Legal Question in Family Law in Maryland

Re: Legal Separation medical issue

If a legally separated husband is required to provide health insurance coverage for his wife and children, but there is no order requiring him to pay all medical expenses, he should not be responsible for the cost of any medical treatment for the wife which is not covered by the insurance. He is responsible for providing her with an insurance card and information about what the policy covers, and any requirements for advance approval of out of state medical care provided by a doctor or hospital which is not on a list of preferred providers. If the insurance coverage is with an HMO, there is often a problem about the approval for medical care out of the HMO's area, and even in emergency situations the HMO often insists on advance notice that the treatment is required. If the wife is provided with the necessary information and doesn't get the approval for treatment, the cost should not be borne by the husband. I would suggest that the disapproved claim be re-submitted, because insurance companies often refuse, the first time around, to approve payments.

Re: Legal Separation/Medical issue/Denial of Coverage

Your question relates more to a medical insurer's denial of coverage than to a marital/divorce matter. Nonetheless, when a separation agreement is entered it is a contract. Accordingly, performance under the contract and enforcement for non-performance is typically under contract law where the separation agreement has not been enrolled in a divorce decree. This is precisely why I strongly recommend hiring an attorney for a separation agreement. Just like any contract, unless it is legal, it is not enforceable.

Many attorneys offer separation agreements for $150 or so. Without specific attention to the details of your separation, you are not likely to have an agreement that suits your needs.

In your case, the provision to carry health insurance is likely to be enforceable. But unless there is a provision for uncovered health events, and such provision is properly drafted and legally effective, the spouse who is to provide health insurance does NOT have to pay for uncovered claims. An attorney should review of your separation agreement in this regard.

As to uncovered medical claims, health insurers are in the business of making money. They are not always amicable with paying claims. An attorney, such as myself, who is knows how to re-file rejected claims may be of assistance. Without knowing the details of the medical claim, little else can be said. In order to pursue this matter you will need to have a copy of the efective medical insurance policy. Details on the claim as initially filed and the rejection notice are also required. Do not accept that this is not a covered claim since health insurers do not readily pay claims that they may otherwise be called upon to pay given the proper presentation of the claim. Be advised that the health insurance policy most probably has limitations upon the re-submission of claims and, if not met, these may result in a proper exclusion of coverage.

G. Joseph Holthaus III

(410) 799-9002