Blog Post

Save Yourself from Additional Heartbreak: Separated Spouses are Ineligible for Health & Welfare Fund Benefits

If you and your spouse separate, you are both required to notify the Health and Welfare Fund right away. Although “spouses” are covered dependent beneficiaries under the terms of the Health & Fund’s plan document, that term has specifically excluded “separated spouses” for over thirty years. As a result, separated spouses are ineligible for Fund benefits.

A married couple will be considered to have “separated’ if they are living separate and apart with an intent to terminate or abandon the marital relationship. The fact that a member and his or her spouse remain legally married, or that the state in which they reside does not recognize the concept of “legal separation” is irrelevant. In addition, the fact that a member is required by state domestic relations laws to maintain health benefits for his or her estranged spouse is also irrelevant as continuation coverage (see below) may be available to the estranged spouse.

If the Health & Welfare Fund becomes aware that a member and his or her spouse have separated, several processes will be set in motion. First, the estranged spouse’s eligibility for Health & Welfare benefits will immediately terminate. The termination of those benefits will be treated as a “qualifying event” that triggers the spouse’s right to elect continuation coverage under the Consolidated Omnibus Reconciliation Act (“COBRA”). Second, the Health & Welfare Fund’s member services representatives will review the estranged spouse’s claims history to determine if any claims were paid by the Fund during the period of separation. If they were, the Fund will demand repayment of the amounts paid on the estranged spouse’s behalf during the separation.

The Health & Welfare Fund has several methods for recouping the benefits improperly paid to a separated spouse as a result of the member’s or spouse’s failure to notify the Fund of their separation. These include requesting that you enter into a payment plan to repay the Fund for the benefits paid and denying payment on claims submitted to the Fund until such time as the value of the claims denied is equal to the amount of the debt owed to the Fund. In certain circumstances, the Fund may also be forced to file a lawsuit against members and their estranged spouse to recover the amounts owed.

The easiest step a member can take to avoid the added heartbreak and financial stress associated with over payments of benefits to separated spouses is to promptly let the Health & Welfare Fund know that you and your spouse are separated. The Fund’s member services personnel will then walk through the process of updating your census information on our computers.  An ounce of prevention is worth a pound of cure!