or on top of roofs thinking they are covered under their spouses plan.
     
    James, Jun 28, 2007
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